rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
1,THE TERRACES OF PHOENIX,35003,7550 NORTH 16TH STREET,PHOENIX,AZ,85020,2018-08-24,623,D,0,1,D0BP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility failed to ensure that the State Long Term Care Ombudsman was sent a copy of the transfer/discharge of one resident (#3). Findings include: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a nurse's notes dated 5/7/2018, revealed the resident was discharged to an acute hospital for increased shortness of breath, fatigue, weakness, wheezing, and moist cough. Review of a nurse's note dated 5/9/18, revealed the resident was re-admitted on [DATE]. A nurse's note dated 6/7/2018, revealed the resident was sent out via ambulance to a hospital for worsening respiratory condition. A nurse's note dated 6/11/2018, revealed the resident was readmitted to the facility 6/11/2018. Further review of the clinical record revealed no documentation that a copy of the transfer notices was sent to the Office of the State Long Term Care Ombudsman. During an interview conducted with the Administrator (staff #59) on 08/23/18 at 10:31 AM, the administrator stated that he is aware of the requirement to notify the Ombudsman of transfers/discharges but that they have not initiated a process to notify the ombudsman.",2020-09-01
2,THE TERRACES OF PHOENIX,35003,7550 NORTH 16TH STREET,PHOENIX,AZ,85020,2018-08-24,658,D,0,1,D0BP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record reviews, staff and resident interviews, and policy, the facility failed to ensure the administration of an intravenous (IV) medication for one resident (#1) was administered according to professional standards and failed to ensure one resident's (#7) medication order was verified for route. Findings include: Resident #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. During a medication administration observation conducted on (MONTH) 21, (YEAR) at 9:10 AM , the Licensed Practical Nurse (LPN/staff #41) was observed administering [MEDICATION NAME] via the PICC. However, the LPN was not observed to check the PICC line for a blood return before administering the antibiotic. An interview was conducted with staff #41 on (MONTH) 21, (YEAR) at 9:16 AM. Staff #41 stated that she usually checks the PICC line for a blood return before administering the antibiotic but that she did not check for a blood return this time. During an interview conducted with the Director of Nursing (DON/staff #49) on (MONTH) 23, (YEAR) at 10:37 AM, the DON stated that it is her expectation that nurses properly check the PICC line for placement before flushing and administering medications. The facility's policy Flushing Midline and Central Line IV Catheters did not include checking the line for a blood return. -Resident #7 was admitted on (MONTH) 24, (YEAR) with a re-admission on (MONTH) 3, (YEAR), with [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed a physician's orders [REDACTED]. On (MONTH) 10, (YEAR), the order was changed to [MEDICATION NAME] by mouth. A review of the resident's MDS (Minimum Data Set) assessments from (MONTH) 10, (YEAR) to (MONTH) 8, (YEAR), revealed the resident had a tube feed. A review of the resident's MARs (Medication Administration Records) from (MONTH) (YEAR) through (MONTH) 20, (YEAR), revealed the resident's [MEDICATION NAME] was administered by mouth. An interview was conducted with resident #7 on (MONTH) 20, (YEAR) at 10:24 a.m. The resident stated that he receives his food and medications through his PEG tube. On (MONTH) 21, (YEAR) at 10:58 a.m., an interview was conducted with RN/staff #6 who stated that she administers all the medications for resident #7 via his PEG tube and that the resident has been NPO (nothing by mouth) since admission. Staff #6 stated the resident is administered the [MEDICATION NAME] on the night shift, but that she knows that the resident receives all medications via the PEG tube. A review of the facility's medication administration policy revealed that the individual administering the medication must check the label to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.",2020-09-01
3,THE TERRACES OF PHOENIX,35003,7550 NORTH 16TH STREET,PHOENIX,AZ,85020,2018-08-24,693,D,0,1,D0BP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interviews, and policy, the facility failed to ensure one resident (#7) with a Percutaneous Endoscopic Gastrostomy (PEG) tube received appropriate services when administering medications. Findings include: Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. The current care plan regarding tube feeding revealed an intervention to check for tube placement and gastric contents/residual volume per facility protocol. During a medication administration observation conducted on (MONTH) 21, (YEAR) at 07:56 AM, a Registered Nurse (RN/staff #6) was observed administering [MEDICATION NAME] and [MEDICATION NAME] via the resident's PEG tube. However, the RN was not observed to check the PEG tube for placement prior to administering the medications. An interview was conducted with staff #6 on (MONTH) 21, (YEAR) at 9:19 a.m. Staff #6 stated that the PEG tube placement should be checked by using a stethoscope to listen for air in the stomach before administering medications. She also stated that she did not check the PEG tube placement before administering [MEDICATION NAME] and [MEDICATION NAME]. During an interview conducted with the Director of Nursing (staff #49) on (MONTH) 23, (YEAR) at 10:37 AM, she stated that the expectation is that the nurse would check the PEG tube placement before administering medications. Review of the facility's policy regarding the administration of medications via PEG tube revealed that gastrostomy tubes should be auscultated by administering approximately 10 cc (cubic centimeters) of air into the tube and listening for a whooshing sound to check placement of the tube in the stomach before administering medications.",2020-09-01
4,THE TERRACES OF PHOENIX,35003,7550 NORTH 16TH STREET,PHOENIX,AZ,85020,2018-08-24,757,D,0,1,D0BP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy, the facility failed to ensure one resident's (#295) physician's order for an antibiotic had an appropriate [DIAGNOSES REDACTED].#295). Findings include: Resident #295 was admitted (MONTH) 4, (YEAR), with [DIAGNOSES REDACTED]. Review of the physician's orders revealed an order dated (MONTH) 4, (YEAR), for [MEDICATION NAME] solution (antibiotic) 0.3% one drop in both eyes two times a day for a [DIAGNOSES REDACTED]. Review of the current care plan revealed a vision problem related to [MEDICAL CONDITION] with an approach to administer [MEDICATION NAME] per orders. Review of the Medication Administration Record [REDACTED]. Review of an order listing report dated (MONTH) 20, (YEAR), revealed the [MEDICATION NAME] order for resident #295 was circled and a written note ? Diagnosis (Dx) was added. During an interview conducted with the Assistant Director of Nursing/infection preventionist (ADON/staff #15) on (MONTH) 21, (YEAR) at 12:29 p.m., she stated that every morning she prints a report containing antibiotic orders for the previous 24 hours. She stated that a stop date is required on all antibiotics except those that are being administered [MEDICATION NAME]. She also stated that she would make sure that the antibiotic had the correct diagnosis. An interview was conducted with the Director of Nursing (DON/staff #49) on (MONTH) 23, (YEAR) at 8:24 a.m. The DON stated that she would expect the nursing staff to follow the facility's policy and protocol regarding antibiotic use. She stated that she would have expected the infection preventionist to have identified the resident had an antibiotic order dated (MONTH) 4, (YEAR) before (MONTH) 20, (YEAR). The DON also stated that the order should have been clarified. Another interview was conducted with the ADON/infection preventionist on (MONTH) 23, (YEAR) at 9:01 a.m. She stated that she should have checked for the [DIAGNOSES REDACTED]. She further stated that an antibiotic administered without an appropriate [DIAGNOSES REDACTED]. An interview was conducted with a Registered Nurse (RN/staff #29) and a Licensed Practical Nurse (LPN/staff #32) on (MONTH) 23, (YEAR) at 10:48 a.m. They stated that if a resident was admitted with an antibiotic order for a non-infection diagnosis; they would need to notify the physician to clarify the order. Review of the facility's policy regarding the antibiotic stewardship program revealed that overuse and misuse of antibiotics includes the use of antibiotics when not needed and continued treatment when no longer necessary. The policy included the goal is to optimize treatment of [REDACTED]. The policy also included that each order is to contain a stop order.",2020-09-01
5,THE TERRACES OF PHOENIX,35003,7550 NORTH 16TH STREET,PHOENIX,AZ,85020,2018-08-24,814,E,0,1,D0BP11,"Based on observations, staff interviews, and policy and procedure, the facility failed to ensure that refuse/garbage was disposed of properly. Findings include: An observation of the facility's main kitchen conducted at 8:10 a.m. on 8/20/18 revealed that when first entering the kitchen, a refuse/garbage-like odor was noted. The outside facility's refuse/garbage receptacles were observed next to the main kitchen that included a large refuse/garbage compacter and a dumpster. The odor was stronger near the compacter. There was liquid and some sort of sludge substance build up on the ground around the compacter. Also on the ground around the compacter was debris including a yogurt container and other packaging. There were two bags of refuse/garbage on the ground; one was leaking an unknown substance. The dumpster that was next to the compacter had bags of refuse/garbage in it and the lids were open. An observation of the skilled nursing portion of the facility conducted at 8:30 a.m. on 8/20/18 revealed a dumpster with an open lid. During an interview conducted with the clinical nutrition manager (staff #113) at 8:35 a.m. on 8/21/18, she stated that the food used at the skilled nursing center is prepared at the main kitchen and then sent over to the center. She stated the compacter is used for all refuse/garbage at the main kitchen and that the skilled nursing center is the only one that uses the smaller dumpster. An observation of the facility's main kitchen conducted at 10:40 a.m. on 8/21/18, revealed the dumpster next to the compacter had refuse/garbage in it and the lids were open. The dumpster was so close to the compacter, that the lids could not be closed without moving the entire dumpster. The area around the compacter had been cleaned, but some build up remained. The odor was somewhat diminished, but was still present in both the areas of the compacter and the kitchen. An observation of the skilled nursing facility's dumpster conducted at 11:00 a.m. on 8/21/18, revealed the dumpster was full of refuse/garbage and one lid was fully open. The other lid was not able to be closed all the way because the dumpster was overfilled. An interview was conducted with the director of dining services (staff #114) at 11:10 a.m. on 8/21/18. He stated that he did not know why there were refuse/garbage bags on the ground on 8/20/18. He stated that the dumpster next to the compacter is used by housekeeping and that the lids should be down. Staff #114 also stated that dietary only uses the compacter and not the dumpster. During an interview conducted with the clinical nutrition manager (staff #113) at 11:20 a.m. on 8/21/18, she stated that the lids on the dumpsters should be closed. She stated that she did not know when the refuse/garbage is collected. The administrator (staff #59) was interviewed at 11:30 a.m. on 8/21/18. He stated that the refuse/garbage should be collected two times per day at the skilled nursing center and that the refuse/garbage is collected at the main kitchen when a sensor in the compacter communicates with the refuse/garbage disposal service that it is full. The facility's refuse disposal policy and procedure revealed all waste, garbage, glass, tin cans, paper, etc. generated within the entire community shall be disposed of in a sanitary manner. The procedure included that all refuse containers are leak-proof, adequate in number and size, emptied frequently, and covered with tight-fitting lids.",2020-09-01
6,THE TERRACES OF PHOENIX,35003,7550 NORTH 16TH STREET,PHOENIX,AZ,85020,2019-10-17,578,D,0,1,EJUZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure 1 of 15 sampled residents (#35) code status was consistent in the clinical record. The deficient practice could result in residents receiving services which are not in accordance with their wishes. Findings include: Resident #35 was admitted to the facility on (MONTH) 28, 2019, with [DIAGNOSES REDACTED]. Review of a nursing health status note dated (MONTH) 28, 2019 revealed the power of attorney (POA) for the resident would be signing the admission paperwork the next day. The note included the resident was willing to sign the paperwork but was unable to. A physician's orders [REDACTED]. Review of the care plan regarding advance directive initiated (MONTH) 28, 2019 revealed the resident and the resident family stated preference is that in the event cardiac function stops initiate CPR. The goal was that the resident preference will be honored in the event of a cardiac emergency. An intervention included that in the absence of breathing and pulse to call 911 and begin CPR. The admission Minimum Data Set (MDS) assessment dated (MONTH) 30, 2019 revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident had intact cognition. However, a Statement of Treatment Preferences signed (MONTH) 8, 2019 by the POA and the facility representative revealed a request that while a resident at the facility the resident will be designated a do not resuscitate (DNR). Per the form, it is understood this means no cardiopulmonary resuscitation will be employed in the plan of treatment, if necessary. A Pre-Hospital Medical Care Directive dated and signed (MONTH) 8, 2019 by the POA, Licensed Health Care Provider, and a witness revealed that in the event of cardiac or respiratory arrest, the resident refuses any resuscitation measures including cardiac compression, endotracheal intubation and other advanced airway management, artificial ventilation, defibrillation, administration or advanced cardiac life support drugs and related emergency medical procedures. Further review of the clinical record revealed no evidence the physician order [REDACTED]. During an interview conducted with the resident on (MONTH) 15, 2019 at 8:49 a.m., the resident stated that he did not want CPR. In an interview conducted on (MONTH) 16, 2019 at 12:13 p.m. with a registered nurse (RN/staff #49), she stated advance directives are completed upon admission. She stated that if the resident is a full code, the nurses will fill out the advance directive form with the resident and make sure that the electronic clinical record reflects the goals stated on the form. She further stated that if the resident's code status is DNR, the nurse will explain the DNR status before the resident, nurse and a witness signs the form. The RN stated that the physician will be notified that the resident is a DNR and will complete the pre-hospital medical care directive form with the resident. She stated the nurse that completes the form is expected to update the advance directives in the electronic clinical record. The RN stated that the day shift will usually tell the supervisor who will update the care plan, but the other shifts will update the care plan themselves. She states that this resident's code status was a mistake because the paper clinical record should be the same as the electronic clinical record, and that this could be a problem as most nurses would check the electronic clinical record and not the paper clinical record. An interview was conducted with the Director of Nursing (DON/staff #4) on (MONTH) 16, 2019 at 12:38 p.m. The DON stated that whoever put the DNR status in the paper clinical chart would be expected to change the status in the electronic clinical record as well. The DON stated that she remembers the resident's POA made this change and that it should have been updated in the electronic clinical record. Review of the facility's policy for Advance Directives revised (MONTH) (YEAR), revealed advance directives will be respected in accordance with state law and facility policy. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. The Care Plan Team should be informed of changes or revocations of a directive so appropriate changes can be made in the care plan. The DON or designee will notify the physician so that appropriate orders can be documented in the clinical record. The policy also revealed that if the resident or the resident representative refuses treatment, the facility and care providers will modify the care plan as appropriate.",2020-09-01
7,THE TERRACES OF PHOENIX,35003,7550 NORTH 16TH STREET,PHOENIX,AZ,85020,2019-10-17,641,D,0,1,EJUZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, resident and staff interviews, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the Minimum Data Set (MDS) assessment for one resident (#13) was accurate regarding restraints. The deficient practice could result in inaccuracies within the resident's clinical record. The census was 53 residents. Findings include: Resident #13 was admitted to the facility on (MONTH) 31, (YEAR), with [DIAGNOSES REDACTED]. A side rail usage assessment dated (MONTH) 15, 2019 revealed the resident required the assistance of one person to enter or exit the bed and was able to move and change positions in bed without assistance. The assessment included the resident preferred to have the rails in place and was able to enter and exit the bed on her own with the rails in use. A physician's orders [REDACTED]. Review of the care plan initiated (MONTH) 7, 2019 for quarter side rails as a therapeutic device to support mobility and independence revealed the goal was to enhance functional independence and promote skin integrity through the use of the right quarter rail for positioning and turning while in bed. Interventions included the resident uses the right side rail to assist with transfers. However, the quarterly MDS assessment dated (MONTH) 9, 2019 revealed resident #13 was coded as having bed rails used daily as a physical restraint. During an observation conducted of resident #13's room on (MONTH) 15, 2019 at 8:51 a.m., quarter rails was observed attached to each side of the resident's bed. An interview was conducted with resident #13 on (MONTH) 15 at 1:40 p.m. The resident stated she likes having the bed rails and that she uses them to help her get in and out of bed. She stated she does not use them all of the time, and the rails do not prevent her from getting out of bed. Resident #13 stated she is able to transfer from her wheelchair to the bed without assistance, and she is able to walk around her room without assistance. An interview was conducted with the MDS coordinator (staff #92) on (MONTH) 17, 2019 at 9:15 a.m. Staff #92 stated resident #13 uses the bed rails to assist her with getting in and out of bed. Staff #92 stated the resident has had the bed rails for a long time, and the resident feels safer with the bed rails up. Staff #92 stated she has checked the RAI manual guidelines and believes any use of bed rails qualifies as a restraint and must be coded as such on the MDS assessment. Staff #92 stated anyone in the facility with bed rails will have a restraint coded on their MDS assessment since the resident is not able to remove the bed rail in case of an emergency. She also stated the bed rail is not used as a restraint, but for mobility assistance. Another interview was conducted with the MDS coordinator (staff #92) on (MONTH) 17, 2019 at 10:45 a.m. Staff #92 stated that after checking with other staff, she has modified the resident's MDS assessment to remove the restraint. Staff #92 stated she was informed that since the bed rails do not restrict the resident's movement or ability to get in and out of bed, they are not classified as a restraint. An interview was conducted with the Director of Nursing (DON/staff #4) on (MONTH) 17 at 10:57 a.m. The DON stated the facility is restraint free and no resident should have a restraint coded on their MDS assessment. The DON stated that the bed rail does not restrict the resident's movement, and the resident is still able to get in and out of bed without assistance with the bed rails in place. Review of the RAI manual revealed physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. The manual also revealed the assessors will evaluate whether or not a device meets the definition of a physical restraint and code only the devices that meet the definition; remember the decision about coding a restraint depends on the effect it has on the resident. The RAI manual included that it is required that the assessment accurately reflects the resident's status and that the importance of accuracy completing and submitting the MDS assessment cannot be overemphasized.",2020-09-01
8,THE TERRACES OF PHOENIX,35003,7550 NORTH 16TH STREET,PHOENIX,AZ,85020,2019-10-17,657,D,0,1,EJUZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure the nutrition care plan was revised for one resident (#19). The deficient practice could result in inaccuracies regarding resident care. Findings include: Resident #19 was admitted on [DATE] with a [DIAGNOSES REDACTED]. A review of the nutrition care plan initiated 12/12/2016 revealed a goal that the resident will maintain adequate nutritional status. Interventions included providing and serving diet as ordered, providing set-up and assistance with meals in the dining room as needed/accepted. Review of the summary of physician orders [REDACTED]. However, further review of the care plan did not reveal the care plan was revised to include the order for the resident to receive 1:1 assistance with her meals. An interview was conducted with a Certified Nursing Assistant (CNA/staff #20) on 10/16/19 at 10:39 AM. She stated the resident makes up her own mind on where and how she wants to eat her meals. She stated the resident will either eat in the dining room or in her room. The CNA stated the resident will not eat sometimes unless staff leaves the room. During an interview conducted with a Licensed Practical Nurse (LPN/staff #61) on 10/16/19 at 12:44 PM., she stated staff follows the care plan for the residents' nutritional needs. The LPN stated that staff will pop in to see the resident every 15-20 minutes to ensure she is eating. During an interview conducted with the Director of Nursing (DON/staff #4) on 10/16/19 at 12:54 PM., the DON stated that the care plan should include the physician order [REDACTED]. She stated the care plans are updated by the nursing supervisor and nursing staff as new orders are written. The DON stated care plans are reviewed weekly and corrected as needed for a change in the resident's condition or if new orders are obtained. She stated she was not aware there was an order for [REDACTED]. An interview was conducted with the Dietary Manager (staff #125) on 10/16/19 at 01:18 PM. She stated she was not aware the resident had an order for [REDACTED].>The facility policy titled Care Planning with an effective date of 11/28/2016 revealed care plan for residents is a critical job function for licensed nurses when new orders are received. The policy also revealed physician orders [REDACTED].",2020-09-01
9,THE TERRACES OF PHOENIX,35003,7550 NORTH 16TH STREET,PHOENIX,AZ,85020,2019-10-17,658,E,0,1,EJUZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, staff interviews, and policy review, the facility failed to ensure services provided met professional standards of quality by failing to follow physician orders [REDACTED].#19). The deficient practice could result in adverse clinical outcomes. Findings include: Resident #19 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of the current care plan revised 9/4/18 revealed the resident had a potential nutritional problem related to decreased cognition as evidenced by variable meal intake around 50% and the need for assistance/coaching. The goal was for the resident to maintain adequate nutritional status. Interventions included providing set-up and assistance with meals in the dining room as needed/accepted and monitoring, documenting, and notifying the physician as needed for refusals to eat and concerns during meals. Review of the percentage of meals eaten revealed the following for (MONTH) and (MONTH) 2019: For July, 36 meals the resident consumed was 50% or less. For August, 39 meals the resident consumed was 50% or less. The quarterly admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident cognitive skills were moderately impaired for daily decision making and the resident required supervision for eating. A quarterly nutrition review dated 8/30/2019 revealed the resident had decreased her consumption of solid food to 26-50% but was not a risk for unintended weight loss. Review of the summary of physician orders [REDACTED]. The percentage of meals eaten for (MONTH) and (MONTH) 2019 revealed the following: For September, 32 meals the resident consumed was 50% or less. For (MONTH) 1-16, 20 meals the resident consumed was 50% or less. Further review of the clinical record revealed no documentation that 1:1 assistance was provided to the resident as ordered or that the care plan included this order. An observation was conducted of the resident on 10/15/19 at 09:38 AM. The resident's breakfast was sitting in front of her on a bedside table. The breakfast was a full size waffle, fries and bacon. The resident was not observed to attempt to eat the food in front of her and no staff were observed in the resident's room. During a lunch observation conducted on 10/15/19 at 12:53 PM, a Certified Nursing Assistant (CNA) was observed to deliver the resident's tray, raise the head of the bed, set up the tray, and leave the room. An observation was conducted of the resident in the north dining room on 10/16/19 at 12:10 PM. She was sitting at a table with three other residents and a CNA was sitting across from the resident assisting two other residents. The resident was observed drinking out of a cup without assistance. The resident was observed unable to grasp the spoon on the table to eat the bowl of food in front of her. The resident was unable to eat until staff assisted her. An attempt was made to interview the resident however; the resident was unable to answer questions. The resident would say one word and make facial expressions. In interview conducted with a CNA (staff #20) on 10/16/19 at 10:39 AM., she stated the resident makes up her own mind about where and when she eats. The CNA stated that when the resident eats her meals in her room sometimes she eats by herself because if staff stays in the room, the resident will not eat. She stated that they will leave the resident alone to eat and will check back on her. The CNA stated that if they notice the resident needs help, they will help her. An interview was conducted with a Licensed Practical Nurse (LPN/staff #61) on 10/16/19 at 12:44 PM. She stated that if the staff is concerned with the resident's meal intake, they can obtain an order for [REDACTED].#61 stated staff will leave the resident alone when she eat her meals in her room but will pop in to check on her every 15-20 minutes. She stated they follow the care plan for the resident's nutritional needs. She also stated the resident is weighed monthly now because she is not a high risk for weight loss. During an interview conducted with the Director of Nursing (DON/staff #4) on 10/16/19 at 12:54 PM., she stated that if a resident is not eating more than 50% of their meals, she expects the CNA to report it to the nurse so the Interdisciplinary Team (IDT) team can address it in the morning meeting. She stated the staff should also address the lack of intake with the resident and offer other options. The DON stated that when a resident is a high risk for weight loss they are weighed weekly. She stated this resident is not at high risk and is weighed monthly. She stated she was not aware there was an order for [REDACTED]. In an interview conducted with the Dietary Manager (staff #125) on 10/16/19 at 01:18 PM., she stated this resident is not at risk for weight loss based on the resident's intake per meal, Body Mass Index (BMI), lab work, and the quarterly/annual reviews. She stated she was not aware the resident had an order for [REDACTED].>The facility's policy titled Clinical Nutrition Services: Nutrition Assessment and Monitoring revised 8/2019 revealed the individualize plan of care will be written and reviewed regularly when changes are noted. The plan of care will be shared with and agreed upon by the resident and/or representative. The nutrition assessment will include data from staff members including meal intake and appetite. Interval assessments will be completed for nutritional concerns such as poor intake of food/fluid and refusal to eat.",2020-09-01
10,THE TERRACES OF PHOENIX,35003,7550 NORTH 16TH STREET,PHOENIX,AZ,85020,2019-10-17,695,D,0,1,EJUZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, resident and staff interviews, and policy review, the facility failed to ensure oxygen tubing for one sampled resident (#8) was changed as ordered and stored consistent with professional standards of practice. The deficient practice could result in respiratory complications and infection. Findings include: Resident #8 was admitted to the facility on (MONTH) 7, (YEAR), with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The Treatment Administration Record (TAR) for (MONTH) 2019 revealed the oxygen tubing was changed on (MONTH) 6 and again on (MONTH) 13. During an observation conducted of the resident's room on (MONTH) 15, 2019 at 9:56 a.m., the resident was not observed using oxygen. The oxygen concentrator was on and in the bathroom shower. The tubing was connected to the concentrator and part of the tubing was lying on the floor of the shower. Another part of the tubing was looped around the grab bars next to the toilet. The tubing extended out of the bathroom, into the resident's room and was wrapped around the table next to the resident who was sitting in a chair. The tubing on the concentrator had a label with the date (MONTH) 12 on it. The nasal cannula had a separate label that had the date (MONTH) 5 on it. An interview was conducted with the resident immediately following this observation. The resident stated the oxygen concentrator was moved into the shower that morning to make room for staff to clean up an accident and that no one noticed the concentrator needed to be moved back into her room. Resident #8 stated that she does not know when the staff changes the oxygen tubing. Another observation was conducted of the resident's room was on (MONTH) 16, 2019 at 1:25 p.m. The oxygen concentrator was observed in the bathroom, but was no longer in the shower. Part of the tubing from the concentrator was wrapped around the grab bars next to the resident's toilet, and part of it was coming out of the bathroom and lying on the floor next to the resident's bed. The label on the tubing was dated (MONTH) 12. The tubing for the nasal cannula was on the table next to the resident's bed, and the label was dated (MONTH) 5. An observation was conducted of resident #8's room on (MONTH) 17 at 10:20 a.m. The oxygen concentrator was observed in the resident's bathroom. The tubing was wrapped around the grab bars behind and next to the toilet, coming out of the bathroom and lying on the table next to the resident's bed. The label on the concentrator tubing contained the date 12. The label on the nasal cannula tubing contained the date (MONTH) 19. An interview was conducted with a Registered Nurse supervisor (RN/staff #102) on (MONTH) 16, 2019 at 2:59 p.m. The RN stated the night shift staff changes the oxygen tubing for all residents who have that order. Staff #102 stated the tubing should be changed at least weekly, and should be done on schedule. She stated once the tubing has been changed and labeled it will documented on the TAR. The RN stated that the night nurse may have missed changing resident #8's oxygen tubing. She also stated that it should not have been documented as done on the TAR if it was not done. The RN stated that the date on the labels is the date the tubing is supposed to be changed. The supervisor stated that she did not want to observe the tubing at this time, and that she would ask the night nurse what happened when she reported for work. An interview was conducted with the Director of Nursing (DON/staff #4) on (MONTH) 17, 2019 at 10:38 a.m. The DON stated all oxygen tubing should be changed weekly and as ordered. She also stated the labels on the tubing should be updated when the tubing is changed, and documentation on the TAR should reflect the task was done. She stated it was brought to her attention yesterday that resident #8's oxygen tubing had not been changed as ordered. She stated the tubing was changed last night (October 16, 2019). The DON stated she did not know why it was documented on the TAR that the oxygen tubing was changed when the labels on the tubing did not reflect it was changed. She stated that the date on the tubing should be the date the tubing was last changed. During an interview conducted with a Certified Nursing Assistant (CNA/staff #68) on (MONTH) 17, 2019 at 12:58 p.m., the CNA stated the oxygen tubing should be kept in a bag in the resident's room when not in use. Another interview was conducted with the DON on (MONTH) 17, 2019 at 1:05 p.m. She stated that all oxygen tubing should be kept in a black antimicrobial bag when not in use. She stated this bag should be stored somewhere near the concentrator. She also said they change the bags every 30 days to prevent infections. The DON stated the tubing should never be stored on the floor. The DON also indicated that she was not aware of how resident #8's oxygen tubing was being stored. The facility's policy and procedure regarding Respiratory Therapy Prevention of Infection revised (MONTH) 2011 revealed the purpose of the procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment among residents and staff. The policy instructs to change the oxygen cannula and tubing every seven days or as needed, and to keep the oxygen cannula and tubing used PRN (as needed) in a plastic bag when not in use.",2020-09-01
11,SANTA ROSA CARE CENTER,35004,1650 NORTH SANTA ROSA AVENUE,TUCSON,AZ,85712,2019-01-25,600,D,1,1,YXH311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff and resident interviews, facility documentation, and a review of the facility's policy and procedures, the facility failed to ensure one resident (#94) was free from abuse from resident (#30) and that resident (#109) was free from abuse from resident (#33). Findings include: -Resident #94 was admitted to the facility on (MONTH) 20, 2013 and readmitted on (MONTH) 12, (YEAR), with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 23, (YEAR) revealed the resident scored a 6 on the Brief Interview for Mental Status (BIMS) indicating the resident had severe cognitive impairment. The assessment included the resident exhibited verbal behavioral symptoms such as threatening and screaming directed toward others A nurse practitioner note dated (MONTH) 7, (YEAR) revealed the resident was awake, alert, and oriented to self with memory loss and confusion and was able to independently propels herself in the wheelchair. A nursing note dated (MONTH) 9, (YEAR) revealed the resident was observed with scratches to her right cheek, back of neck, and right upper arm. A behavioral health team note dated (MONTH) 11, (YEAR) revealed on (MONTH) 9, (YEAR) the resident (#94) was witnessed to have scratches on her right cheek, back of her neck, and the right upper arm. Per the documentation, when the resident was asked about the scratches on her cheek, the resident stated that resident #30 caused the scratches. The documentation included the resident was asked why resident #30 scratched her and that she stated I don't know she (resident #30) just hates me and that they were talking when resident #30 struck her. The documentation included the resident was unable to elaborate more and stared blankly. -Resident #30 was admitted to the facility on (MONTH) 25, (YEAR) with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated (MONTH) 27, (YEAR) revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. The assessment included the resident exhibited verbal behavioral symptoms such as threatening and screaming directed toward others Review of the monthly behavior summary report dated (MONTH) 20, (YEAR) dated (MONTH) 20, (YEAR) revealed the resident was being monitored for physical aggression as evidence by striking out and verbal aggression as evidence by yelling and antagonizing others. Interventions included 1:1 redirection, activities, and to anticipate possible triggers. A nursing note dated (MONTH) 9, (YEAR) at 12:00 p.m. revealed a CNA called the nurse to the patio area and that the nurse noticed resident #94 had multiple scratches to her right cheek, back of neck, and right upper arm. The note included resident #94 stated resident #30 scratched her and that resident #30 stated resident #94 was trying to take her bread. A behavioral health team progress note dated (MONTH) 11, (YEAR) revealed resident #30 was seen for a resident to resident altercation. Per the note, staff reported the resident was experiencing increased aggression and had an altercation. The progress note included that when the resident was asked about the altercation, she stated that she had the altercation with resident #94 because she gets in my way. Review of the facility's documentation dated (MONTH) 13, (YEAR) revealed that on (MONTH) 9, (YEAR) at 12:00 p.m., resident #94 and resident #30 were in the patio when a Certified Nursing Assistant (CNA/staff #14) saw resident #30 hands on resident #94 shoulders. Per the documentation, staff intervened and scratches were noted on resident #94's right shoulder, right cheek, and right biceps area. Review of the behavior and intervention monthly flow record for (MONTH) (YEAR) dated (MONTH) 16, (YEAR) revealed the resident (#30) was being monitored for yelling and striking out. The record included the resident exhibited multiple episodes of yelling out but no episodes of striking out were documented. During an interview conducted on (MONTH) 24, 2019 at 7:54 a.m. with a registered nurse (RN/staff #105), he stated a resident to resident altercation is a form of abuse. The RN stated that at the time of the incident resident #30 was exhibiting more aggression and hallucinations and that she was diagnosed with [REDACTED]. He further stated resident #30 had no prior altercations with other residents. An interview was conducted on (MONTH) 24, 2019 at 10:34 a.m. with a CNA (staff #14). She stated resident to resident altercations are a form of abuse. She stated resident #94 is not aggressive and does not fights with other residents but that she does yell loudly. The CNA stated that during lunch the residents were outside on the patio when she observed resident #30's hands on resident #94's neck. She stated resident #94 was trying to get away from resident #30 and yelled get her off of me. The CNA stated that when she called out to the residents, the residents separated and that she observed scratches on resident #94. She stated she notified the licensed practical nurse (LPN/staff #15). Staff #14 further stated resident #30 and resident #94 were good friends prior to the incident. An interview was conducted on (MONTH) 24, 2019 at 11:05 a.m. with an LPN (staff #15). He stated that he did not recall the altercation between the two residents. During an interview conducted on (MONTH) 24, 2019 at 1:45 p.m. with resident #30, she stated that she did not have an altercation with resident #94. During an interview conducted on (MONTH) 25, 2019 at 9:31 a.m. with resident #94, she stated that she and resident #30 were outside on the patio arguing about money when resident #30 scratched her. She stated that she told resident #30 to get away. An interview was conducted on (MONTH) 25, 2019 at 10:58 a.m. with the Director of Nursing (DON/ staff #99). The DON stated resident #30 was experiencing an acute episode of [MEDICAL CONDITION] related to an infection at the time of the altercation. He stated that to his knowledge resident #30 had no prior incidents of verbal or physician aggression toward other residents. The DON stated that it was not witnessed how the altercation occurred, but that it was witnessed that resident #30 had her hands on resident #94 shoulders and resident #94 had scratches afterward. He stated the incident was identified as a behavioral occurrence because he was unable to conclude if there was intent or if resident #30 was responding to internal stimuli. He stated when resident #30 was questioned, she ignored him and did not say if she was trying to hurt resident #94. -Resident #109 was admitted to the facility on (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. A review of the admission MDS assessment dated (MONTH) 2, 2019 revealed the resident scored a 14 on the BIMS indicating the resident was cognitively intact. -Resident #33 was readmitted to the facility on (MONTH) 21, (YEAR), with [DIAGNOSES REDACTED]. A review of the quarterly MDS (Minimum Data Set) assessment dated (MONTH) 3, (YEAR) revealed the resident scored a 13 on the Brief Interview for Mental Status (BIMS) indicating that the resident was cognitively intact. A behavior Care Plan revised on (MONTH) 15, (YEAR) revealed the resident had chronic combative and disruptive behavior and had the potential for violence toward himself and others. Interventions included assessing and monitoring the resident's agitation and combativeness which included hitting, pinching, kicking etc. and removing the resident from situations when he was combative. Review of the facility's investigative documentation dated (MONTH) 2, 2019 revealed that on (MONTH) 29, (YEAR) at 6:45 a.m., resident #33 was using the adjoining bathroom to his room, which is shared with resident #109. The toilet was clogged and resident #109 opened the bathroom door to tell resident #33 that the toilet was clogged and asked him not to flush the toilet. Resident #33 then pushed the bathroom door open and jumped on resident #109. The documentation included resident #33 choked resident #109 leaving red marks on his neck and scratched his right cheek. Resident #33 was not injured. When staff heard yelling, they responded and pulled the residents apart. The documentation included resident #33 agreed to move to another room further away from resident #109. On (MONTH) 23, 2019 at 1:40 p.m., an interview was conducted with resident #109 who stated that on the day resident #33 attacked him; the toilet in the bathroom located between their adjoining rooms was clogged. He stated resident #33 entered the bathroom from his room to use the toilet and that he barely opened the bathroom door from his room to asked resident #33 not to flush the toilet because the toilet was clogged. He said that resident #33 then pushed the door open and jumped on him. He said he fell and hit his head on the floor and resident #33 scratched the right side of his face and put both of his hands around his neck. He stated that he did not hit resident #33, but he did grab his head with both hands and tried to push him off of him. Resident #109 stated that resident #33 jumped on him twice. He stated staff came quickly to help him and were trying to pull resident #33 off of him. He said the police came and asked him if he wanted to press charges and he said, Yes, but that he has not heard anything. During an interview conducted on (MONTH) 24, 2019 at 8:49 a.m. with a CNA (staff #81), the CNA stated that there is always a CNA monitoring the hallway and completing room checks every 15 minutes. He stated that he has not seen resident #33 strike anyone because as soon as resident #33 begins raising his voice he intervenes before the resident becomes physically aggressive. An interview was conducted on (MONTH) 24, 2019 at 9:10 a.m. with a Licensed Practical Nurse (LPN/staff #90) who stated that resident #33 is very vocal when he is upset and that she knows to redirect him when he is upset and/or yelling before his behavior can escalate to physical aggression. The LPN stated that she will try to redirect him to the hallway area when he is upset, so that he can be monitored more closely. She said that resident #33 is checked on every 15 minutes. The LPN stated that the residents were educated to lock the bathroom door when they are in the bathroom. She also stated that when the bathroom door is locked, residents are to ask staff for assistance if they need to use the bathroom. Review of the facility's abuse policy revealed the facility is committed to protecting residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, and staff from other agencies. The facility's abuse prevention program policy revealed residents have the right to be free from abuse, neglect, and exploitation and that the facility is committed to protecting residents from abuse by anyone including other residents.",2020-09-01
12,SANTA ROSA CARE CENTER,35004,1650 NORTH SANTA ROSA AVENUE,TUCSON,AZ,85712,2019-01-25,607,D,1,1,YXH311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews, facility documentation, and policy review, the facility failed to implement their abuse policy regarding reporting an allegation of abuse involving two residents (#94 and #30). Findings include: -Resident #94 was admitted to the facility on (MONTH) 20, 2013 and readmitted on e (MONTH) 12, (YEAR), with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 23, (YEAR) revealed the resident scored a 6 on the Brief Interview for Mental Status (BIMS) indicating the resident had severe cognitive impairment. -Resident #30 was admitted to the facility on (MONTH) 25, (YEAR) with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 27, (YEAR) revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. Review of facility documentation dated (MONTH) 13, (YEAR) revealed that on (MONTH) 9, (YEAR) at 12 p.m. resident #94 and resident #30 were outside on the patio when a staff member (#14) observed resident #30's hands on resident #94's shoulders. Per the documentation, staff intervened and scratches were noted on resident #94's right shoulder, right cheek, and right biceps area. The documentation included that this incident was reported to the State Agency on (MONTH) 9, (YEAR) at 8:30 p.m. An interview was conducted on (MONTH) 24, 2019 at 7:54 a.m. with a registered nurse (RN/staff #105). He stated a resident to resident altercation is a form of abuse. The RN stated that for a resident to resident altercation the abuse is reported right away to all managers, Adult Protective Services, the State Agency, and the police within 2 hours. During an interview conducted on (MONTH) 25, 2019 at 9:09 a.m. with the Social Services Director (staff #26), she stated an allegation of abuse is to be reported within two hours to the State Agency. An interview was conducted on (MONTH) 25, 2019 at 10:58 a.m. with the Director of Nursing (DON/ staff #99). He stated staff are expected to immediately intervene if abuse is witnessed. He stated the abuse is then reported to the DON and administrator. The DON stated the State Agency is notified as soon as possible once a allegation of abuse has been reported. He stated that the incident between the resident #94 and resident #30 occurred at 12 p.m. and that he notified the State Agency at 8:30 p.m. The facility's policy regarding reporting allegations of resident abuse revealed the administrator must report incidents or allegations of abuse to the State Agency immediately in accordance with State and Federal regulations/statues.",2020-09-01
13,SANTA ROSA CARE CENTER,35004,1650 NORTH SANTA ROSA AVENUE,TUCSON,AZ,85712,2019-01-25,609,D,1,1,YXH311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews, facility documentation, and policy review, the facility failed to ensure an allegation of abuse involving two residents (#94 and #30) was reported to the State Agency within two hours. Findings include: -Resident #94 was admitted to the facility on (MONTH) 20, 2013 and readmitted on e (MONTH) 12, (YEAR), with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 23, (YEAR) revealed the resident scored a 6 on the Brief Interview for Mental Status (BIMS) indicating the resident had severe cognitive impairment. -Resident #30 was admitted to the facility on (MONTH) 25, (YEAR) with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 27, (YEAR) revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS) indicating the resident is cognitively intact. Review of facility documentation dated (MONTH) 13, (YEAR) revealed on (MONTH) 9, (YEAR) at 12 p.m. resident #94 and resident #30 were outside on the patio when a staff member (#14) observed resident #30's hands on resident #94's shoulders. Per the documentation, staff intervened and scratches were noted on resident #94's right shoulder, right cheek, and right biceps area. The documentation included that this incident was reported to the State Agency on (MONTH) 9, (YEAR) at 8:30 p.m. An interview was conducted on (MONTH) 24, 2019 at 7:54 a.m. with a registered nurse (RN/staff #105). He stated a resident to resident altercation is a form of abuse. The RN stated that for a resident to resident altercation the abuse is reported right away to all managers, Adult Protective Services, the State Agency, and the police within 2 hours. During an interview conducted on (MONTH) 25, 2019 at 9:09 a.m. with the Social Services Director (staff #26), she stated an allegation of abuse is to be reported within two hours to the State Agency. An interview was conducted on (MONTH) 25, 2019 at 10:58 a.m. with the Director of Nursing (DON/ staff #99). He stated staff are expected to immediately intervene if abuse is witnessed. He stated the abuse is then reported to the DON and administrator. The DON stated the State Agency is notified as soon as possible once a allegation of abuse has been reported. He stated that the incident between the resident #94 and resident #30 occurred at 12 p.m. and that he notified the State Agency at 8:30 p.m. The facility's policy regarding reporting allegations of resident abuse revealed the administrator must report incidents or allegations of abuse to the State Agency immediately in accordance with State and Federal regulations/statues.",2020-09-01
14,SANTA ROSA CARE CENTER,35004,1650 NORTH SANTA ROSA AVENUE,TUCSON,AZ,85712,2019-01-25,655,D,0,1,YXH311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and resident and staff interviews, the facility failed to ensure a summary of the baseline care plan was provided to one resident (#63). Findings include: Resident #63 was admitted to the facility on (MONTH) 28, (YEAR) with [DIAGNOSES REDACTED]. Review of the clinical record revealed a form titled Baseline Care Plan Summary, this form included the resident's goals during his admission, medication orders, and diet orders. This form included a space for the resident to sign. However, there was no resident signature documented. Further review of the clinical record revealed no evidence the resident was provided with a summary of his baseline care plan. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 5, (YEAR) revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was cognitively intact. During an interview conducted on (MONTH) 22, 2019 at 12:28 p.m. with the resident, he stated that the staff do not include him in his care. An interview was conducted on (MONTH) 25, 2019 at 10:04 a.m. with a unit coordinator/ registered nurse (RN/ staff #40). She stated baseline care plans are developed within two days after admission and include resident diagnoses, activities of daily living needs, and dietary status. She stated baseline care plans and goals are reviewed with the resident and a copy is offered to the resident. The RN stated that the resident will sign on the baseline care plan summary that a copy of the baseline care plan was provided to them. After reviewing the clinical record, she stated the baseline care plan summary for resident #63 was not signed but that she reviewed the care plan with the resident. An interview was conducted on (MONTH) 25, 2019 at 10:58 a.m. with the Director of Nursing (DON/ staff #99). He stated baseline care plans are developed within 48 hours after admission. He stated the baseline care plan includes medications, high risk concerns, and activities of daily living. The DON stated a final summary of the baseline care plan is given to the resident or the resident's representative. He stated on the baseline care plan summary form the resident will sign indicating the resident received or refused a copy of the baseline care plan. He stated that it is the facility's expectation that a copy of the baseline care plan is given to the resident or the resident's representative. The DON also stated that the facility does not have a policy for baseline care plans.",2020-09-01
15,SANTA ROSA CARE CENTER,35004,1650 NORTH SANTA ROSA AVENUE,TUCSON,AZ,85712,2016-09-14,253,E,0,1,MTU811,"Based on observations, resident and staff interviews and facility documentation, the facility failed to provide housekeeping and maintenance services necessary to maintain a comfortable interior for residents, and failed to ensure odor levels were acceptable throughout the facility. Findings include: -An environmental tour was conducted on (MONTH) 14, (YEAR) at 1:00 p.m., with the housekeeping director (staff #23) and the maintenance director (staff #44). Prior to the tour, staff #23 stated that the staffing coordinator does the walk through rounds daily on each of the facility's five units, so that every resident room is inspected weekly for safety issues and broken items. Staff #23 further stated that if repairs need to be made, a work order is completed and given to the maintenance director. At this same time, staff #44 stated that when he receives a work order, he tries to repair the area the same day. The following concerns were observed during the environmental tour: -Room A12: There was an area on the wall near the bathroom door where the wallpaper was peeling. The area was approximately 16 inches long. Also, near the toilet there was an area of cove base which was approximately 18 inch long, which was loose. An interview was conducted with staff #44 who stated that he received a work order last month regarding the wallpaper and that he will have to tear all of the wallpaper off the wall, as he can't glue it back on. He stated that he was not aware of the loose cove base in the bathroom. Review of facility documentation revealed that a Maintenance Work Order for the wallpaper was completed on (MONTH) 29, (YEAR). -Room A8: Under the entire width of the window on the wall, the paint was scraped/gouged. An interview was conducted with staff #44 who stated that it was difficult to repair and paint resident rooms, when the residents are in the rooms. The documentation from the Morning Walk Through Rounds dated (MONTH) 23 and 30, (YEAR) included to paint the window wall. -Room A3: The wallpaper around the nightlight on the wall near the door was observed to be torn. An interview was conducted with staff #44. He stated that he had to cut the wallpaper in order to repair it and that he had a work order regarding this. Review of facility documentation revealed that a Maintenance Work Order for the wallpaper was dated (MONTH) 30, (YEAR). -Room A24: There were several slats which were missing from the window blinds. An interview was conducted with the maintenance director. He stated that he was probably told about this, but probably overlooked it. Review of the Morning Walk Through Rounds documentation dated (MONTH) 29, (YEAR) revealed there was no mention regarding the missing slats. -Room B11: There were multiple screw/nail holes and chipped paint on the wall near the door. An interview was conducted with staff #44 on (MONTH) 16, (YEAR). He stated that he was not aware of how long the wall had been in need of repair. The Morning Walk Through Rounds documentation dated (MONTH) 31, (YEAR) did not include that the wall needed to be repaired. An interview was conducted with the Administrator on (MONTH) 14, (YEAR) at 3:30 p.m. The Administrator stated that the facility did not have a policy on routine maintenance. The Administrator stated that rounds are supposed to be done daily and work orders filled out if repairs need to be made. -During an interview with a resident on the A hall on (MONTH) 13, (YEAR) at 10:50 a.m., the resident stated that the whole facility smelled like dirt and bowel movements. During the survey on (MONTH) 13 and 14, (YEAR), pervasive odors were noted throughout the facility. The odors were noted to be the strongest on the central hallway, on the A hall, and on the La Onieta unit. An environmental tour was conducted on (MONTH) 14, (YEAR) at 1:00 p.m., with the housekeeping director (staff #23) and the maintenance director (staff #44). At this time, strong urine odors were noted in two rooms on the A hall. An interview was conducted with staff #23 on (MONTH) 14, (YEAR) at 1:20 p.m. Staff #23 stated that sometimes the facility has odors when residents are being changed or after an incontinent episode. She said that she ordered new chemicals, which pretty much got rid of the odor problem within the facility. An interview was conducted with the Administrator (staff #8) on (MONTH) 14, (YEAR) at 3:30 p.m., who stated that the facility did not have a policy regarding the prevention of odors, but facility rounds are supposed to be done daily. The Administrator further stated that environmental issues are discussed every morning in the facility's department head meeting.",2020-09-01
16,SANTA ROSA CARE CENTER,35004,1650 NORTH SANTA ROSA AVENUE,TUCSON,AZ,85712,2016-09-14,371,D,0,1,MTU811,"Based on observations, staff interviews and policy and procedures, the facility failed to ensure one staff member (#82) wore a hair net in the kitchen and failed to ensure foods were dated when opened. Findings include: -On (MONTH) 12, (YEAR) at 10:00 a.m., an initial kitchen tour was completed with the dietary manager (staff #82). At this time, the dietary manager was observed not wearing a hairnet. Also during the initial kitchen tour, there was frozen pork in the freezer which was wrapped in plastic. The pork was not dated when opened. There was also a box of pork patties in the freezer which was opened, but not dated. The meat was not wrapped and was exposed to the air. An interview was conducted with staff #82 on (MONTH) 14, (YEAR) at 8:30 a.m. She stated that she knew she was suppose to wear a hairnet in the kitchen. She stated that she knew the opened items should have been dated when opened. An interview was conducted on (MONTH) 14, (YEAR), with the nutrition consultant (staff #146). She stated foods should be dated when opened and prior to being put back in the freezer. At this time, the freezer was inspected and there was a zip lock bag with frozen chicken, and it was not dated when opened. There was also a box of churros which was opened and not dated. The churros were not wrapped and were exposed to the air. Staff #146 stated that those items should have been dated after being opened. Staff #146 also stated that a hair net should be worn at all times in the kitchen. Review of the facility policy titled, Personal Hygiene Training revealed that a hair restraint should be worn when around exposed foods, in the kitchen or food service areas including the dining areas. A policy regarding Food Storage included that all foods will be checked to assure that foods will be consumed by their use by dates or discarded and that Food should be labeled and dated.",2020-09-01
17,SANTA ROSA CARE CENTER,35004,1650 NORTH SANTA ROSA AVENUE,TUCSON,AZ,85712,2016-09-14,441,D,0,1,MTU811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, observations, staff interviews and review of policy and procedures, the facility failed to ensure that proper hand washing techniques were implemented during pressure ulcer treatments for two residents (#34 and #145). Findings include: -Resident #34 was readmitted on (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. A review of the clinical record revealed that on (MONTH) 14, (YEAR), one stage 4 pressure ulcer was still present on the resident's right hip. The (MONTH) (YEAR) recapitulation of physician's orders [REDACTED]. A pressure ulcer treatment observation was conducted on (MONTH) 14, (YEAR) at 9:30 a.m. At this time, the LPN (Licensed Practical Nurse/staff #127) was observed to wash her hands, donn gloves and cleansed the stage 4 pressure ulcer on the resident's right hip. Staff #127 was then observed to remove her gloves and donn another pair of gloves. Staff #127 then applied zinc oxide to the skin surrounding the pressure ulcer and proceeded to pack the pressure ulcer with the alginate and apply the border dressing. However, staff #127 was not observed to disinfect or wash her hands after cleansing the pressure ulcer and removing her gloves, after the application of the zinc oxide to the surrounding skin and prior to packing the pressure ulcer. An interview was conducted on (MONTH) 14, (YEAR) at 11:30 a.m., with staff #127. She stated that her usual practice was to only wash her hands at the beginning and the end of treatment. An interview with the Director of Nursing (DON/staff #109) was conducted immediately following this interview. Staff #109 stated that the LPN should have washed her hands after she cleansed the pressure ulcer and removed her gloves, after she applied the zinc oxide and prior to the application of the alginate and dressing. Staff #109 stated that the purpose of handwashing is for infection control and to not spread any bacteria that may be present. -Resident #145 was admitted to the facility on (MONTH) 12, (YEAR), with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Review of the clinical record revealed documentation that as of (MONTH) 14, (YEAR), two stage 4 pressure ulcers were still present on the right and left ischium. A pressure ulcer treatment observation was conducted on (MONTH) 14, (YEAR) at 10:13 a.m., with a LPN (staff #127). The LPN was observed to wash her hands, donn gloves, and then removed the soiled dressing from the resident's left ischium pressure ulcer. Staff #127 did not remove her gloves or wash her hands, after removing the soiled dressing. Using the same gloved hands, she cleansed the pressure ulcer with puracyn and packed it with calcium alginate. Staff #127 then removed her gloves, however; she was not observed to wash her hands or use a disinfectant. She then proceeded to donn clean gloves, removed the soiled dressing from the resident's right ischium pressure ulcer, cleansed it with puracyn, and packed the wound with the calcium alginate. She was not observed to change her gloves, wash her hands or use a disinfectant, after removing the soiled dressing from the resident's right ischium pressure ulcer. An interview was conducted with staff #127 on (MONTH) 14, (YEAR) at 11:44 a.m. She stated she should have washed her hands, after the removal of the soiled dressings and before she started the treatment. She also stated that handwashing should have been done between the treatments of the two pressure ulcers. An interview was conducted with the the DON (staff #109) on (MONTH) 14, (YEAR) at 11:50 a.m. He stated that handwashing was required between the removal of soiled dressings and before treatment was provided. He also stated that good handwashing needed to be done between the treatments of the pressure ulcers to aid in preventing infection. A facility policy titled, Handwashing/Hand Hygiene included the following: Objective-to prevent and control the spread of infectious disease. The policy also included the following: 3. The use of gloves does not replace handwashing. 4. If hands are not visibly soiled, use an alcohol based hand rub for all of the following: e. Before handling clean or soiled dressings, gauze pads, etc.; f. Before moving from a contaminated body site to a clean body site during resident care; h. After handling used dressings, contaminated equipment, etc.; j. After removing gloves. Another facility policy titled, treatment of [REDACTED]. Wash your hands thoroughly with soap and water at the following intervals: d. When changing/removing gloves or any personal protective equipment.",2020-09-01
18,SANTA ROSA CARE CENTER,35004,1650 NORTH SANTA ROSA AVENUE,TUCSON,AZ,85712,2016-09-14,469,D,0,1,MTU811,"Based on observation and staff interviews, the facility failed to ensure that flies were not present in the residents' dining room. Findings include: An observation of the lunch meal was conducted on (MONTH) 12, (YEAR) at 11:45 a.m., on the La Oneita nursing unit. During this observation, two fly/bug lights were observed on the wall in the dining room and an air blower was positioned above the outside door leading into the dining room. A weak air current was felt at the top of the door frame. Further observations revealed there were multiple flies on residents, on the dining tables, on the residents' food, on the cups/glasses and on the milk cartons. Residents and staff were also observed swatting at the flies. A resident interview was conducted on (MONTH) 14, (YEAR) at 8:30 a.m. During this interview the resident agreed that there were flies in the dining room and stated, You just get use to it. An interview was conducted on (MONTH) 14, (YEAR) at 8:30 a.m., with a LPN (Licensed Practical Nurse/staff #113). Staff #113 stated that although the staff keep the outside door closed and have the fly/bug lights and the air blower, flies are still present in the dining room. Another interview was conducted on (MONTH) 14, (YEAR) at 8:45 a.m., with maintenance staff (staff #4). Staff #4 stated that the two fly/bug lights in the residents' dining room trap the flies on a sticky paper inside and the paper is changed about every two weeks. He stated that he just had his worker change the sticky paper. At this time, the two used sticky papers were observed sticking out of the open trash can in the dining room. Both sticky papers were covered with dead flies. Staff #4 stated that maybe he should start to change the sticky paper every week, since he was informed by the pest control provider that once the sticky paper had too many flies on it, additional flies will not land on it. Staff #4 also stated that he did not keep a maintenance schedule on the fly/bug lights and therefore, was unable to provide any documentation when the sticky paper was last changed, prior to this date. In regards to the air blower, he stated that he had installed it about four months ago and agreed that the blower did not produce much air current. On (MONTH) 14, (YEAR) at 9:00 a.m., an interview was conducted with the Administrator (staff #8). She stated that she thought the fly problem in the La Oneita dining room had been taken care of. Staff #8 later provided a form titled Fly Trap Changing Schedule, which was suppose to be used by the maintenance department. However, during a follow up interview with staff #4, he stated that he had not been aware of this form.",2020-09-01
19,SANTA ROSA CARE CENTER,35004,1650 NORTH SANTA ROSA AVENUE,TUCSON,AZ,85712,2017-10-05,225,D,0,1,2ZZS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility investigation report review, orientation sheet review, staff interviews, and policy, the facility failed to ensure that a registry certified nursing assistant reported an allegation of verbal abuse in a timely manner. Findings include: Resident #7 was readmitted on (MONTH) 2, (YEAR), with [DIAGNOSES REDACTED]. Review of the Minimum Data Set quarterly assessment dated (MONTH) 24, (YEAR) revealed that the resident was moderately impaired and was totally dependent on staff for activities of daily living. Review of the clinical record revealed a nurse's notes dated (MONTH) 3, (YEAR) regarding an allegation of a staff verbally insulting resident #7. Review of the facility's investigation report revealed an allegation of abuse that occurred (MONTH) 28, (YEAR) on the 3 p.m. to 11 p.m. shift was reported (MONTH) 2, (YEAR) by a registry certified nursing assistant (staff #146). The allegation was that a certified nursing assistant (staff #147) was verbally abusive to resident #7. Staff #147 was yelling and cursing at resident #7. During an interview conducted with a licensed practical nurse (staff #129) (MONTH) 4, (YEAR) at 8:45 a.m., staff #129 stated the staff are to immediately report any incidents to the charge nurse or directly to the Director of Nursing. She also stated that agency staff are to review a book on the unit which contains facility policy. She further stated that when their orientation to the facility is completed they sign a document. An interview was conducted (MONTH) 4, (YEAR) at 9:27 a.m. with the staffing coordinator (staff #141). She stated that all agency staff must complete orientation during their first shift at the facility. She further stated once the orientation is completed, the agency staff signs the orientation sheet which it is kept on file in the staffing office. Review of the orientation sheet revealed the agency certified nursing assistant (staff #146) completed and signed the Orientation of Registry CNA Personnel for abuse training. During an interview conducted with the Director of Nursing (staff #107) on (MONTH) 4, (YEAR) at 9:54 a.m., staff #107 stated the (MONTH) 28, (YEAR) allegation of verbal abuse between staff #147 and resident #7 was reported on (MONTH) 2, (YEAR). The policy Investigation and Reporting of Allegations of Resident Abuse, Neglect, Exploitation, Resident Injuries of Unknown Origin or Misappropriation of Resident Property included that any employee who receives a report or allegation of abuse, neglect, or misappropriation from any source, including the alleged victim, must IMMEDIATELY inform the following: Administrator, Director of Nursing or Assistant Director of Nursing, Director of Social Work, Attending Physician, Adult Protective Services, Resident's guardian, POA and/or emergency contact, Payer Source Case Manager and Ombudsman.",2020-09-01
20,SANTA ROSA CARE CENTER,35004,1650 NORTH SANTA ROSA AVENUE,TUCSON,AZ,85712,2017-10-05,278,E,0,1,2ZZS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure the MDS (Minimum Data Set) assessments were accurate for three residents (#1, #102, and #106). Findings include: -Resident #102 was admitted (MONTH) 17, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed a Preadmission Screening Resident Review (PASRR) level 2 evaluation dated (MONTH) 16, (YEAR) that included the resident had a serious mental illness and required nursing facility level care. However, an admission MDS assessment dated (MONTH) 26, (YEAR), revealed the resident was not considered by the level 2 PASRR process to have a serious mental illness. During an interview with the Social Services Director (staff #57) conducted on (MONTH) 4, (YEAR) at 1:16 p.m., staff #57 stated that a copy of the PASRR level 2 evaluation is placed it in the resident's clinical record. An interview was conducted with the MDS Coordinator (staff #130) on (MONTH) 5, (YEAR) at 2:05 p.m. Staff #130 stated that she reviews information in the resident's clinical record to complete the PASRR section of the MDS. The RAI manual instructs under PASRR level 2 conditions to code for serious mental illness if the resident has been diagnosed with [REDACTED]. -Resident #1 was readmitted (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated (MONTH) 21, (YEAR) revealed the resident had no natural teeth or tooth fragments. Further review revealed the dental Care Area Assessment (CAA) that included the resident was edentulous and on a mechanically altered diet. An observation of the resident was conducted (MONTH) 2, (YEAR) at 1:26 p.m. It was observed that the resident's teeth were in poor condition and that she had many missing teeth, but she had some teeth present. An interview was conducted on (MONTH) 5, (YEAR) at 11:47 a.m. with the MDS Licensed Practical Nurse (LPN/staff #130). She stated that a resident would be marked edentulous when they have no teeth and no tooth fragments, just gum tissue in oral cavity. Staff #130 stated that she coded the MDS based on the monthly summary for dentition done by the nurses on the floor. She stated that she does not personally do an oral assessment. Staff # 130 further stated I could have made a mistake. An interview was conducted on (MONTH) 5, (YEAR) at 12:20 p.m. with the Director of Nurses (DON/staff #107). He stated that his expectation of the MDS assessment is that it would accurately reflect the resident's level of care. The RAI manual for Oral Status instructs to conduct an exam of the resident's oral cavity and to code edentulous if the resident lacks all natural teeth or parts of teeth. -Resident #106 was admitted (MONTH) 24, (YEAR), with [DIAGNOSES REDACTED]. Review of the Weekly Pressure Ulcer Quality Improvement Log dated (MONTH) 25, (YEAR) revealed the resident had a left upper buttock stage 4 and a left lower buttock stage 4 pressure ulcer that were facility acquired with an onset date of (MONTH) 15, (YEAR) and a right buttock stage 4 pressure ulcer which was facility acquired with an onset date of (MONTH) 30, (YEAR). However, review of the quarterly MDS assessment dated (MONTH) 27, (YEAR) revealed three stage 4 pressure ulcers that were present on admission. An interview was conducted on (MONTH) 4, (YEAR) at 12:49 p.m. with MDS LPN/staff #130. She stated the pressure ulcers on the Quarterly MDS assessment dated (MONTH) 27, (YEAR) were marked as present on admission in error. An interview was conducted with the DON/staff #107 on (MONTH) 5, (YEAR) at 12:20 p.m. He stated that the MDS assessments are coded based off the floor nurses documentation and that he expects the MDS assessment to accurately reflect the resident's level of care. The RAI instructs in order to determine Present on Admission for each pressure ulcer, determine if the pressure ulcer was present at the time of admission/entry or reentry and not acquired while the resident was in the care of the nursing home.",2020-09-01
21,SANTA ROSA CARE CENTER,35004,1650 NORTH SANTA ROSA AVENUE,TUCSON,AZ,85712,2017-10-05,281,E,0,1,2ZZS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, interviews, and policy and procedures, the facility failed to ensure that one resident (#121) was provided a medication through a PEG (percutaneous endoscopic Gastrostomy) tube in a safe manner and failed to ensure narcotic medications were signed as administered immediately after administering the medications. Findings include: Resident #121 was readmitted (MONTH) 18, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed a physician's orders [REDACTED]. A Minimum Data Set (MDS) assessment dated (MONTH) 27, (YEAR), revealed the resident was unable to answer questions, the resident had a PEG tube, and the resident was on a mechanically altered diet. A medication administration observation was conducted on (MONTH) 2, (YEAR) at 11:20 a.m. with a licensed practical nurse (staff #70). During the observation, the nurse flushed the PEG tube with 80 cc. of water using a 60 cc syringe prior to administering a medication, mixed a crushed pill with 30 cc of water and pushed it into the tube, and pushed another 80 cc of water into the tube after administering the medication. However, the nurse depressed the plunger on the syringe to push the water and medication into the resident's PEG tube, rather than removing the plunger on the syringe, pouring the water and medication into the syringe, and allowing gravity to allow the water and medication to flow into the PEG tube. During an interview with staff #70 conducted on (MONTH) 2, (YEAR) at 11:25 a.m., the nurse stated that she did not know if she was supposed to use the plunger on the 60 cc syringe to push the flushes and the medication into the PEG tube, or remove the plunger on the syringe and allow gravity to pull the flushes and the medication into the PEG tube. The nurse stated that she had been provided training regarding how to administer medications into a PEG tube, and that she would review the facility's policy. During an interview with staff #70 conducted on (MONTH) 2, (YEAR) at 11:40 a.m., the nurse stated that she had review the policy and that she should have removed the plunger on the syringe and allowed gravity to pull the flushes and the medication into the PEG tube, and not pushed the water and medication into the tube. The policy Enteral Tubes included the statement Allow medication to flow down tube via gravity. -During a review of the controlled substance sheets conducted (MONTH) 4, (YEAR) at 1:03 p.m. with Licensed Practical Nurse (LPN/staff #45), it was observed that 6 narcotic controlled count sheets did not match the 6 narcotic count medication cards. The narcotic count medication card had less than indicated on the narcotic controlled count sheets. Review of the Medication Administration Record (MAR) for these six narcotics revealed 3 had been initialed as having been administered on the MAR and 3 were not. Staff #45 stated he administered the medications and proceeded to sign the narcotic controlled count sheets and the MAR indicating that the medications had been administered. Continued observation with staff #45 revealed another narcotic count medication card had one more narcotic than the narcotic controlled count sheet. Staff #45 stated he signed out the narcotic on the narcotic controlled count sheet by mistake because he usually works the evening shift. An observation was conducted (MONTH) 4, (YEAR) at 1:13 p.m. with staff #45. Review of the narcotic controlled count sheet revealed that a dose of [MEDICATION NAME] extended release 15 milligrams was signed out by staff# 45 at 8 a.m. and that the remaining doses should be 25, however, it was observed that there was 26 doses remaining of the medication. Review of the MAR revealed the medication was initialed as administered. Staff #45 stated I must not have given it. An interview was conducted with staff #45 on (MONTH) 4, (YEAR) immediately following the above observations. He stated that the expectation is that the nurse signed out the medication immediately after the medication is administered. He further stated that as a result of not administrating the scheduled narcotic medication he would need to evaluate the resident for pain, notify his supervisor, and then follow the direction given by the physician. An interview was conducted with the Director of Nurses (DON/staff #107) on (MONTH) 4, (YEAR) at 1:26 p.m. He stated that the expectation is that the nurse is to sign out a medication as soon as it is administered. Staff #107 also stated he expects the nurses to observe the five rights of medication administration which are: the right patient, the right drug, the right dose, the right route, and the right time. He further stated that medication administration is supervised by the Unit Coordinators on each unit to assure compliance with policy. An interview was conducted with the Unit Coordinator (LPN/staff #113) on (MONTH) 5, (YEAR) at 10:39 a.m. He stated that the expectation is that the nurses follow the five rights of medication administration when administering medication. The policy Medication Administration included medications are administered as prescribed, medications are administered within 60 minutes of scheduled time unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center. The individual who administers the medication dose records the administration on the resident's MAR immediately following the medication being given.",2020-09-01
22,SANTA ROSA CARE CENTER,35004,1650 NORTH SANTA ROSA AVENUE,TUCSON,AZ,85712,2017-10-05,323,D,0,1,2ZZS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#33) was free from an accident hazard by not following physician orders. Findings include: Resident #33 was admitted (MONTH) 21, 2008 with [DIAGNOSES REDACTED]. Two physician's orders [REDACTED]. A care plan updated on (MONTH) 30, (YEAR), regarding the resident's risk for injury included the resident had actual and a potential for injury related to sensory deficits, lack of awareness, and limited mobility. Interventions for the care plan included removing hazards from the environment and bed bolsters for the resident to have for safety, comfort, and positioning. An MDS (Minimum Data set) assessment dated (MONTH) 2, (YEAR), revealed the resident's cognitive skills for daily decision making were severely impaired. An observation of the resident was conducted (MONTH) 3, (YEAR) at 8:46 a.m. The resident was lying in bed with one side of the bed against the wall. On the opposite side of the bed, the mattress was observed to have a pillow and a blue wedge underneath it to tilt the mattress toward the wall. The whole length of the mattress was propped up with these items. The resident was non-interviewable at this time. An additional observation was conducted (MONTH) 3, (YEAR) at 11:16 a.m. The resident was observed lying in bed with the observed same items wedged underneath the mattress. An observation of the resident was conducted (MONTH) 4, (YEAR) at 12:17 p.m. The resident was lying in bed with the same items wedged underneath the mattress of the bed. The resident was sleeping at this time. In an interview conducted on (MONTH) 5, (YEAR) at 12:23 p.m. with the unit coordinator (staff #78), she stated the resident had an order for [REDACTED]. An observation was made of the resident with staff #78. The resident was lying in bed with the pillow and wedge under the mattress as in previous observations. Staff #78 stated that is not what is meant by bed bolsters and that she was going to find out if maybe bed bolsters were unavailable for some reason. At 12:31 p.m. the same day, staff #78 stated that the pillows should not have been there and the proper bed bolster would be only one wedge which would be in the middle of the resident's bed. In an interview conducted (MONTH) 5, (YEAR) at 12:35 p.m. with the Director of Nursing (DON/staff #107), he stated when a resident has an order for [REDACTED]. Staff #107 also stated that bolsters are to help with positioning the resident and that the bolsters can be obtained from central supply. During this interview, a staff member was observed carrying a blue triangular wedge with straps into the resident's room. Staff #78 was by the resident's door and stated that was a bed bolster was going to be applied to the resident's bed. Staff #107 stated that his expectation is that no improvisations are to be made with equipment and that staff should have the right equipment to use correctly. A report sheet for this unit was provided, it included that this resident was a fall risk and had bed bolsters. In an interview with the Administrator (staff #9) on (MONTH) 5, (YEAR) at 1:30 p.m., she stated this sheet is used so that staff can be on the same page regarding knowing important information about residents and responsibilities. A policy Follow through of MD Orders included if orders are unable to be carried out for any reason the health care provider should be notified and it should be documented in nurses' notes, including any further orders.",2020-09-01
23,SANTA ROSA CARE CENTER,35004,1650 NORTH SANTA ROSA AVENUE,TUCSON,AZ,85712,2017-10-05,441,E,0,1,2ZZS11,"Based on staff interviews, the facility failed to implement a water management program that included environmental testing for pathogens including the bacterium Legionella. Findings include: During an interview with the Director of Nursing (staff #107) conducted on (MONTH) 4, (YEAR), at 10:40 a.m., staff #107 stated that the facility's water softener and cooling systems were maintained by outside vendors. However, the facility did not have a policy or a program to test the facility's water for pathogens including the Legionella bacterium. During an interview conducted on (MONTH) 4, (YEAR) at 10:45 a.m. with the Administrator (staff #9), the administrator stated that the facility did not have a policy or program for testing the facility's water supply for waterborne pathogens including Legionella.",2020-09-01
24,DESERT TERRACE HEALTHCARE CENTER,35014,2509 NORTH 24TH STREET,PHOENIX,AZ,85008,2019-03-08,580,D,0,1,QDGY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy review, the facility failed to notify one resident's (#281) physician of a low blood sugar value. The total sample size was 17. The deficient practice has the potential for adverse effects on residents with sliding scale insulin orders. Findings include: Resident #281 was admitted (MONTH) 23, (YEAR), with [DIAGNOSES REDACTED]. The physician's admission orders [REDACTED]= 0 units and call MD (physician); 71-150 = 0 units; 151-200 = 3 units; 201-250 = 5 units; 251-300 = 7 units; 201-350 = 10 units; 351-400 = 12 units; greater than 401 = 14 units and notify MD. Review of the Medication Administration Record [REDACTED]. Further review of the clinical record did not reveal any documentation that the physician was notified of the low blood sugar. An interview was conducted with the Director of Nursing (DON/staff #56) on (MONTH) 6, 2019 at 7:48 a.m. Staff #56 stated staff should follow the physician's orders [REDACTED]. The DON further stated that no documentation was found the physician was notified when the resident blood sugar level dropped to 63. The facility's policy regarding change of condition revealed all changes in a resident's condition will be communicated to the physician.",2020-09-01
25,DESERT TERRACE HEALTHCARE CENTER,35014,2509 NORTH 24TH STREET,PHOENIX,AZ,85008,2019-03-08,637,D,0,1,QDGY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure a Significant Change in Status (SCSA) Minimum Data Set (MDS) assessment was completed for one resident (#36), who was discharged from hospice services. The sample size was 17. This deficient practice could affect the resident's continuity of care. Findings include: Resident #36 was admitted on (MONTH) 13, 2012, with [DIAGNOSES REDACTED]. Review of the clinical record revealed a physician's orders [REDACTED]. The SCSA MDS assessment dated (MONTH) 13, (YEAR), revealed the resident was receiving hospice services. Additional review of the clinical record revealed a physician's orders [REDACTED]. However, continued review of the clinical record did not reveal a SCSA MDS assessment was completed. On (MONTH) 7, 2019 at 10:25 AM, an interview was conducted with the MDS coordinator (staff #22). She stated that when a resident is discharged from hospice services, a SCSA MDS assessment needs to be completed. She also stated that she did not know this resident had been discharged from hospice services because she was not notified. Later that morning at 11:38 AM, staff #22 stated that a SCSA MDS assessment should have been completed for resident #36 in (MONTH) 2019. She said she missed it. The RAI manual instructs a SCSA MDS assessment is required when hospice services are discontinued and that the Assessment Reference Date must be within 14 days.",2020-09-01
26,DESERT TERRACE HEALTHCARE CENTER,35014,2509 NORTH 24TH STREET,PHOENIX,AZ,85008,2019-03-08,641,D,0,1,QDGY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that Minimum Data Set (MDS) assessments were accurate for two residents (#382 and #81). The sample size was 31. This deficient practice could affect residents' continuity of care. Findings include: -Resident #382 was admitted on (MONTH) 21, 2019, with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The orders also included blood sugar accuchecks before meals and at bedtime. Review of the Medication Administration Record [REDACTED]. A Nursing Progress Note dated (MONTH) 22, 2019, revealed the resident threw her medications when the medications were placed in her hand per her request. Review of the MAR indicated [REDACTED]. The admission MDS assessment dated (MONTH) 28, 2019 revealed a Brief Interview for Mental Status score of 15 which indicated the resident was cognitively intact. The assessment also included the resident had no behaviors during the seven day look-back period which included no verbal or other behaviors directed towards others, and no rejection of care. An interview conducted on (MONTH) 7, 2019 at 12:55 p.m. with the Certified Nursing Assistant (CNA/staff #57) who had completed the section of the MDS assessment for behavior. She stated that she was aware the resident had refused medications and treatments and had slapped and scratched the nurse. The CNA stated that she did not include the behaviors on the MDS assessment because she understood why the resident had those behaviors. She stated that it was a communication problem. An interview was conducted on (MONTH) 8, 2019 at 9:43 a.m. with the Licensed Practical Nurse (LPN/staff #22) MDS Coordinator and the MDS resource Registered Nurse (RN/staff #128). Staff #22 stated that she did not review the behavior section of the MDS assessment. Staff #22 further stated that if she was completing the behavior section for this resident, she would ask the resource nurse how to code this resident's behaviors. The RN stated that her instructions would be to include the resident's behaviors in the behavior section of the assessment and develop a care plan for the behaviors. They both agreed that they use the RAI Manual as the policy and procedure guide for coding the MDS assessment. The RAI manual revealed the behavior section of the MDS assessment focuses on the resident's actions, not the intent of the resident's behavior. The RAI Manual also included that once the frequency and impact of behavioral symptoms are accurately determined, follow-up evaluation and care plan interventions can be developed to improve the symptoms or reduce their impact. -Resident #81 was admitted on (MONTH) 15, 2019, with a [DIAGNOSES REDACTED]. Review of the closed record revealed a discharge summary progress note dated (MONTH) 24, 2019 that the resident was discharged home on (MONTH) 24, 2019. However, review of the discharge MDS assessment dated (MONTH) 25, 2019, revealed the resident was discharged to an acute care hospital on (MONTH) 24, 2019. An interview was conducted on (MONTH) 7, 2019 at 1:23 p.m. with the MDS coordinator (staff #22). The MDS coordinator stated the resident was discharged home and not to the hospital. Staff #22 also stated that the discharge MDS assessment regarding the resident's discharge location was an error. An interview conducted on (MONTH) 8, 2019 at 8:20 a.m. with the Director of Nursing (DON/staff #56). She stated the resident was discharged home and that the MDS assessment was coded incorrectly. The DON stated that they follow the RAI manual for coding the MDS assessments. The RAI manual instructs to review the medical record including the discharge plan and discharge orders for documentation of discharge location and select the code that corresponds to the resident's discharge status. The RAI manual also included that it is required that the assessment accurately reflects the resident's status and that the importance of accurately completing and submitting the MDS assessments cannot be over-emphasized.",2020-09-01
27,DESERT TERRACE HEALTHCARE CENTER,35014,2509 NORTH 24TH STREET,PHOENIX,AZ,85008,2019-03-08,656,D,0,1,QDGY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and policy review, the facility failed to ensure that a care plan for [MEDICAL CONDITION] risk was developed for one resident (#32). This deficient practice has the potential to cause delays in assessments and care. The sample size was 2. The universe was 17. Findings include: Resident #32 was admitted to the facility on (MONTH) 5, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed a care plan dated (MONTH) 17, (YEAR), which included goals and interventions related to a [DIAGNOSES REDACTED]. The resident was discharged from the facility with a return anticipated on (MONTH) 13, (YEAR). The resident was readmitted on (MONTH) 25, (YEAR). A new care plan was initiated for the resident on (MONTH) 25, (YEAR). However, the care plan did not include the resident's [DIAGNOSES REDACTED]. Review of the PPS (Prospective Payment System) 5 day MDS assessment dated (MONTH) 2, (YEAR), revealed the resident continued to have a [DIAGNOSES REDACTED]. An interview was conducted on (MONTH) 6, 2019 at 8:36 a.m. with the Director of Nursing (DON/staff #56). She stated that facility's protocol directs staff to discontinue a resident's orders and care plan if the resident is discharged from the facility for more than 24 hours. The DON stated that new orders and a new care plan would be initiated upon the resident's re-admission to the facility. A follow-up interview was conducted with the DON on (MONTH) 6, 2019 at 9:28 a.m. She stated that her expectation is that the comprehensive care plan include the resident's risk for [MEDICAL CONDITION]. The DON also stated there was a lapse in communication, and that the resident's risk for [MEDICAL CONDITION] was not included in the care plan when the resident was readmitted . Review of the facility's policy for care planning revealed the following: -The interdisciplinary team shall develop a comprehensive care plan for each resident. -The resident's care plan will be developed and implemented within 48 hours of admission.",2020-09-01
28,DESERT TERRACE HEALTHCARE CENTER,35014,2509 NORTH 24TH STREET,PHOENIX,AZ,85008,2019-03-08,657,D,0,1,QDGY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy review, the facility failed to ensure one of three sampled resident's (#36) comprehensive care plan was revised to reflect the change in hospice services. This deficient practice could result in a delay of care. Findings include: Resident #36 was admitted on (MONTH) 13, 2012, with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of the care plan dated (MONTH) 8, (YEAR) regarding hospice services revealed interventions to consult with the resident's physician and social services to have hospice care for the resident in the facility and working with nursing staff to provide maximum comfort for the resident. A physician's orders [REDACTED]. A social service progress note dated (MONTH) 23, 2019, revealed the IDT (interdisciplinary team) had met for a care conference. The note included a discussion of the resident's change in Hospice services. The note did not include a discussion about revising the care plan. However, review of the resident's current care plan did not reveal the care plan had been revised to reflect the resident's discharge from hospice. An interview was conducted on (MONTH) 6, 2019 at 10:39 AM with the Director of Nursing (DON/staff #56). She said that facility's protocol and her expectation would include revising the resident's care plan to reflect the change in hospice services. The DON also said their policy states any member of the IDT could make that revision. On (MONTH) 7, 2019 at 09:40 AM, an interview was conducted with a licensed practical nurse (LPN/staff #62). The LPN stated that if a resident is admitted or discharged from hospice services, it would trigger a change of condition due to a change of services. She stated that the MDS (minimum data set) coordinator would revise the care plan. Review of the facility's policy for care planning revealed the resident's plan of care is reviewed and revised on an ongoing basis, quarterly at a minimum and/or as needed with changes in condition.",2020-09-01
29,DESERT TERRACE HEALTHCARE CENTER,35014,2509 NORTH 24TH STREET,PHOENIX,AZ,85008,2019-03-08,684,D,1,1,QDGY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, clinical record review and staff interview, the facility failed to ensure one resident (#281) had blood glucose monitoring done as ordered by the physician. The deficient practice could result in treatment not being provided, as a result of high/low blood sugars. The total sample size was 17. Findings include: Resident #281 was admitted on (MONTH) 23, (YEAR) at approximately 3:00 p.m. [DIAGNOSES REDACTED]. A review of the clinical record revealed admission orders [REDACTED] blood sugar 0-70 = 0 units and call MD (physician); 71-150 = 0 units; 151-200 = 3 units; 201-250 = 5 units; 251-300 = 7 units; 201-350 = 10 units; 351-400 = 12 units; greater than 401 = 14 units and notify MD. A review of the MAR (Medication Administration Record) for (MONTH) (YEAR), revealed the resident's blood sugar monitoring was to be done at 7:30 a.m., 11:30 a.m., 4:30 p.m. and 8:00 p.m. Further review of the MAR indicated [REDACTED] During an interview with the Director of Nursing (DON/staff #56) on (MONTH) 6, 2019 at 8:58 a.m., staff #56 stated that the nurse should have documented the resident's glucose levels. Staff #56 stated the facility did not have a policy regarding blood glucose monitoring and documentation and that the nurses are to follow the order on the MAR.",2020-09-01
30,DESERT TERRACE HEALTHCARE CENTER,35014,2509 NORTH 24TH STREET,PHOENIX,AZ,85008,2019-03-08,757,E,0,1,QDGY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review and staff interviews, the facility failed to ensure one of five sampled residents (#36) was free of unnecessary drugs, by failing to administer a narcotic pain medication as ordered by the physician. The potential outcome includes receiving a medication which may be unnecessary. Findings include: Resident #36 was admitted on (MONTH) 13, 2012, with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. A pain care plan area dated (MONTH) 16, (YEAR) included that opioids were prescribed for chronic pain. Interventions included administering medication as ordered, monitoring for side-effects, monitoring for medication efficacy and educating the resident on alternatives. The Medication Administration Record [REDACTED]. Per the MAR, [MEDICATION NAME] 5 mg was administered six times outside of the physician ordered parameters as follows: twice on (MONTH) 17 for pain levels of 3 and 4; on (MONTH) 21 for a pain level of 3; on (MONTH) 23 for a pain level of 4; and on (MONTH) 25 and 28, for a pain level of 4. A physician's orders [REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated (MONTH) 13, 2019, revealed the resident had severe cognitive impairment. Review of the MAR for (MONTH) 2019 revealed [MEDICATION NAME] 5 mg was administered 6 times outside of the physician ordered parameters as follows: on (MONTH) 4 for a pain level of 4; on (MONTH) 5 for a pain level of 3; on (MONTH) 6 for a pain level of 3; twice on (MONTH) 9 for pain levels of 4; and on (MONTH) 24 for a pain level of 4. Review of the MAR for (MONTH) 2019 revealed that [MEDICATION NAME] 5 mg was administered once outside of the physician ordered parameters on (MONTH) 20, for a pain level of 4. An observation of resident #36 was conducted on (MONTH) 6, 2019 at 12:05 p.m., in the dining room. The resident was asleep at the table and was not eating her lunch. A Certified Nursing Assistant (CNA) woke the resident up and asked her if she was going to eat her lunch. The resident said she wanted her yogurt, but took only one bite. The resident appeared to be sleepy. Another observation was conducted on (MONTH) 6, 2019 at 1:37 p.m., in the dining room. Resident #36 was still sitting at the table, asleep. An interview was conducted on (MONTH) 8, 2019 at 8:18 a.m., with a Licensed Practical Nurse (LPN/staff #62). She said she administers medications according to the physician's orders [REDACTED]. An interview was conducted on (MONTH) 8, 2019 at 10:20 a.m., with a LPN (staff #123). She said that she would not go outside of the ordered parameters when administering medication. An interview was conducted on (MONTH) 8, 2019 at 10:32 a.m., with the Director of Nursing (DON/staff #56). She stated that her expectation is for the nurses to administer medications according to the proper timeframe and pain scales. She said she expects the nurses to administer medications according to the order and within the parameters.",2020-09-01
31,DESERT TERRACE HEALTHCARE CENTER,35014,2509 NORTH 24TH STREET,PHOENIX,AZ,85008,2016-11-02,250,E,0,1,VT7X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interview, the facility failed to provide medically-related social services for one resident (#124). Findings include: Resident #124 was readmitted on (MONTH) 19, 2014, with [DIAGNOSES REDACTED]. A review of the clinical record revealed that the resident's BIMS (Brief Interview for Mental Status) score was a 3, which indicated severe cognitive impairment. A dental consultation dated (MONTH) 7, (YEAR), included a recommendation for multiple teeth extractions, as well as instructions for the resident or the resident's medical power of attorney. These included the following: 1. Need Primary Care Physician or Nurse Practitioner signature's for treatment. 2. Responsible party to sign, date, initial, and have witnessed the consent for extractions. 3. Pre medication orders, including a sedative. 5. Specific financial arrangements to be made. However, a review of the clinical record, inclusive of the social services documentation, revealed no documented evidence that anyone was designated or responsible to make informed decisions for this resident. An interview was conducted on (MONTH) 2, (YEAR), with the social service staff (staff #91), who stated that a responsible party had not been obtained to make decisions for this resident. Another interview was conducted on (MONTH) 2, (YEAR) at 1:57 p.m., with staff #99 (corporate resource staff), who stated that the facility did not have a policy to address guardianships or pubic fiduciaries.",2020-09-01
32,DESERT TERRACE HEALTHCARE CENTER,35014,2509 NORTH 24TH STREET,PHOENIX,AZ,85008,2016-11-02,412,D,0,1,VT7X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interviews, and facility policy, the facility failed to ensure one resident (#124) was assisted with dental services. Findings include: Resident #124 was readmitted on (MONTH) 19, 2014, with [DIAGNOSES REDACTED]. A review of the clinical record revealed a physician's orders [REDACTED]. However, a dental consultation report was unable to be located in the clinical record. The resident was not interviewable, with a BIMS (Brief Interview for Mental Status) score of 3, which indicated severe cognitive impairment. An interview was conducted on (MONTH) 2, (YEAR) at 8:30 a.m., with a LPN (Licensed Practical Nurse-staff #44), who stated that she recalled that the resident had received a dental consultation and that recommendations had been made to have several teeth extractions but was unable to recall when the dental consultation was provided. Staff #44 stated that the social services staff would have been responsible to arrange for the dental consultation and to follow up on any recommendations that were made. An interview was conducted on (MONTH) 2, (YEAR) at 8:45 a.m., with Social Service staff (staff #91). She confirmed that it was her responsibility to arrange for the dental consultation and follow up regarding any recommendations. Following a review of the clinical record, inclusive of social services documentation, staff #91 stated that she was unable to locate any documentation regarding this dental consultation. Staff #91 stated she would now need to call the dental office to obtain a copy of the consultation and recommendations. On (MONTH) 2, (YEAR), the facility provided a copy of the dental consultation, which was dated (MONTH) 7, (YEAR). The consultation included that the resident required multiple tooth extractions. Another interview was conducted on (MONTH) 2, (YEAR) at 10:30 a.m., with the DON (Director of Nursing-staff #100), who stated that the social services staff should have followed up with the dental provider after the consultation to ensure that any recommendations were initiated. An interview was conducted on (MONTH) 2, (YEAR) with the social service staff (staff #91), who confirmed that she had not followed up with the dental provider but was unable to state why. A facility policy, titled, Social Services Policy and Procedure Manual-Subject Dental, Optometry and Audiology Evaluations, included, It is the policy of this facility that Social Services staff will coordinate Dental, Optometry, and Audiology evaluations for resident. The policy also included the following: 1. Social Services will maintain a system to monitor the Dental, Optometry, and Audiology evaluations. 3. Evaluation dates will be documented on the Social Services concrete needs sheet and/or in the Social Services progress notes.",2020-09-01
33,DESERT TERRACE HEALTHCARE CENTER,35014,2509 NORTH 24TH STREET,PHOENIX,AZ,85008,2017-12-05,583,D,0,1,6GPJ11,"Based on observation, staff interviews and policy review, the facility failed to ensure that confidential resident information was secured. Findings include: An observation was conducted on (MONTH) 4, (YEAR) at 11:47 a.m., in the hallway near the station 2 nurse's station. At this time, a computer type device was observed to be mounted on the wall. The computer screen was on and was visible to anyone walking down the hallway. The computer screen displayed a resident's name, picture, room number and vital signs. An interview was conducted with a certified nursing assistant (CNA #98) on (MONTH) 4, (YEAR) at 11:58 a.m. Staff #98 stated that she got distracted and forgot to close the computer screen. An interview was conducted with the Director of Nursing (DON/staff #66), who stated that it is against policy to leave the computer screens unattended and open, displaying resident information. Review of a facility policy titled Notice Of Privacy Practices included, We are legally required to protect the privacy of your health information. We call this information Protected Health Information or PHI for short, and it includes information that can be used to identify you .your past, present, or future health or condition, the provision of health care to you .We must provide you with this notice about our privacy practices that explain how, when, and why we use and disclose your PHI. With some exceptions, we may not use or disclose any more of your PHI that is necessary to accomplish the purpose of the use or disclosure.",2020-09-01
34,DESERT TERRACE HEALTHCARE CENTER,35014,2509 NORTH 24TH STREET,PHOENIX,AZ,85008,2017-12-05,641,D,0,1,6GPJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that Minimum Data Set (MDS) assessments for two resident's (#66 and #68) accurately reflected their status. Findings include: -Resident #66 was admitted to the facility on (MONTH) 25, (YEAR), with [DIAGNOSES REDACTED]. Review of an admission MDS assessment dated (MONTH) 1, (YEAR), revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had no cognitive impairment. However, a physician's progress note dated (MONTH) 11, (YEAR) included the resident remains in chronic vegetative state, non-communicative. A resident interview was attempted on (MONTH) 28, (YEAR) at 1:00 p.m. The resident appeared to be in a vegetative state and was unable to answer questions. A family member was at the bedside and confirmed that the resident was unable to understand questions or communicate in any manner. An interview was conducted on (MONTH) 5, (YEAR) at 9:26 a.m., with two MDS nurses (staff #116 and staff #117). They stated that they did not know why the MDS was coded in this manner, as it was a mistake and that the nurse who did the coding was no longer employed there. -Resident #68 was readmitted to the facility on (MONTH) 7, (YEAR) and discharged on (MONTH) 18, (YEAR), with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. The orders also included for [MEDICATION NAME] (antianxiety medication) 1 milligram by mouth two times a day as needed for anxiety. Review of the Medication Assessment Record (MAR) for (MONTH) (YEAR) revealed the resident received Ertapenem Sodium Solution from (MONTH) 8 through 18. Further review revealed that the resident received [MEDICATION NAME] on (MONTH) 11, 12, 13 and 14. However, review of the MDS assessment dated (MONTH) 14, (YEAR), revealed documentation in Section N, that antibiotics had not been administered to the resident. The MDS also included documentation that the resident had only received three days of antianxiety medication. An interview was conducted with the MDS coordinator (Licensed Practical Nurse/LPN/staff #116) on (MONTH) 1, (YEAR) at 9:31 a.m. She stated that in coding Section N of the MDS, she pulls up the MAR and counts the days the resident received the medications during the 7 day look back period. At this time, the MDS was reviewed for antibiotic and antianxiety medication use. She stated that the MDS was inaccurate as the MAR showed that the resident received an antibiotic and had received the antianxiety medication on 4 days. Staff #116 stated the expectation is that the MDS is accurate regarding the care the resident is receiving during the look back period of the MDS. During an interview conducted on (MONTH) 1, (YEAR) at 9:43 a.m. with the Director of Nursing (DON/staff #66), she stated the expectation is that the MDS would accurately reflect the residents status and care. Staff #66 stated that the MDS nurse is to follow the RAI manual in completing the assessment. She further stated that the facility has no policy regarding the accuracy of the MDS, as the facility uses the RAI manual. Review of the RAI manual for the MDS revealed the importance of accurately completing and submitting the MDS assessment cannot be over emphasized. The MDS assessment is the basis for the development of an individualized care plan.",2020-09-01
35,DESERT TERRACE HEALTHCARE CENTER,35014,2509 NORTH 24TH STREET,PHOENIX,AZ,85008,2017-12-05,655,D,1,1,6GPJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews and policy review, the facility failed to ensure that a baseline care plan regarding respiratory needs was developed for one resident (#301). Findings include: Resident #301 was admitted on (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. The admission physician orders [REDACTED]. The orders also included for [MEDICATION NAME]-[MEDICATION NAME] solution ([MEDICATION NAME][MEDICATION NAME]) 3 milliliters via nebulizer every 4 hours as necessary for shortness of breath or wheezing. According to the Medication Administration Record [REDACTED]. Review of the clinical record including the resident's baseline care plans revealed no evidence that a baseline care plan had been developed within 48 hours to address the resident's respiratory needs related to [MEDICAL CONDITION], and the need for oxygen and nebulizer treatments. An interview was conducted with a Licensed Practical Nurse (LPN/staff #63) on (MONTH) 23, (YEAR) at 12:43 p.m. She stated the admitting nurse is responsible to make sure the baseline care plans are done right away and should include the resident's major problems. An interview was conducted with the Director of Nursing (DON/staff #66) on (MONTH) 30, (YEAR) at 12:50 p.m. She stated that baseline care plans should be developed for all new admissions, within 48 hours. Staff #66 acknowledged that no baseline care plan had been developed to address the resident's respiratory needs. A facility policy regarding care planning included that resident care plans will be initiated within 48 hours of admission.",2020-09-01
36,DESERT TERRACE HEALTHCARE CENTER,35014,2509 NORTH 24TH STREET,PHOENIX,AZ,85008,2017-12-05,657,D,0,1,6GPJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff and resident interviews and policy review, the facility failed to ensure one resident (#55) was able to participate in the care planning process. Findings include: Resident #55 was admitted to the facility on (MONTH) 26, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed a care plan meeting invitation for the resident dated (MONTH) 1, (YEAR), which informed the resident that a care plan conference was scheduled for (MONTH) 9, (YEAR). An admission MDS (Minimum Data Set) assessment dated (MONTH) 2, (YEAR), included the resident had a BIMS (Brief Interview for Mental Status) score of 15, which indicated the resident was cognitively intact. A progress note written by the Social Service Supervisor (staff #92) dated (MONTH) 2, (YEAR), included documentation that the resident was invited to her care plan meeting. In an interview with resident #55 on (MONTH) 29, (YEAR) at 8:57 a.m., the resident stated that she was supposed to have a care plan conference, but it did not happen. She stated they told her that she was going to have one at another time, but that did not happen either. An interview with staff #92 was conducted on (MONTH) 1, (YEAR) at 11:30 a.m. She stated that resident's who are in the facility for skilled care have a care plan meeting scheduled 14 to 21 days, after their admission. She stated the residents receive an invitation, and then they are to let her know if they would like to attend or not. Staff #92 stated that care plan meetings are held on Thursdays, and the residents can choose a time that works for them. Another interview was conducted with staff #92 on (MONTH) 4, (YEAR) at 11:47 a.m. She stated that resident #55 wanted to attend, however, did not show up at the scheduled time and location for the meeting, so the meeting was held without the resident. She stated that later in the day of the scheduled conference, resident #55 reported that she had been waiting at the social workers office during the meeting time, instead of the conference room where the meeting was held. Staff #92 further stated she offered to hold another care plan conference the next week for the resident, but the resident never followed up to schedule a time. Staff #92 stated when a care conference meeting is held, there should be an IDT (interdisciplinary team) note that can be found in the resident's record regarding what was discussed in the meeting, who attended, if there were any concerns, and if there was anything that needs to be followed up on. Review of the clinical record revealed no documentation of a care plan meeting taking place in (MONTH) (YEAR). An interview with staff #92 was conducted on (MONTH) 5, (YEAR) at 3:05 p.m. She stated that there was no documentation of the care plan meeting which was held for this resident and there should have been documentation of it. In an interview with the Director of Nursing (DON/staff #66) on (MONTH) 4, (YEAR) at 3:08 p.m., she stated the expectation is that there should be documentation of the care plan meetings, whether the resident is in attendance or not, and it should be documented as to what was discussed and if there was anything to follow up on. Review of a policy titled Care Planning included that the resident should participate to the extent possible, in the development of the care plan. The policy also included that Every effort will be made to schedule care plan meetings to accommodate the availability of the resident.",2020-09-01
37,DESERT TERRACE HEALTHCARE CENTER,35014,2509 NORTH 24TH STREET,PHOENIX,AZ,85008,2017-12-05,684,D,0,1,6GPJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, facility documentation and policy review, the facility failed to ensure the necessary treatment and services were provided for one resident (#147), as ordered by the physician. Findings include: Resident #147 was admitted on (MONTH) 20, (YEAR), with [DIAGNOSES REDACTED]. The Initial Admission Record dated (MONTH) 20, (YEAR) included the resident was alert and oriented to time, place and person. Skin integrity findings included the resident had a surgical wound to the left outer ankle. According to the skin integrity care plan dated (MONTH) 21, (YEAR), the resident had actual skin impairment. A goal included that the surgical wounds to the left lower extremity (LLE) would heal. However, the locations of the wounds to the left lower extremity were not identified. An intervention included following the facility protocol for treatment of [REDACTED]. A physician's orders [REDACTED]. A Weekly Skilled Review note dated (MONTH) 28, (YEAR) included the resident received wound care twice a day to the lateral side of the LLE. Review of the Wound Administration Record from (MONTH) 22 through 30, (YEAR) revealed the order to cleanse the left outer leg with wound cleanser, apply Dakin soaked gauze, apply an ABD pad and wrap with Kerlix, twice daily. However, the documentation showed that the treatment was only provided once daily, instead of twice daily as ordered. An interview with the resident was conducted on (MONTH) 4, (YEAR) at 1:39 p.m. She stated that she receives wound treatment to her left lower leg once daily. An interview with a wound nurse (staff #44) was conducted on (MONTH) 4, (YEAR) at 1:42 p.m. She stated the wound care was ordered once daily to the left lower leg. An interview with another wound nurse (staff #48) was conducted on (MONTH) 5, (YEAR) at 8:56 a.m. She stated that the resident receives daily wound treatments to the left outer leg. At this time, the wound treatment orders for the left outer leg was conducted with staff #48. She stated that the frequency of wound treatment for [REDACTED]. A review of the Wound Administration Record was then conducted with staff #48, who stated the record only shows that the treatment was done on the day shift and was not done on the evening shift. An interview with the Assistance Director of Nursing (ADON/staff #61) was conducted on (MONTH) 5, (YEAR) at 1:15 p.m. She stated the wound treatment should be done as ordered by the physician. Staff #61 stated that if a treatment is ordered twice daily, it should be done on the day shift and on the evening shift. Review of a facility policy regarding Physician order [REDACTED].",2020-09-01
38,DESERT TERRACE HEALTHCARE CENTER,35014,2509 NORTH 24TH STREET,PHOENIX,AZ,85008,2017-12-05,686,D,0,1,6GPJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, resident and staff interviews, review of the National Pressure Ulcer Advisory Panel's (NPUAP) Pressure Injury Stages guidelines and policy review, the facility failed to ensure a pressure ulcer was accurately staged, thoroughly assessed and consistently monitored for one resident (#147). Findings include: Resident #147 was admitted on (MONTH) 20, (YEAR), with [DIAGNOSES REDACTED]. The Initial Admission Record dated (MONTH) 20, (YEAR) included the resident was alert and oriented to time, place and person. Skin integrity findings included the resident had a surgical wound to left outer ankle. There was no documentation that the resident had any pressure ulcers upon admission. However, a nutrition care plan dated (MONTH) 20, (YEAR) included the resident required increased calories and protein needs related to wound healing, due to a pressure injury. The stage and location of the pressure injury was not identified. Review of the Weekly Skin Evaluation dated (MONTH) 21, (YEAR) revealed the resident had a stage II pressure ulcer to the left inner lower leg, which measured 3.5 centimeters (cm) x 1.0 cm, and the wound bed was described as having yellow slough. However, a stage II pressure ulcer in this document was defined as partial thickness loss of dermis, presenting as shallow open ulcer with a red pink wound bed without slough. A stage III pressure ulcer was defined as full thickness tissue loss and slough may be present. Further review of the evaluation revealed there was no documentation if the wound had any drainage, odor, the condition of the surrounding skin or progress of the wound. The skin integrity care plan dated (MONTH) 21, (YEAR) included the resident had actual skin impairment. However, the care plan did not include the identification of the pressure ulcer to the left inner lower leg. Interventions included following facility protocol for treatment of [REDACTED]. A physician's orders [REDACTED]. A physician's note dated (MONTH) 23, (YEAR) included the resident was alert and oriented to person and purpose and that the left lower extremities could not be accurately assessed, due to orthopedic splinting. The note did not include that the resident had a pressure ulcer to the left leg. Per the Weekly Skin Evaluation dated (MONTH) 23, (YEAR), the pressure ulcer continued to be documented as a stage II to the inner leg, with slough. No measurements or description of the pressure ulcer was included. A review of the Dietary Admission Evaluation dated (MONTH) 27, (YEAR) revealed the resident had a stage II pressure ulcer to the left leg. The admission MDS (Minimum Data Set) assessment dated (MONTH) 27, (YEAR) included the resident had one stage II pressure ulcer, with slough which was present on admission. However, a stage II pressure ulcer as defined in the MDS includes partial thickness loss of dermis, presenting as shallow open ulcer with a red pink wound bed, without slough. Per the Wound Administration Record for (MONTH) (YEAR), the treatments were provided as ordered. In the Weekly Skin Ulcer Note dated (MONTH) 5, (YEAR), the pressure ulcer to the left inner leg was not included in the documentation. Despite documentation that the resident had a pressure ulcer with slough to the left inner leg, there was no documentation that it had been thoroughly and accurately assessed from admission through (MONTH) 5, (YEAR). An interview with a wound nurse (staff #48) was conducted on (MONTH) 5, (YEAR) at 8:56 a.m. She stated that she conducts a head to toe assessment of the resident the day after admission and is responsible to ensure accurate identification, including staging, a description of the wound bed, surrounding skin and measurements. She stated that the floor nurses are not allowed to identify the specific type of wound and cannot stage a pressure ulcer. She said that pressure ulcers are assessed twice daily. Further, she stated that each wound is documented separately and pressure ulcers are documented on the Weekly Pressure Ulcer note. Staff #48 stated that the documentation should include the stage, measurements a description of the wound bed and surrounding area. She also stated that the status of the wound whether it is improving or not should be in the wound notes. Staff #48 stated that resident #147 has one stage II pressure ulcer to the back of the left ankle, which was first identified on (MONTH) 21. In an interview with a licensed practical nurse (LPN/staff #73) conducted on (MONTH) 5, (YEAR) at 11:27 a.m., she stated that when a wound is observed on a resident, she will notify the wound nurse who will accurately identify, stage and provide daily treatments to the wounds. She stated that she cannot identify the type of wound but would describe what she sees in her notes. During an interview with the Assistant Director of Nursing (ADON/staff #61) conducted on (MONTH) 5, (YEAR) at 1:15 p.m., she stated that if the resident has any type of wound, the floor nurses will only describe what they see. She stated that the wound nurse ensures weekly measurements of wounds and documentation includes measurements, description of the wound bed, any drainage and surrounding skin. In an interview with the Director of Nursing (DON/staff #66) conducted on (MONTH) 5, (YEAR) at 3 p.m., she stated the resident has one stage II pressure ulcer to the left inner lower leg, which was identified upon admission. She stated that the wound nurses have not been documenting the assessment of the resident's pressure ulcer and she has educated them to document the assessments on the pressure ulcer sheet. During another interview with staff #66 conducted on (MONTH) 5, (YEAR) at 3:20 p.m., she stated that there were no complete assessments of the resident's pressure ulcer, prior to (MONTH) 5, (YEAR). Review of the NPUAP Pressure Injury Staging guidelines revealed that a stage II pressure injury was described as having partial-thickness skin loss with exposed dermis, with a viable, pink or red, moist wound bed and slough and eschar are not present. Further, a stage III pressure injury was defined as a full-thickness skin loss and slough and/or eschar may be visible. Regarding the CAM boot: The Physical Therapy (PT) Evaluation and Plan of Treatment dated (MONTH) 21, (YEAR) included the resident was status [REDACTED]. The section on Medical Precaution/Contraindications included for a left CAM (Controlled Ankle Motion) boot. However, there was no documentation as to when this boot should be applied or removed, or the duration (days, weeks etc) the boot was to be utilized. Review of the resident's care plans dated (MONTH) 21, (YEAR) revealed the use of a cam boot to the left lower leg was not included as an intervention. A nurse practitioner (NP) progress note dated (MONTH) 22, (YEAR) included an alert and oriented resident with an assessment of polytrauma and difficulty of walking. Musculoskeletal findings included the left lower extremity had a dressing and a stabilization splint. The plan included for physical and occupational therapy, and to monitor the resident's progress. There was no documentation regarding the use of the CAM boot as part of the plan of care. A physician's note dated (MONTH) 23, (YEAR) included the left lower extremity could not be accurately assessed, due to orthopedic splinting. Review of the physician's orders [REDACTED]. Review of the clinical record including the Treatment Administration Record from (MONTH) 20, through (MONTH) 31, (YEAR) revealed no evidence that use of the boot to the left lower leg was monitored and documented. An observation was conducted on (MONTH) 4, (YEAR) at approximately 12:55 p.m. of the resident in bed, with a black boot on the left lower leg, which was laying on top of a pillow. At this time, the resident stated that the boot was for her left leg, because of her accident. Another observation was conducted on (MONTH) 5, (YEAR) at 8:51 a.m., of the resident sitting in her wheelchair. The black boot was observed to be on her left leg. An interview was conducted with a certified nursing assistant (CNA/staff #9) on (MONTH) 5, (YEAR) at 10:54 a.m. She stated the resident wears a boot on her left leg for strengthening. She stated that the resident puts it on and takes it off by herself. She also stated that the resident is supposed to remove the boot when in bed and put it back on when out of bed. Staff #9 stated she tries to ensure that the resident does this and will inform the nurse if it's not done, because there is no way for her to document it. During an interview with a certified occupational therapist (COTA/staff #118) conducted on (MONTH) 5, (YEAR) at 11:08 a.m., he stated that the resident has weight bearing limitations on her left side. He stated the boot to the left leg was for protection of the leg status [REDACTED]. An interview with a physical therapist (PT/staff #119) was conducted immediately following. Staff #119 stated that the order for the use of [REDACTED]. He stated that if the order did not specify a frequency, then the boot is to be worn at all times. An interview with an LPN (staff #73) was conducted on (MONTH) 5, (YEAR) at 11:27 a.m. She stated that the resident has a black boot on her left leg. At this time, a review of the clinical record was conducted and staff #73 stated that she could not find an order for [REDACTED].>An interview with the wound nurse (staff #48) was conducted on (MONTH) 5, (YEAR) at 11:25 a.m. She stated that there usually is an order for [REDACTED]. A review of the clinical record was conducted with the Assistant Director of Nursing (ADON/staff #61) on (MONTH) 5, (YEAR) at 1:15 p.m. She stated that she could not find an order for [REDACTED].>In a later interview with staff #61 on (MONTH) 5, (YEAR) at 1:52 p.m., she stated that she reviewed the records and found no orders for the CAM boot. Staff #61 stated if a resident uses a CAM boot, the floor nurse is expected to ensure that there is an order for [REDACTED]. During an interview with the Director of Nursing (DON/staff #66) conducted on (MONTH) 5, (YEAR) at 2:06 p.m., she stated there was no order for the use of [REDACTED]. She stated that if the resident came with a boot and there was no order for its use, the nurses are expected to communicate, document and call the physician to verify the continued use of the boot. She also said that per the therapy department, the resident still needed the boot, so the physician has been notified. Review of the policy regarding Physician order [REDACTED]. of care. The policy on Wound Management included that it the facility's policy to have a central consistent flow sheet to enable medical staff to evaluate the status of wounds. The policy also included that weekly skin assessments on all residents will be done and documented in the nurses notes. Per the policy, each wound will be measured in centimeters weekly and include drainage, odor, color and a short statement on progress (or lack of) and this will be documented on the wound flow sheet.",2020-09-01
39,DESERT TERRACE HEALTHCARE CENTER,35014,2509 NORTH 24TH STREET,PHOENIX,AZ,85008,2017-12-05,761,D,0,1,6GPJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, facility documentation, staff and resident interviews, and policy and procedures, the facility failed to ensure that medications for two residents (#54 and #144) were secured in a locked storage area and were only accessible to authorized personnel. Findings include: -Resident #54 was admitted on (MONTH) 25, (YEAR), with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated (MONTH) 28, (YEAR) revealed the resident had a Brief Interview of Mental Status (BIMS) score of 15, which indicated no cognitive impairment. physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. An observation was conducted in the resident's room on (MONTH) 29, (YEAR) at 9:08 a.m. A vial of [MEDICATION NAME] Nebulizing Solution was observed on the bedside table. The resident stated that the medication was left by a nurse (LPN/staff #46) the night before. At this time, a Licensed Practical Nurse (LPN/staff #63) entered the resident's room and the resident notified her of the presence of the medication. The nurse then removed the medication from the bedside table and placed it in her pocket and left the room. Following this, an interview was conducted with staff #63. She stated that it was the first time she had been in the resident's room that day and that the medication was [MEDICATION NAME]. An interview was conducted with the Director of Nursing (DON/staff #66) on (MONTH) 5, (YEAR) at 9:08 a.m. She stated that staff are never to leave medications at the bedside. She stated that staff are expected to observe residents taking the medication before leaving the room. She stated the nurses have received training on medication storage and that training and reminders are ongoing. An interview was conducted with LPN (staff #46) on (MONTH) 5, (YEAR) at 2:38 p.m. She stated that she forgot and left the [MEDICATION NAME] at the bedside. She stated the policy and expectation in the facility is not to leave medication at the bedside. She stated that she knows not to leave medication at the bedside. -Resident #144 was admitted on (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed an admission assessement dated (MONTH) 27, (YEAR), which documented the resident was alert and oriented times three and did not desire to self administer drugs. An observation was conducted on (MONTH) 29, (YEAR) at 9:52 a.m., of resident #144's room. At this time, one bottle of multi-vitamins with minerals was observed on the resident's bedside table. The resident stated that he purchased them and no one from the facility had said anything about them. Review of the label on the vitamin bottle revealed the following: DG Complete 100 IU (International Units) Vitamin D adults over 50 multi-vitamin with minerals. Review of the admission physician's orders [REDACTED]. An interview was conducted on (MONTH) 29, (YEAR) at 10:10 a.m., with a registered nurse (staff #45). Staff #45 reviewed the physician's orders [REDACTED]. Staff #45 stated she had not noticed the vitamin bottle in the resident's room and that it should have been removed. She stated the physician should have been notified regarding an order for [REDACTED]. Review of a facility policy on Medication Access and Storage revealed to store all drugs in locked compartments and that the medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.",2020-09-01
40,DESERT TERRACE HEALTHCARE CENTER,35014,2509 NORTH 24TH STREET,PHOENIX,AZ,85008,2017-12-05,812,D,0,1,6GPJ11,"Based on observations, staff interview and policy review, the facility failed to ensure eating utensils were dry and ready to use, prior to being placed on resident's food trays. Findings include: An observation was conducted of the tray line on (MONTH) 30, (YEAR) at 12:05 p.m. Staff were observed placing wet eating utensils on the resident's food trays, just prior to the food trays being placed in the food cart for delivery to the unit. At this time, a dietary staff member directed the staff to make sure the utensils were not wet, and some of the wet utensils were removed off of the trays. However, further observations revealed that staff continued to place wet utensils on the food trays. An interview was conducted with a dietary staff member (staff #57) on (MONTH) 30, (YEAR) at 1:00 p.m. Staff #57 stated that he was responsible for ensuring that the utensils placed on the resident's trays were clean and dry. Staff #57 stated that the utensils had just come from the dishwasher and he missed some. Review of a policy regarding clean and dry dishware and utensils revealed documentation that all flatware, serving dishes, and cookware will be washed, rinsed, and sanitized after each use. The policy included that dishes and utensils were to air dry on the dish rack and were not to be dried with towels, and that when removing dishes, staff were to inspect them for cleanliness and dryness.",2020-09-01
41,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2019-01-08,578,D,0,1,ZWO111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews and policy review, the facility failed to have documentation of advanced directives for one resident (#10) and obtain physician orders once obtained, and failed to obtain physician orders in accordance with the advance directive for one resident (#171). Findings include: -Resident #10 was admitted to the facility on (MONTH) 30, (YEAR) and readmitted to the facility on (MONTH) 10, (YEAR), with [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment dated (MONTH) 8, (YEAR) revealed the resident had a Brief Interview for Mental Status score of 3, which indicated severe cognitive impairment. Review of the clinical record on (MONTH) 5, 2019 revealed no documentation regarding advance directives for resident #10. There were also no physician orders for any advance directives. An interview was conducted with two licensed practical nurses (LPN/staff #52/staff #53) on (MONTH) 6, 2019 at 2:50 p.m. The nurses stated that they were unable to locate advance directive information for resident #10. Staff #52 stated that the nurses usually get a new order when a resident returns from the hospital, because the directive could change at anytime. Staff #52 stated that she would need to have the responsible party for the resident sign the form and that she would contact the responsible party right away. Review of the clinical record on (MONTH) 7, 2019 revealed advance directives had been obtained for resident #10. The advance directives were obtained from the resident's responsible party by telephone on (MONTH) 6, 2019 and included for a Do Not Resuscitate (DNR) status. Further review of the physician orders on (MONTH) 7, 2019 revealed there was no physician order for [REDACTED].>-Resident #171 was admitted to the facility on (MONTH) 31, (YEAR), with [DIAGNOSES REDACTED]. A review of the clinical record revealed an Advanced Directive form indicating the resident was a DNR status, which was signed by the resident's power of attorney on (MONTH) 2, 2019. However, review of the physician orders on (MONTH) 7, 2019 revealed there were no orders for a DNR status. An interview was conducted with two licensed practical nurses present (LPN/staff #52/staff #53) on (MONTH) 6, 2019 at 2:50 p.m. Staff #52 stated that there is an Advance Directive for a DNR on the paper chart which was signed on (MONTH) 2, 2019, but there is no physician's order at present. An interview was conducted on (MONTH) 8, 2019 at 12:17 p.m. with the Director of Nursing (DON/staff #160). She stated that Social Services interview residents or responsible parties and obtains advance directives on admission, or shortly after admission. Staff #160 stated if the resident desires a DNR status, Social Services will inform nursing so they can contact the provider to get an order in place and obtain the orange card (Prehospital Medical Care Directive). She also stated there should be a physician's order for a DNR. Review of the facility's policy regarding Advance Directives revealed the facility will respect advance directives in accordance with state law and facility policy and that the Director of Nursing or designee will notify the attending physician of advance directives. so that appropriate orders can be documented in the resident's medical record and plan of care.",2020-09-01
42,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2019-01-08,640,D,0,1,ZWO111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documents and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that a Minimum Data Set (MDS) assessment was transmitted, within 14 days after completion for one resident (#2). Findings include: Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed a discharge MDS assessment was completed and dated 8/6/18. Review of the MDS transmittal report revealed that the discharge MDS assessment dated [DATE] had not been transmitted. An interview was conducted on 1/08/2019 at 11:23 a.m., with the MDS Coordinator (staff #116). Staff #116 stated the MDS assessments are completed by reviewing each chart, checking history and physicals, reviewing all physician orders [REDACTED]. Staff #116 stated when a resident is a planned discharged , a MDS-return not anticipated is completed. Staff #116 stated that she will open the discharge MDS like a regular assessment and will verify there are no errors. Staff #116 said that either the Assistant Director of Nursing (staff #117) or the Director of Nursing (staff #160) will sign off when the MDS is complete. Staff #116 stated the MDS would then be ready for transmission to CMS (Centers for Medicare/Medicaid Services). Staff #116 provided the MDS transmission report and stated that the discharge MDS dated [DATE] did not get transmitted. Staff #116 stated that the facility has 20 days to transmit a completed MDS. Staff #116 stated the facility policy is to use the RAI manual to ensure MDS accuracy and transmission. An interview was conducted on 1/8/2019 at 1:01 p.m. with the Director of Nursing (staff #160), who stated the expectation for the MDS nursing staff is to ensure that each MDS is completed and transmitted to CMS, within the required timeframe. Staff #160 stated the facility uses the RAI manual for all MDS expectations. Review of the RAI manual revealed that discharge MDS assessments must be submitted within 14 days of the MDS completion date.",2020-09-01
43,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2019-01-08,641,D,0,1,ZWO111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that Minimum Data Set (MDS) assessments were accurate for two residents (#'s 36 and 52). Findings include: -Resident #36 was admitted on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED].#36 revealed that resident #36 had an onset of pneumonia on (MONTH) 24, (YEAR). Review of a quarterly Minimum Data Set (MDS) assessment dated (MONTH) 20, (YEAR) revealed documentation of an active [DIAGNOSES REDACTED]. However, review of the clinical record revealed that resident #36 had a history of [REDACTED]. An interview was conducted on 1/8/2019 at 11:23 a.m. with the MDS Coordinator (staff #116). Staff #116 stated the MDS assessments are completed by reviewing each chart, checking the history and physical, reviewing all physician orders [REDACTED]. Staff #116 stated the electronic chart is also reviewed for a 7-day look-back period, which includes all progress notes, current diagnoses, medications and treatments. Staff #116 stated that current [DIAGNOSES REDACTED]. Staff #116 stated if it was a non-active diagnoses, it would not be included on the MDS. An interview was conducted on 1/08/2019 at 1:01 p.m. with the Director of Nursing (staff #160), who stated the expectation for the MDS nursing staff is to ensure that each MDS is accurate and completed within the required timeframe. -Resident #52 was admitted to the facility on (MONTH) 7, (YEAR), with [DIAGNOSES REDACTED]. Review of the MDS assessment dated (MONTH) 14, (YEAR), revealed the resident did not receive an antipsychotic medication in the past seven days or since admission. However, the MDS assessment also included the following in the Antipsychotic Medication Review section: since admission the resident had received antipsychotic medications on a routine basis only, and that a Gradual Dose Reduction (GDR) had not been attempted. Review of the physician's orders [REDACTED].#52. Review of the Medication Administration Record [REDACTED]. An interview was conducted on (MONTH) 8, 2019 at 11:23 a.m., with the MDS Coordinator (staff #116). She stated the facility follows the instructions in the RAI manual to ensure MDS accuracy. She stated the information in the MDS regarding a resident's medications would come from reviewing the resident's MAR. She stated that since the resident had not received an antipsychotic medication, the Antipsychotic Medication Review section of the MDS assessment should have been coded to reflect that antipsychotics were not received. An interview was conducted on (MONTH) 8, 2019 at 1:01 p.m., with the Director of Nursing (DON/staff #160). She stated her expectation was that each MDS assessment should be accurate. She stated accuracy should be determined by both MDS nurses double checking their work. She stated that if a resident was not taking an antipsychotic, the MDS assessment should record zero days of antipsychotic use, followed by a statement that antipsychotics were not received in the Antipsychotic Medication Review section. She stated that when all three areas of documentation matched, the MDS assessment would be accurate. Review of the RAI manual revealed the following requirements: The MDS assessment must accurately reflect the resident's status; A registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals; and the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts.",2020-09-01
44,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2019-01-08,689,D,1,1,ZWO111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, facility documentation and staff interviews, the facility failed to provide adequate supervision for one resident (#268) with known aggressive behaviors. Findings include: -Resident #268 was admitted to the facility on (MONTH) 13, (YEAR), with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment for resident #268 dated (MONTH) 20, (YEAR), revealed the resident scored a 3 on the Brief Interview for Mental Status (BIMS), which indicated severe cognitive impairment. The MDS also documented that the resident had physical behavioral symptoms against others that significantly interfered with the resident's care and put others at significant risk for injury. An activities note dated (MONTH) 21, (YEAR) stated the resident became agitated during bingo and began throwing bingo cards in the direction of other residents. An activities note dated (MONTH) 22, (YEAR) stated that resident #268 hit a staff member on the arm. Review of a care plan dated (MONTH) 23, (YEAR) revealed the resident exhibited behaviors of physical aggression such as hitting and kicking, during routine care. Interventions included to intervene before agitation escalates, guide resident away from the source of distress, provide one-on-one interaction, staff to re-approach the resident later or have a different staff member attempt to assist the resident, and if the resident becomes aggressive, staff should ensure her safety and give her time to calm down. A nursing note dated (MONTH) 25, (YEAR) included that resident #268 hit three staff members in the stomach and tried to kick them. Review of the behavior monitoring record for (MONTH) and (MONTH) (YEAR) revealed 4 episodes of resident #268 yelling out and 5 episodes of the resident striking out at staff. A physician's orders [REDACTED]. A nursing note dated (MONTH) 24, (YEAR) at 1:08 a.m., stated the resident was awake, roaming the halls and refusing care. The resident's pants were half on/half off and the resident was removing her clothes in the middle of the hall. A nursing note dated (MONTH) 18, (YEAR) included the resident was verbally aggressive with staff in a common area where other residents were present. The note also stated the resident tried to ram her wheelchair in the direction of another resident. Review of the resident's care plans revealed no evidence that they were updated to address the resident's aggressive behaviors toward other residents. Further review of the clinical record revealed there was no documentation that the resident was provided increased supervision, despite documentation of aggressive behaviors toward residents. A nursing note dated (MONTH) 25, (YEAR) revealed that resident #268 was extremely agitated, was screaming loudly, and swinging out, when a female resident was walking by, the resident hit her in the chest/abdomen area. The note also included that resident #268 was immediately removed from the area, staff continued to keep her away from other residents, and she began to wander in the hallway screaming loudly and speaking inaudible words. Review of the facility's investigative report regarding the incident on (MONTH) 25, (YEAR), revealed resident #268 was seen striking another resident as the resident walked by her. Per the clinical record, the resident was discharged to the hospital on (MONTH) 28, (YEAR) for continued/worsening altered mental status. An interview was conducted on (MONTH) 8, 2019 at 9:32 a.m., with a Licensed Practical Nurse (LPN/staff #52). She stated she witnessed the event between the two residents, and she was the author of the nursing note that documented the event. She stated that another resident was walking by as resident #268 was very agitated. She stated the arm of resident #268 was flailing when it struck the other resident. She stated neither resident was injured during the event.",2020-09-01
45,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2019-01-08,758,E,0,1,ZWO111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews and staff interviews, the facility failed to ensure there was adequate monitoring for adverse side effects for three residents (#10, #52 and #171) on [MEDICAL CONDITION] medications and failed to monitor target behaviors for one resident (#52) on an antidepressant medication. Findings include: -Resident #10 was admitted on (MONTH) 30, (YEAR) and readmitted on (MONTH) 10, (YEAR), with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 8, (YEAR) revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS also included the resident received antipsychotic medication 7 of 7 days and antidepressant medication 6 of 7 days of the lookback period. A review of the resident's care plan regarding the use of [MEDICAL CONDITION] medications included a goal that the resident would remain free of complications related to [MEDICAL CONDITION] drugs. Interventions were to monitor for side effects and effectiveness each shift and to monitor/document/report as needed any adverse reactions of [MEDICAL CONDITION] medications such as: unsteady gait, tardive dyskinesia, shuffling gate, rigid muscles, shaking, frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, [MEDICAL CONDITION], social isolation, blurred vision, diarrhea, fatigue, [MEDICAL CONDITION], loss of appetite, weight loss, muscle cramps, nausea, vomiting and behavioral symptoms not usual to the person. The physician orders [REDACTED]. The orders did not include to monitor for adverse effects of these medications. Review of the Pharmacist New Admission Medication Review dated (MONTH) 10, (YEAR) revealed a recommendation to the physician/prescriber which stated [MEDICATION NAME] and [MEDICATION NAME] in combination may increase the risk of serotoni[DIAGNOSES REDACTED], if either drug is increased in dose/frequency, monitor for adverse events. A review of the Nurse Practitioner hospital discharge follow up note dated (MONTH) 11, (YEAR) revealed a medication review and an assessment of major [MEDICAL CONDITION], with a plan to follow response to medications and circumstances. Further review of the clinical record revealed a form titled, Side Effects Monthly Flow Sheet for (MONTH) 2019. The form included instructions to use the form for the following medication classes: antianxiety, antidepressant, antipsychotic and sedative/hypnotic. This form also included the side effects/adverse effects of each of these drug classes, with areas to document if any adverse effects. This form was blank. In addition, there was no clinical record documentation that the resident was being monitored for adverse effects of the [MEDICAL CONDITION] medications in (MONTH) (YEAR) and (MONTH) 2019. -Resident #171 was admitted on (MONTH) 31, (YEAR), with [DIAGNOSES REDACTED]. A review of the physician orders [REDACTED]. The orders did not include to monitor for any adverse effects of the medications. A baseline care plan identified a focus area related to a mood problem. Interventions included to administer medications as ordered, and to monitor/document for side effects and effectiveness. Review of the clinical record revealed there was no documentation that the resident was consistently monitored for adverse side effects related to the use of [MEDICAL CONDITION] medications. An interview was conducted with Licensed Practical Nurse (LPN/staff #53) on (MONTH) 6, 2019 at 1:30 p.m. Staff #53 stated the nurses are to document on the Side Effects Monthly Flow Sheets that are placed in the book. She said that she was not sure who was responsible to place the forms in the book. She also stated that she was unable to find documentation that resident #10 and #171 were being consistently monitored for adverse effects of [MEDICAL CONDITION] medications. -Resident #52 was admitted to the facility on (MONTH) 7, (YEAR), with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. An informed consent was obtained for the use of [MEDICATION NAME] on (MONTH) 10, (YEAR). Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 14, (YEAR), revealed the resident scored a 9 on the Brief Interview for Mental Status (BIMS), which indicated moderate cognitive impairment. The MDS assessment further documented that the resident had received an antidepressant for seven out of the past seven days. Review of the resident's care plans revealed there was no plan developed to address the use of an antidepressant medication. According to the Medication Administration Record [REDACTED]. However, there was no clinical record documentation from (MONTH) 9, (YEAR) through (MONTH) 6, 2019 that the resident had been monitored for any target behaviors related to depression, or that the resident was consistently monitored for adverse side effects related to an antidepressant medication. An interview was conducted on (MONTH) 7, 2019 at 9:24 a.m., with a Registered Nurse (RN/staff #104). She stated that when a resident receives an antidepressant, the nurse would be expected to verify an appropriate [DIAGNOSES REDACTED]. Staff #104 said the nurse would also be expected to monitor and document target behaviors related to antidepressant use each shift on the behavior sheets. She stated there was no behavior sheet or monitoring for resident #52, but there should have been since the resident was taking [MEDICATION NAME]. She stated the behavior sheets were normally initiated on admission and kept in the behavior binder, but she did not know the process for how the sheets were started and placed in the binder. An interview was conducted on (MONTH) 8, 2019 at 11:16 a.m., with the Director of Nursing (DON/staff #160). She stated it was the responsibility of the admitting nurse or the MDS coordinator to initiate behavior monitoring sheets and side effect monitoring sheets for residents taking antidepressants. She stated it was the responsibility of nurses who were administering antidepressant medications to monitor for and document the resident's target behaviors and side effects. She stated documentation should be done on the behavior and side effect sheets kept in the behavior binders on the units. She stated that there were no side effect monitoring sheets for resident #52 in the behavior binder, and they should have been there. She also said the facility did not have a policy for [MEDICAL CONDITION] medication administration, only a policy specifically for antipsychotic medication administration.",2020-09-01
46,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2019-01-08,880,E,0,1,ZWO111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, staff interviews, review of the Center for Disease Control (CDC) guidelines and policy and procedures, the facility failed to implement infection control measures for one resident (#222) on contact isolation precautions and failed to ensure infection control measures were implemented regarding catheters for two residents (#41 and #321). Findings include: -Resident #222 was admitted (MONTH) 4, 2019, with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Physician orders [REDACTED]. A nursing progress note dated (MONTH) 4, 2019 at 3:30 p.m. revealed the resident was placed on isolation precautions. A care plan dated (MONTH) 5, 2019 revealed the resident had [MEDICAL CONDITION]. Interventions included the following: Contact Isolation: wear gowns and masks when changing contaminated linens; educate resident, family and staff regarding preventive measures to contain the infection; place in private room with contact isolation precautions and disinfect all equipment before leaving the room. An observation was conducted on (MONTH) 5, 2019 at 11:03 a.m., outside of resident #222's room. A visitor was observed inside the resident's room and was wearing a gown that was not secured, and was slipping off her shoulders. The visitor also only had one glove on her right hand. The visitor was observed moving items on and off the bedside table with both hands. During the observation, the visitor stepped into the hallway over the threshold, two times with the unsecured gown and one glove still on, and then re-entered the room. At one point, the visitor removed the gown and one glove, and placed them into the red biohazard bag by the door and exited the room. The visitor did not wash her hands prior to leaving the room. The visitor then picked up her personal items from the top of the isolation cart which was outside of the resident's room, and proceeded to leave the building without washing her hands. An interview was conducted on (MONTH) 5, 2019 at 11:42 a.m. with a Licensed Practical Nurse (LPN/ staff #85), who stated that when a resident is placed on isolation, there is a lot of education done with staff and visitors prior to entering the isolation room. Staff #85 stated that both staff and visitors are educated to put on a gown and gloves, secure the gown, and are taught proper removal of the gown and gloves. Staff #85 stated that staff and visitors are also educated to wash their hands with soap and water prior to exiting the room, because hand sanitizer is not effective. An observation was conducted on (MONTH) 5, 2019 at 12:09 p. m. of a Certified Nursing Assistant (CNA/staff #150) who put on a gown but did not secure it and donned gloves. Staff #150 briefly spoke to resident #222, then removed the gown and gloves and placed them into the red biohazard. Staff #150 then used hand sanitizer and exited the room. Staff #150 did not wash her hands with soap and water prior to exiting the room. Immediately following the observation, staff #150 stated that because she did not touch anything in the room, the hand sanitizer was acceptable to use. An observation was conducted on (MONTH) 5, 2019 at 12:21 p.m., outside of resident #222's room. At this time, the resident's call light was on. The administrator (staff #147) was observed to walk into resident #222's room carrying a notebook, without donning a gown or gloves. Staff #147 then set the notebook on the resident's bedside table which was next to the resident and then reached over the resident to turn off the call light. Staff #147 conversed with resident #222, then picked up the notebook from the bedside table and walked out of the room, without washing his hands. Immediately following the observation, an interview was conducted with staff #147 who stated that the facility policy for entering a contact isolation room is to put on a gown and gloves, prior to entering the isolation room. Staff #147 said that before exiting the room, remove the gown and gloves, dispose of them in the red biohazard bag inside the room, and wash your hands with soap and water. Staff #147 stated that hand sanitizer would not be acceptable to use when leaving an isolation room. Staff #147 stated he did not do any of those things when he entered and exited the room. Staff #147 then proceeded to apply hand sanitizer to his hands, however, did not wash his hands with soap and water. An interview was conducted on (MONTH) 7, 2019 at 10:13 a.m. with a LPN (staff #151), who stated that when a resident is on contact isolation precautions, the person entering the room should use hand sanitizer prior to applying a gown and gloves, and tie the gown around their neck and waist to secure the gown. Staff #151 said that before exiting the room, the gown and gloves should be removed and placed into the red biohazard bag inside the room, then wash their hands with soap and water. Staff #151 stated that soap and water will ensure the [MEDICAL CONDITION] spores are killed, as hand sanitizer is not effective. An interview was conducted on (MONTH) 8, 2019 at 8:39 a.m. with the Director of Nursing (staff #160), who stated when a resident is on isolation precautions, an isolation cart is set up outside of the resident's room. Staff #160 stated for contact isolation precautions, all people who enter the room, including staff and visitors are to put on a gown and gloves, prior to entering the room every time they enter. Staff #160 said that prior to leaving the room, the person should remove the gown and gloves and dispose of them in the designated biohazard trash bag. Staff #160 stated the person should then wash their hands with soap and water and exit the room, without touching anything else in the room. Review of the facility's Infection Control policy revealed the purpose is to minimize as far as possible, the risks of harm to staff, residents, volunteers, family members and visitors, which may arise through pathogens being passed from one person to another. Staff and residents are most likely sources of infectious agents and are also the most common susceptible hosts. Other people visiting the premises may be at risk of both infection and transmission. The facility ensures effective implementation of infection control. Hand washing and hand care are considered the most important measures in infection control. Effective infection control is central to providing high quality support for residents and a safe work environment for the facility's employees, board members and visitors. Infection control is integral to resident support, not an additional set of practices. Risks of infections are regularly assessed, identified, and managed and mechanisms are put in place for compliance with infection control procedures. Review of a policy regarding Transmission-Based Precautions revealed it is our policy to take appropriate precautions to prevent transmission of infectious agents. Transmission-based precautions are additional controls based on a particular infectious agent and the agent's mode of transmission. These precautions are to be used in adjunct with standard precautions. The policy further included an order for [REDACTED]. Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. Donning personal protective equipment (PPE) upon entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g. [MEDICAL CONDITION], norovirus and other intestinal tract pathogens). Review of the CDC guidelines revealed that [MEDICAL CONDITION] is a spore forming bacterium that causes inflammation of the colon known as [MEDICAL CONDITION]. [MEDICAL CONDITION] spores are shed in feces and transferred to patients mainly via the hands of people who have touched a contaminated surface or item. For the prevention of transmission of [MEDICAL CONDITION] in healthcare settings, use contact precautions for patients with known or suspected [MEDICAL CONDITION]. The guidelines included to use gloves and gowns when entering patient rooms and during care and for all interactions that may involve contact with patient or potentially contaminated areas in the patients environment. The guidelines also stated that before exiting the patient room, discard gowns and gloves, and wash hands with soap and water to contain the [MEDICAL CONDITION] pathogens. -Resident #41 was admitted (MONTH) 3, (YEAR), with [DIAGNOSES REDACTED]. Review of a care plan dated (MONTH) 22, (YEAR) revealed the resident had an indwelling catheter for [MEDICAL CONDITION] bladder. The goal included the resident will have no signs or symptoms of a UTI through the next review date. Interventions included the following: -position tubing below the level of the bladder. -monitor and document for pain/discomfort due to the catheter -monitor/record/report to MD for signs or symptoms of UTI including pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, foul smelling urine, fever and chills. The quarterly Minimum Data Set (MDS) assessment dated (MONTH) 28, (YEAR) revealed the resident had a Brief Interview of Mental Status (BIMS) score of 3, indicating severe cognitive impairment. This MDS also revealed the use of an indwelling catheter. Review of the physician's orders [REDACTED]. During a random observation conducted on (MONTH) 6, 2019 at 8:31 a.m., resident #41 was in bed and the catheter bag was hanging on the bed rail, and approximately 5 inches of the catheter tubing was on the floor. Another observation was conducted on (MONTH) 6, 2019 at 2:49 p.m. of the resident in bed. The catheter bag was observed hanging on the bed rail and approximately 3-4 inches of the catheter tubing was on the floor. An interview was conducted on (MONTH) 7, 2019 at 10:13 a.m. with a Licensed Practical Nurse (LPN/staff #151), who stated that when a resident has a catheter, it is never acceptable for the catheter bag or tubing to be on the floor for infection control prevention. An interview was conducted on (MONTH) 7, 2019 at 1:56 p.m., with a Certified Nursing Assistant (CNA/staff #2). Staff #2 stated that the catheter tubing comes with a clip so it can be secured so it does not drag on the floor. Staff #2 stated that if the tubing drags on the floor, the entire tubing would have to be replaced by the nurse, because the tubing would be contaminated, as it would pick up germs from the floor, and those germs should not be transferred to the resident from the catheter tubing. An interview was conducted on (MONTH) 8, 2019 at 8:39 a.m. with the Director of Nursing (staff #160), who stated that catheter tubing should not be dragging on the floor for infection control purposes. -Resident #321 was admitted on (MONTH) 30, (YEAR), with the [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. An observation was conducted at 11:25 a.m. on (MONTH) 5, 2019, of the resident lying in bed. The resident's catheter bag was hanging under the bed facing the door, and the catheter tubing and the catheter bag was observed touching the floor. Another observation was conducted at 12:01 p.m. on (MONTH) 6, 2019, of a certified nursing assistant (CNA/staff #171) pushing the resident in the wheelchair down the hallway to the dining room. During the transport, approximately 4 inches of the catheter tubing was observed dragging on the floor. At 12:30 p.m. on (MONTH) 6, 2019, the resident was observed in the dining room eating lunch. The catheter tubing was observed resting on the floor under the wheelchair. At 12:55 p.m. on (MONTH) 6, 2019, staff #171 was observed pushing the resident in the wheelchair down the hall from the dining room to the resident's room. The catheter tubing was again dragging on the floor. Following the observation, an interview was conducted with staff #171. He stated that he did not see an issue with the catheter tubing dragging on the floor. He stated there was no way he could secure the tubing higher and prevent it from dragging on the floor. He then stated that he could tuck the tubing in the Foley bag and proceeded to tuck the tubing in the bag. An interview was conducted at 10:13 a.m. on (MONTH) 7, 2019, with a Licensed Practical Nurse (LPN/staff #151). She stated that the urinary catheter tubing or the Foley bag should never touch the floor. An interview was conducted with the Director of Nursing (DON/staff #160), who stated that all Foley drainage bags need to have a privacy bag and that the urinary catheter tubing should not be dragging on the ground. Review of policy and procedure for Catheter Care Urinary revealed the main goal is to prevent catheter-associated urinary tract infection. Under infection control, the policy included Be sure the catheter tubing and drainage bag are kept off the floor.",2020-09-01
47,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2018-06-28,622,D,1,0,KWBO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, review of hospital documentation, staff interviews and review of facility policies and procedures, the facility failed to ensure there was documentation in one resident's (#2) clinical record regarding the basis for the transfer. The sample size was three. Findings include: Resident #2 was admitted to the facility on (MONTH) 15, (YEAR) with [DIAGNOSES REDACTED]. Nursing Note dated (MONTH) 15, (YEAR) documented Arrived from (name of hospital) at 3:15 p.m .Alert and oriented x 3 but slow to speak appears exhausted .Oxygen two liters - not on home oxygen . Review of a Social Services Note dated (MONTH) 18, (YEAR) at 2:03 p.m. documented .requesting that patient be transferred to (another skilled nursing facility) to continue her skilled related to family's dissatisfaction with her care. Writer obtained telephone order for discharge . Review of a Physician Telephone Order dated (MONTH) 18, (YEAR) at 6:18 p.m. documented Send to ER (emergency room ). There was no documentation on the telephone order as to the reason for the transfer and the order was not signed by the resident's primary physician at the facility. Review of the clinical record revealed no documentation regarding the basis for the transfer to the hospital. Review of hospital documentation dated (MONTH) 18, (YEAR) at 10:30 p.m. documented .per her primary care physician .who saw the patient today, patient was somnolent and hypoventilating this afternoon and hypoxic (83% on room air) . An interview was conducted with the medical records clerk, staff #76 on (MONTH) 27, (YEAR) at 11:38 a.m. The medical records clerk stated that the resident did not get transferred to the other skilled nursing facility because of insurance purposes but that she thought the resident's family took the resident to the hospital. An interview was conducted with the DON (director of nursing), staff #64 on (MONTH) 27, (YEAR) at 2:00 p.m. The DON stated that she did not think the resident had a change of condition but that she did not have anything to back that up because the agency nurse did not document why the resident was discharged . An interview was conducted with the resident's primary physician on (MONTH) 27, (YEAR) at 4:00 p.m. The physician stated that he was the resident's primary physician while she resided at the facility but did not give an order to send the resident to the hospital. An interview was conducted with the DON, staff #64 on (MONTH) 27, (YEAR) at 4:05 p.m. The DON stated that the resident also had a concierge physician who must have gave the order to transfer the resident to the hospital as the telephone order did not indicate which physician gave the order and it was not signed by a physician. The DON further stated that the licensed nurse did not document the reason for discharge to the hospital. Another interview was conducted with the DON, staff #64 on (MONTH) 28, (YEAR) at 9:10 a.m. The DON stated that the nurse who got the order to transfer the resident to the hospital was an agency nurse. The DON stated that she noticed there was no documentation in the clinical record so she called the agency to ask the agency nurse to document as to why the resident was sent to the hospital. The DON stated that the agency nurse stated that she could not remember. An interview was conducted with an RN (registered nurse), staff #92 on (MONTH) 28, (YEAR) at 12:28 p.m. The RN stated that if she had to transfer a resident to the hospital that she would write a basic summary of what was going on with the resident, who was notified such as the physician and family, and document that in the resident's clinical record. An interview was conducted with a LPN (licensed practical nurse), staff #93 on (MONTH) 28, (YEAR) at 12:35 p.m. The LPN stated that if she transferred a resident to the hospital that she would document the reason as to why the resident was being transferred, who was notified, who gave the order and any other pertinent information. The LPN further stated that she would document that in the resident's clinical record. Review of the facility's policy Emergency Transfer or Discharge documented .Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: .Prepare a transfer form to send with the resident .",2020-09-01
48,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2018-06-28,689,G,1,0,KWBO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, and review of facility policies and procedures, the facilty failed to ensure that one resident (#1) was transferred appropriately to prevent a fracture to her humerus. The sample size was three. Findings include: Resident #1 was admitted to the facility on (MONTH) 19, 2012 with [DIAGNOSES REDACTED]. Review of an ADL (activities of daily living) care plan dated (MONTH) 13, (YEAR) revealed Resident requires extensive assist with ADLs with two staff members for transfers .due to debility, due [MEDICAL CONDITION] and right sided sensory impairment. A goal documented was Resident will .have daily needs met by staff. Approaches documented were Two staff members for all transfers. Patient and her daughters refuse gait belt use. They have been educated but continue to state their refusal . Review of the quarterly MDS (Minimum Data Set) assessment dated (MONTH) 4, (YEAR), section G Functional Status revealed the resident required the extensive assistance of 2 for transfers and support. Nursing Note dated (MONTH) 23, (YEAR) documented Resident was being transferred by CNA (certified nursing assistant) from bed to wheelchair. When resident's legs touched the front wheel of the wheelchair and CNA was unable to complete transfer safely that's when CNA lowered resident gently to the floor and called for help. Nursing Note dated (MONTH) 23, (YEAR) documented Resident x-rays came back abnormal for RUE (right upper extremity). Orders were received and transcribed. Family is aware of transportation to (name of hospital) emergency room for further evaluation . An Accident/Incident Report dated (MONTH) 23, (YEAR) by the CNA who transferred the resident when she fell , staff #91, documented We were pivoting to sit in chair. Then she said oh. I looked down and seen her left foot slide behind her small front wheel. I could not hold her up and get her right foot in the right place so I slowly slid down my leg to a soft sit then held her up till nurse came and helped. I only held her under her arms. Got her feet in right place. I lifted her up and nurse had her legs. We sat her in the chair. Have never had a transfer go this way . A hospital History and Physical dated (MONTH) 23, (YEAR) documented .she had a fall while she was being lifted from the bed on her right side, complaining or right hip pain, right arm pain, about 7 out of 10 .Humerus fracture . Review of a nurse practitioner progress note dated (MONTH) 29, (YEAR) documented .Her right side is her weak side affected [MEDICAL CONDITION] when purposely moved with transfers or care, the area remains painful for patient .[MEDICATION NAME] increased to BID (twice a day) . An interview was conducted with a CNA, staff #41 on (MONTH) 28, (YEAR) at 9:02 a.m. The CNA stated that if she is unsure how a resident should be transferred she asks the nurse or physical therapist prior to transferring the resident. The CNA stated that the licensed nurse documents on the Report Sheet how a resident should be transferred. The CNA stated that if a new staff person or agency staff is working we always tell them how a resident should be transferred. An interview was conducted with a CNA, staff #21 on (MONTH) 28, (YEAR) at 9:10 a.m. The CNA stated that when a new resident is admitted we get report on how to care for them. The CNA stated that he always checks with the nurse first to see how a resident should be transferred. The CNA further stated that he would never transfer a resident without checking with the nurse first because you could do more harm than good. An interview was conducted with the DON (director of nursing), staff #64 on (MONTH) 28, (YEAR) at 9:15 a.m. The DON stated that the CNA who transferred the resident when she fell was an agency CNA but that she had been familiar with the residents. The DON stated that she thought the resident required the assistance of one person for transfers. When the resident's care plan was reviewed with the DON, the DON acknowledged that it was the assistance of two for transfers but stated that the facility usually used a mechanical lift if the resident required the assistance of two for transfers. The DON further stated that the MDS coordinator develops the care plan and then refers the information to the licensed nurse on the unit. An interview was conducted with the MDS coordinator, staff #15 on (MONTH) 28, (YEAR) at 9:30 a.m. The MDS coordinator stated that she completed the MDS and the care plan prior to the resident's fall and the resident was assessed to require two staff for transfers because of her [MEDICAL CONDITION]. The MDS coordinator further stated as far as I know she should have had two CNA's to transfer her at the time of the fall. An interview was conducted with the CNA, staff #91, who transferred the resident at the time of the fall on (MONTH) 28, (YEAR) at 10:50 a.m. The CNA stated that she worked at the facility as an agency CNA quite a few times. The CNA stated that she asked and was told that the resident was weight bearing and a one person transfer. The CNA stated that she always checked with facility staff first before she transferred a resident. The CNA stated that she did not want the resident to fall so she lowered her to the floor. The CNA stated she found out later that the resident was not feeling good that day. The CNA further stated the resident did not fall, she was an assist to sit. Another interview was conducted with the DON, staff #64 on (MONTH) 28, (YEAR) at 1:00 p.m. The DON stated that the facility did not have a specific policy regarding safe transfers but that she would expect staff to transfer residents safely and follow the care plan. A review of the facilty's policy Managing Falls and Fall Risk documented Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling .",2020-09-01
49,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2016-10-06,241,D,0,1,VEV011,"Based on observation, staff interviews, and policy and procedures, the facility failed to promote care for residents in a manner that enhances each resident's dignity and respect, by failing to offer residents condiments with their meals and by failing to promptly clean a resident after a beverage spill. Findings include: A dining observation was conducted on (MONTH) 3, (YEAR) at 11:45 a.m., on the secured dementia unit. Prior to the start of the lunch meal, one resident was observed to spill a can of soda on her clothing and on the table where she was seated. The resident was observed to call out I need some help over here, please. One CNA (Certified Nursing Assistant) responded to the resident's call for help and proceeded to wipe up the soda spill from the table. However; the CNA neglected to clean or offer to change the resident's wet clothing. The resident ate her meal in wet clothing. In addition, during this meal observation no condiments, including salt and pepper were offered to the residents. An interview was conducted on (MONTH) 4, (YEAR) at 12:40 p.m., with a LPN (Licensed Practical Nurse/staff #177). She stated that salt and pepper and other condiments are provided to residents if they ask for it. She stated that if a resident was unable to request any condiments and was eating good, then the food must be alright and the condiments would not be offered. Another interview was conducted on (MONTH) 4, (YEAR) at 12:45 p.m., with a CNA (staff #224). She stated that she had not cleaned the resident after the soda spill, because it was a crazy day. She stated that she should have cleaned and changed the resident right after the spill. An interview was conducted on (MONTH) 4, (YEAR) at 2:30 p.m., with the DON (Director of Nursing/staff #161). She stated that all residents should have been offered condiments for their meal. She also stated that the resident who spilled the soda should have been cleaned and changed, since she would want clean, dry clothing on for her meal. A facility policy titled Condiments, Food Baskets and Food Items at the Table included, Individuals who are able should be allowed to self-select items such as condiments, bread and crackers. Condiments placed on the tables for meal service will be monitored for diet compliance to prescribed physician prescribed diets .by designated facility staff during meal service. The facility was unable to provide a written policy regarding the care of residents during a meal.",2020-09-01
50,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2016-10-06,279,D,0,1,VEV011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to ensure that a comprehensive care plan was developed, as indicated in Section V. of the MDS (Minimum Data Set) assessment for one resident (#76). Findings include: Resident #76 was admitted on (MONTH) 13, (YEAR), with [DIAGNOSES REDACTED]. A review of Section V. of the admission (Minimum Data Set (MDS) assessment dated (MONTH) 20, (YEAR), revealed the care area for activities of daily living triggered and a care plan would be developed to address the resident's needs. However, the clinical record did not include any documented evidence that an activities of daily living care plan had been developed. An interview was conducted on (MONTH) 6, (YEAR), with MDS staff #234, who following a review and comparison of the MDS assessment and care plans, stated that an activities of daily living care plan should have been developed as indicated in Section V. of the MDS assessment. An interview was conducted on (MONTH) 6, (YEAR) at 12:13 p.m., with the ADON (Assistant Director of Nursing/staff #178), who following a review of the clinical record stated that the expectation was that care plans would be developed as indicated. Staff #178 also stated that the facility did not have a policy regarding the development of comprehensive care plans based on Section V. of the MDS assessment.",2020-09-01
51,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2016-10-06,314,E,0,1,VEV011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that pressure ulcer care and services were consistently provided for one resident (#24). Findings include: Resident #24 was readmitted on (MONTH) 16, (YEAR), with [DIAGNOSES REDACTED]. The admission nursing evaluation dated (MONTH) 16, (YEAR), included that the resident's left heel had a round black area, which measured 4 by 4 cm (centimeters) and that it was possibly a deep tissue injury. A pressure ulcer care plan was developed on (MONTH) 16, (YEAR), and included documentation that an unstageable pressure ulcer was present on the resident's left heel. A Braden Risk assessment dated (MONTH) 16, (YEAR), identified that the resident was a high risk for the development of a pressure ulcer. The resident's score was a 12 and according to the Braden risk assessment key, a score of 10 to 12 indicated a high risk. Review of the clinical record revealed there were no specific admission treatment orders for the unstageable pressure ulcer to the resident's left heel. A history and physical dated (MONTH) 22, (YEAR), included that eschar was present on the resident's left heel. A physician's orders [REDACTED]. The (MONTH) (YEAR), TAR included the physician's orders [REDACTED]. The next pressure ulcer assessment was not completed until 13 days later on (MONTH) 29, (YEAR). The documentation included that an unstageable pressure ulcer was present on the resident's left heel, which measured 2.5 by 3 cm and to continue the skin prep every shift and prn. Review of a nurse's note dated (MONTH) 6, (YEAR), revealed the resident had an unstageable pressure ulcer to the left heel, which measured 2 x 4 cm with 100% eschar. A review of the (MONTH) (YEAR), TARs revealed that the skin prep order which was to be done every shift had been transcribed to be done nightly and prn, and not every shift as physician ordered. Further review revealed that the skin prep was only applied three times from (MONTH) 1 through 7, by the night shift. A physician's orders [REDACTED]. Another physician's orders [REDACTED]. The next pressure ulcer assessment was not completed until 21 days later on (MONTH) 19, (YEAR), which included that an unstageable pressure ulcer was present on the resident's left heel, which measured 2 by 3.5 cm with slough/eschar present. The new recommendation was to apply Santyl everyday and prn to the slough/eschar. A physician's orders [REDACTED]. The next pressure ulcer assessment was dated (MONTH) 26, (YEAR), and included that the resident had a pressure injury to the left heel, which was unstageable and measured 2.4 by 3.7 cm with slough present. The recommendation was to continue with the same treatment. On (MONTH) 26, (YEAR), another physician's orders [REDACTED]. Review of the (MONTH) (YEAR), TAR revealed there was no documented evidence that the prescribed Santyl treatment had been provided on (MONTH) 29, as scheduled. The next pressure ulcer assessment was not completed until 28 days later on (MONTH) 23, (YEAR). The documentation included that an unstageable pressure injury was present on the resident's left heel and measured 2 by 3 cm, with slough present. The recommendation was to continue with the current treatment plan. A review of the (MONTH) (YEAR), TAR revealed the transcription of the Santyl order and to apply it every two days. However, according to the (MONTH) (YEAR), TAR, the Santyl treatment had been provided daily instead of every two days as physician ordered, except on (MONTH) 11, and 29, which were blank. An interview was conducted on (MONTH) 5, (YEAR), with the DON (Director of Nursing/staff #161). She stated that she provides the monthly pressure ulcer assessments, but the nursing staff were responsible to do the required weekly skin assessments, which would include a complete evaluation of any pressure ulcers which were present. Staff #161 stated she was not aware that the weekly wound assessments had not been provided by the licensed staff. Another interview was conducted on (MONTH) 6, (YEAR), with staff #161. She stated that the (MONTH) and (MONTH) treatment orders were not always administered as physician ordered. She also stated that the TARs were suppose to be signed when the prescribed treatment was administered. A facility policy titled, Pressure Ulcer Risk Assessment included that the purpose was to provide guidelines for the assessment and identification of residents at risk of developing pressure ulcers. The policy included that pressure ulcers are a serious skin condition for the resident and to routinely assess and document the condition of the resident's skin, per the facility's wound and skin care program. Skin assessments are to be completed weekly or more frequently if indicated. Per the policy, the at risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. The admission evaluation helps identify those initial approaches and interventions. In addition, the policy included that the admission evaluation may identify pre-existing signs (such as a purple or very dark area that is surrounded by profound redness, [MEDICAL CONDITION], or induration) suggesting that deep tissue damage has already occurred and additional deep tissue loss may occur. This deep tissue damage could lead to the appearance of an unavoidable stage 3 or 4 pressure ulcer or progression of a stage 1 pressure ulcer to and ulcer with eschar or exudate within days of admission. The policy also included that the following should be recorded in the resident's clinical record: 5. The condition of the resident's skin 9. Observations of anything unusual exhibited by the resident. 11. Initiation of a (pressure or non-pressure) form related to the type of alteration in skin noted.",2020-09-01
52,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2016-10-06,334,D,0,1,VEV011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and policy review, the facility failed to ensure that the Pneumococcal vaccine was offered to one resident (#166). Findings include: Resident #166 was admitted (MONTH) 31, (YEAR), with [DIAGNOSES REDACTED]. Review of the (MONTH) (YEAR) recapitulation of physician orders [REDACTED]. However, review of the clinical record revealed no documented evidence that the pneumococcal vaccine was offered to the resident or that the resident refused the vaccine, or that the vaccine was contraindicated. An interview was conducted on (MONTH) 6, (YEAR) at 2:45 p.m., with the Assistant Director of Nursing (staff #178). She was unable to locate any documented evidence that the pneumococcal vaccine had been offered. A facility policy titled, Pneumococcal Vaccine included all residents will be offered the Pneumococcal vaccine to aid in preventing pneumonia/Pneumococcal infection. The policy also included: 1. Prior to admission, residents will be assessed for eligibility to receive the Pneumococcal vaccine series., and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. 3. Before receiving a Pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of Pneumococcal vaccine.",2020-09-01
53,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2016-10-06,364,D,0,1,VEV011,"Based on observations and staff interviews, the facility failed to ensure that residents were assisted with their meals in a timely manner, in order to maintain food at preferable temperatures. Findings include: A dinning observation was conducted on (MONTH) 3, (YEAR) at 11:45 a.m. on the Kalmanovitz secured dementia unit. During this observation, two residents were seated in their wheelchairs at the same table. Once the noon meal arrived on the unit, the food was served to both of the residents and the plate covers were removed. At this time, neither resident was observed to attempt to feed themselves, nor did staff attempt to feed either resident. After 15 minutes, a CNA (Certified Nursing Assistant/staff #224) attempted to assist one of the residents with her meal. The resident was observed to not want to eat the meal. After 5 minutes, the CNA moved to the second resident and attempted to feed this resident. However, this resident also did not want to eat her food. Further observations revealed that the CNA, nor any other staff member was observed to offer to re-heat the resident's food. An interview was conducted with staff #224 immediately following this observation. Although the lunch meal had sat uncovered for 15-20 minutes, staff #224 stated that she thought the food would still be warm, because she could feel the warmth from the food, while she cut the noodles up with a spoon. Another interview was conducted on (MONTH) 4, (YEAR) at 2:30 p.m., with the DON (Director of Nursing/staff #161). She stated that the residents' food should have remained covered until staff were ready to assist the residents with their meals. She also stated that the meal could have been re-heated if needed.",2020-09-01
54,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2016-10-06,371,D,0,1,VEV011,"Based on observation, staff interviews and policy review, the facility failed to ensure that staff did not touch ready to eat food with bare hands. Findings include: A dining observation was conducted on (MONTH) 3, (YEAR) at 11:45 a.m. on the Kalmanovitz secured dementia unit. During this observation, a CNA (Certified Nursing Assistant/staff #185) was observed to touch a resident's muffin, with her bare hands. An interview was conducted on (MONTH) 4, (YEAR) at 12:30 p.m., with the CN[NAME] Although the CNA was unable to recall if she had touched any resident's food with her bare hands, she stated that would be a sanitary problem. Another interview was conducted on (MONTH) 4, (YEAR) at 2:30 p.m., with the Director of Nursing (staff #161) who stated that staff should not handle ready to eat food with their hands and that utensils should have been used. A facility policy titled, Assistance with Meals included: 7. All employees who provide resident assistance with meals will be trained and shall demonstrate competency in the prevention of foodborne illness, including personal hygiene practices and safe food handling.",2020-09-01
55,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2016-10-06,431,E,0,1,VEV011,"Based on observations, staff interviews and review of policies and procedures, the facility failed to ensure that medications were properly stored, and that expired medication and laboratory supplies were not expired and available for resident use. The facility also failed to ensure that the medication refrigerator temperatures were consistently monitored. Findings include: A medication storage observation was conducted on (MONTH) 3, (YEAR), on all of the nursing units and the following concerns were identified: Kalmanovitz secured dementia unit: In the Medication storage room, there was an unlocked medication refrigerator which contained a locked plastic narcotic box. However, the narcotic box was not affixed to the inside of the medication refrigerator. Further observations revealed that the plastic narcotic box did not fully close, and the opening was large enough to withdraw medications from the box, without unlocking it. Inside the plastic narcotic box were a total of 23 vials of Lorazepam (an anti-anxiety medication). At this time, the medication refrigerator temperature log for (MONTH) (YEAR) was reviewed and revealed that there was no documentation that the temperature of the refrigerator was monitored on one day. An interview was conducted on (MONTH) 4, (YEAR) at 12:45 p.m., with a LPN (Licensed Practical Nurse/staff #177). She stated that she had contacted the maintaince department and had the narcotic box permanently secured. At this time, another observation of the narcotic box was conducted. Inside of the unlocked refrigerator was a locked plastic narcotic box. The narcotic box was now attached to a shelf in the refrigerator. However, the shelf was able to be easily removed, along with the narcotic box. Rich unit: In the medication storage room there were eight yellow cap laboratory tubes, which had an expiration date of (MONTH) (YEAR). In addition, the medication refrigerator temperature logs were reviewed and revealed the following: in (MONTH) (YEAR), there were four days with no evidence that the temperature had been monitored; in (MONTH) (YEAR), there were two days with no documented evidence that the temperature had been monitored; and in (MONTH) (YEAR), there were two days with no documented evidence that the temperature had been monitored. Following this observation, an interview was conducted with a LPN (Licensed Practical Nurse/staff #6). She stated that the laboratory test tubes were occasionally used when blood was needed to be drawn. Staff #6 stated that the night shift nurses were responsible to monitor and document the medication refrigerator temperatures. She stated that the day shift nurses will now need to double check that it was done. Bregman unit: On the Medication cart, there was one vial of Lantus Insulin with an opened date of (MONTH) 26, (YEAR). Per the manufacturer's instructions, the insulin would expire 28 days after the date of opening. There were also two opened sets of Insulin Control Solution, which had an expiration date of (MONTH) (YEAR). In addition, there was an unlocked medication refrigerator which was located inside the locked medication storage room. Inside of the refrigerator was a locked narcotic box, however, it was not permanently affixed to the refrigerator. The narcotic box contained a box of 15 tablets of Dronabinol (a controlled drug used to treat nausea and vomiting associated with chemotherapy). The medication refrigerator temperature logs were also reviewed and revealed the following: in (MONTH) (YEAR), there was one day without a recorded temperature; in (MONTH) (YEAR), there were six days without a recorded temperature and in (MONTH) (YEAR), there were four days without a recorded temperature. Following this observation an interview was conducted with a LPN (staff #106), who stated that it was the night shifts responsibility to check weekly for expired medications and supplies. Golding unit: The medication refrigerator temperature logs were reviewed and revealed the following: in (MONTH) (YEAR), there were eight days without a recorded temperature; in (MONTH) (YEAR), there were two days without a recorded temperature and in (MONTH) (YEAR), there were two days without a recorded temperature. An interview was conducted on (MONTH) 4, (YEAR), with the DON (Director of Nursing/staff #161). She stated that she was not aware that the refrigerated narcotic boxes were not permanently affixed. She stated that the boxes need to be secured and that locking them to a removal shelf did not ensure that they were permanently affixed. The DON also stated that both the laboratory provider and the nursing staff were responsible to ensure that expired items were not available. According to the DON, the night shift licensed staff were responsible to check the medication refrigerator temperatures nightly, and the medication carts for expired medications and medical supplies. Per the DON, any expired medication or medical item, should be discarded and replaced. A facility policy titled, Storage of Medications included The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The policy also included the following: 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Another facility policy titled, Controlled Substances included The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Scheduled II and other controlled substances. The policy also included the following: 5. Controlled substances must be stored in the medication room in a locked container, separate from containers for any non-controlled medications. The container must remain locked at all times, except when it is accessed to obtain medications for residents.",2020-09-01
56,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2016-10-06,441,D,0,1,VEV011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, and review of policies and procedures, the facility failed to ensure that dietary staff used proper handwashing techniques and failed to ensure proper infection control practices were implemented during a pressure ulcer treatment for one resident (#24). Findings include: -Observations were conducted on (MONTH) 5, (YEAR) of multiple dietary staff members washing their hands in the kitchen sinks. The handwashing sinks were equipped with faucet rods in the center of the faucet spigot. The purpose of the faucet rods were to turn the water on and off. To turn on the water, the faucet rod had to be moved and the rod had to be held onto, in order to keep the water flowing. If you let go of the rod, the water turned off. Multiple observations revealed that dietary staff touched the faucet rods with their soiled hands to turn on the water, then let go of the faucet rod and lathered their hands with soap, then they had to touch the faucet rod again with their clean hands to start the flow of water, in order to rinse their hands. An interview was conducted with the dietician (staff #233) on (MONTH) 5, (YEAR) at 11:20 a.m. The dietician stated that the faucet rod was contaminated, unless it was facility procedure to clean the faucet rods after each use. An interview was conducted with the food service assistant manager (staff #63) on (MONTH) 5, (YEAR) at 12:00 p.m. The food service assistant manager did not recognize a problem with this handwashing procedure. A review of the facility's policy on Hand Washing revealed for staff to wash hands following proper hand washing procedures. Instructions on how to wash hands included to turn on the faucet using a paper towel to avoid contaminating the faucet, wet hands and scrub with soap and additional water as needed, rinse thoroughly, dry hands with a paper towel and turn the faucet off with a paper towel. -Resident #24 was readmitted on (MONTH) 16, (YEAR), with [DIAGNOSES REDACTED]. A review of the clinical record revealed documentation that the resident had an unstageable pressure ulcer on the left heel A pressure ulcer treatment observation was conducted on (MONTH) 4, (YEAR) at 1:15 p.m., with a RN (registered nurse/staff #222). At this time, staff #222 was observed to gather the treatment supplies, enter the resident's room, donn gloves and place all of the treatment supplies, including a tube of Santyl and various dressings, on the resident's bedside table. However, staff #222 was not observed to wash or disinfect her hands prior to this. A clean barrier also had not been placed on the bedside table. Staff #22 then raised the head of the resident's bed and changed her gloves. Staff #222 then removed the old dressing and changed her gloves. However, staff #222 was not observed to wash or disinfect her hands after the removal of the soiled dressing. Staff #222 then proceeded to wash the pressure ulcer with soap and water, measured the wound, removed her gloves and washed her hands. However, she was only observed to rinse her hands under the water for five seconds and did not use any soap. She then touched the automatic paper towel dispenser twice, with her clean hands, thereby, coming into contact with a potentially contaminated surface (the paper towel dispenser). Once her hands were dry, staff #222 was observed to donn gloves and apply the Santyl ointment with her gloved finger to the pressure ulcer and then placed a dressing on the wound. An interview was conducted on (MONTH) 4, (YEAR) at 2:15 p.m., with staff #222. She stated that she had washed her hands prior to gathering the treatment supplies, but agreed that she had not washed her hands prior to donning gloves at the start of the treatment. Staff #222 also stated that she should have cleaned the bedside table surface or placed a barrier on it. In regards to handwashing, staff #222 stated that she should have washed her hands every time she changed her gloves and that she should have washed her hands with soap and water for 30 seconds. An interview was conducted on (MONTH) 4, (YEAR) with the DON (Director of Nursing/staff #161), who stated that the RN should have washed or disinfected her hands, prior to the start of the pressure ulcer treatment and should have washed her hands with soap and water for 30 seconds, and she should not have touched the paper towel dispenser with her hands after washing. Staff #161 also stated that the resident's bedside table should have been wiped down or a paper towel placed on it, in order to provide a clean work surface. A facility policy titled, Handwashing/Hand Hygiene included This facility considers hand hygiene the primary means to prevent the spread of infections. The policy also included the following: 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: b. Before and after direct contact with residents; g. Before handling clean or soiled dressings, gauze pads, etc; j. After contact with blood or bodily fluids; k. After handling used dressings, contaminated equipment, etc. m. After removing gloves; 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. In addition, the policy included a section for proper hand washing. It included the following: 1. Vigorously lather hands with soap and rub together creating friction to all surfaces for a minimum of 20 seconds (or longer) under a moderate stream of running water, at a comfortable temperature. The handwashing/hand hygiene policy also included a section titled, Applying and Removing Gloves and the following was included: 1. Perform hand hygiene before applying non-sterile gloves.",2020-09-01
57,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2017-10-19,154,E,0,1,PP4811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, and policy review, the facility failed to ensure three residents and/or representatives (#94, #195 and #230) were informed of the risks and benefits of [MEDICAL CONDITION] medications, prior to administering. Findings include: -Resident #94 was admitted (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. A care plan dated (MONTH) 1, (YEAR) included that the resident exhibited intrusive behaviors and was difficult to redirect related to [DIAGNOSES REDACTED]. Interventions included for medications to be administered as ordered by the provider. Review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 5, (YEAR) revealed a BIMS (Brief Interview for Mental Status) score of 13, which indicated the resident was cognitively intact. The MDS also included the resident received an anti-depressant. The physician's orders [REDACTED]. However, review of the clinical record revealed no evidence that the resident was informed of the risks and benefits of the Trazadone and the [MEDICATION NAME]. In an interview conducted with a Licensed Practical Nurse (LPN/staff #131) on (MONTH) 19, (YEAR) at 9:30 a.m., she stated that before a resident is administered [MEDICAL CONDITION] medications, the risks and benefits should be explained to the resident. Staff #131 stated that an informed consent which includes the risks and benefits of the medication should be signed by the resident or resident representative before administration. During an interview conducted on (MONTH) 19, (YEAR) at 12:11 p.m. with the Director of Nursing (DON/staff 64), she stated that she was unable to locate an informed consent for these medications for this resident. -Resident #195 was admitted on (MONTH) 26, (YEAR), with [DIAGNOSES REDACTED]. Review of an admission MDS assessment dated (MONTH) 3, (YEAR) revealed the resident had a BIMS score of 8, which indicated moderate cognitive impairment. A care plan dated (MONTH) 2, (YEAR) included the resident was at risk for side effects and adverse reactions due to the use of an antidepressant medication. An approach included to involve family in resident care. A physician's orders [REDACTED]. However, there was no clinical record documentation that the risks and benefits of Trazadone were discussed with the resident/resident representative, prior to administration. An interview was conducted with staff #64 on (MONTH) 19, (YEAR) at 8:24 a.m. She stated that she was unable to locate an informed consent for the Trazadone. -Resident #230 was admitted on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A care plan dated (MONTH) 1, (YEAR) included the resident was at risk for side effects and adverse reactions due to the use of antidepressant medications. An approach included to involve the family in resident care. Review of the MDS assessment dated (MONTH) 8, (YEAR) revealed a BIMS score of 8, which indicated the resident had moderate cognitive impairment. The MDS also included the resident was administered antipsychotic and antidepressant medications. Further review of the clinical record revealed that a consent form was signed by the resident's family member dated (MONTH) 1, (YEAR). However, the consent form did not include the name of any medications or any information regarding the risks and benefits of the medications. An interview was conducted with a Licensed Practical Nurse (LPN/staff #128) on (MONTH) 19, (YEAR) at 9:16 a.m. She stated that prior to administering [MEDICAL CONDITION] medications, an informed consent containing the name of the medication and the risks and benefits of the medication needs to be signed by the resident/resident representative. An interview was conducted with staff #64 on (MONTH) 19, (YEAR) at 9:27 a.m. She stated that an informed consent containing the risks and benefits of the medication must be obtained prior to administering the medication. She stated that if a resident is unable to sign the informed consent, then the resident's responsible person would be contacted to obtain the informed consent. A policy regarding Antipsychotic Medication Use did not address the need to obtain informed consent for antipsychotic medications or of the need to inform residents/resident representative of the risks and benefits, prior to administration.",2020-09-01
58,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2017-10-19,278,D,0,1,PP4811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for one resident (#195). Findings include: Resident #195 was admitted (MONTH) 26, (YEAR), with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of an admission Minimum Data Set (MDS) assessment dated (MONTH) 3, (YEAR) revealed the resident was administered an antipsychotic medication for 7 days during the look back period. However, review of the (MONTH) and (MONTH) (YEAR) Medication Administration Record [REDACTED]. The MDS further included that the resident was administered a hypnotic medication on 5 days, during the look back period. However, review of the (MONTH) 27 through (MONTH) 3, (YEAR) MARs revealed the resident received the hypnotic medication for 3 days during the look back period. In addition, the MDS included that the resident was not administered an anticoagulant medication. However, review of the (MONTH) 27 through (MONTH) 3, (YEAR) MARs revealed the resident was administered an anticoagulant medication for 7 days. The MDS further included the resident was administered an antibiotic medication for 7 days. However, review of the (MONTH) 27 through (MONTH) 3, (YEAR) MARs revealed the resident was administered an antibiotic medication for 5 days during the look back period. An interview was conducted with the MDS coordinator/Assistant Director of Nursing (ADON/staff #8) on (MONTH) 19, (YEAR) at 8:49 a.m. She stated that when coding medications administered on the MDS, the MAR indicated [REDACTED]. Staff #8 stated that the correct coding for the MDS assessment dated (MONTH) 3, (YEAR), should have included that an anticoagulant medication was administered for 7 days, an antipsychotic medication was administered for 6 days, an antibiotic medication was administered for 5 days, and a hypnotic medication was administered for 3 days. She stated that the expectation is that the MDS assessment is accurate. Review of the RAI manual revealed to review the resident's medical record for documentation that certain medications were administered to the resident during the 7 day look-back period and to record the number of days that the select medications were administered to the resident during this time.",2020-09-01
59,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2017-10-19,281,D,0,1,PP4811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy review, the facility failed to ensure an order was clarified with the physician regarding the frequency for administering a narcotic pain medication to one resident (#257). Findings include: Resident #257 was admitted (MONTH) 8, (YEAR) with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The order did not include a frequency for administration. Review of the Medication Administration Record [REDACTED]. However, the MAR indicated [REDACTED]. Review of the clinical record revealed there was no order for the [MEDICATION NAME] to be administered every four hours PRN. An interview was conducted on (MONTH) 18, (YEAR) at 9:28 a.m., with a licensed practical nurse (staff #141). She stated the order for [MEDICATION NAME] did not have a frequency and should have been clarified with the physician. Staff #141 stated that physician's orders [REDACTED]. An interview was conducted on (MONTH) 18, (YEAR) at 9:51 a.m., with the Assistant Director of Nursing (staff #8). Staff #8 stated medication orders should include the frequency. She stated the expectation is for nurses to call the physician to clarify an order. Staff #8 stated the [MEDICATION NAME] order did not have a frequency and the order was not clarified with the physician. During an interview conducted (MONTH) 19, (YEAR) at 11:23 a.m. with the Director of Nursing (staff #64), staff #64 stated medication orders should include the medication frequency, and if the frequency is not written, the nurse is to clarify the order with the physician. Review of the facility's policy regarding Administering Medications revealed that medications must be administered in accordance with the orders, including any required time frame.",2020-09-01
60,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2017-10-19,371,E,0,1,PP4811,"Based on observations, facility documentation, staff interviews and policy and procedures, the facility failed to ensure that food and kitchenware were stored in a clean and sanitary manner, and failed to ensure sanitation levels for the dishwashing machine were consistently monitored. Findings include: Regarding the food storage: An observation of the kitchen was conducted at 11:00 a.m. on (MONTH) 16, (YEAR) and the following was observed: -A head of romaine lettuce was stored uncovered on a wheeled cart. The lettuce was in contact with the surface of the cart. -In the dry storage room there were multiple tea bags stored on a food rack. The tea bags were uncovered and in direct contact with the rack. In an interview with the assistant food service manager (staff #105) at 11:05 a.m. on (MONTH) 16, (YEAR), he stated that these items should not be stored this way. The Food Storage policy included that sufficient storage facilities are provided to keep foods safe. The policy also included food is stored in an area that is clean, dry, and free from contaminants and that food should be stored in covered containers or wrapped carefully and securely. Regarding the storage of kitchenware: An observation of the kitchen was conducted at 10:35 a.m. on (MONTH) 18, (YEAR) and the following was observed: -A tray with multiple ready-to-use bowls was stored near the dish room. The bowls were observed to be wet and when handled, the water dripped to the floor. -Multiple ready-to-use plastic cups which were stacked on top of each other were observed to be wet and when handled, water dripped onto the floor. -Multiple ready-to-use plates were stored on a rack with food debris on them. The food debris fell to the floor when the plates were lifted. -Two small pans stored ready-to-use had dried food debris on them. -A large rack had stuck-on debris on it and was stored ready-to-use. -Two metal bowl grill covers stored ready-to-use had blackened debris on them. An interview was conducted with staff #105 at 10:45 a.m. on (MONTH) 18, (YEAR). He stated that ready-to-use dishes should be stored clean. Staff #105 stated that the large rack is used as a cooling rack and that it should have been cleaned better before it was put away. He stated the metal bowls are used to cover hamburgers that are cooked on the grill and did not know what was on them. An interview was conducted with the dishwasher (staff #73) at 11:00 a.m. on (MONTH) 18, (YEAR). He stated that he makes sure that dishes are dry and clean before putting them away. The policy regarding Clean Equipment and Utensils included that clean equipment and utensils will be handled to prevent contamination. Clean equipment will be stored in a clean and dry location in a way that protects them from splashes, dust or other contamination. The policy further included that glasses and cups will be stored in an inverted position, and stored utensils should be covered or inverted wherever possible. Regarding the dishwashing machine sanitation monitoring: Review of the dishwashing machine sanitation monitoring log for (MONTH) (YEAR) revealed kitchen staff were checking the dishwashing sanitation levels twice a day, once in the morning and once in the evening. Further review of the log revealed no documentation that the sanitation level was checked on the evening of (MONTH) 17, and on the morning of (MONTH) 18. At this time, a copy of the log was requested. When the log was provided, the missing information regarding the checking of the sanitation levels had been filled in for (MONTH) 17 and 18. The initials of a staff member (identified as staff #73) were documented for the evening check on (MONTH) 17. An interview was conducted with staff #105 at 10:45 a.m. on (MONTH) 18, (YEAR). Staff #105 stated a dishwasher (staff #69) had checked the dishmachine this morning, but did not document it. He stated that staff #69 wrote in the information for today on the log after it was identified. He stated that another dishwasher (staff #73) had filled in the information for the evening of (MONTH) 17. During an interview with a dishwasher (staff #73) at 11:00 a.m. on (MONTH) 18, (YEAR), she stated that she did not work the evening shift on (MONTH) 17, (YEAR) and did not know why her initials were on the log. An interview with staff #69 was conducted at 11:25 a.m. on (MONTH) 18, (YEAR). He stated that he had checked the dishwashing machine sanitation this morning, but had not documented it on the log, until the missing documentation had been identified. Review of the policy regarding the Dishwashing Machine Temperature Log revealed that the dishwashing staff will monitor and record dish machine temperatures to assure proper sanitizing of dishes. The policy included that the staff will be trained to record dishwashing machine temperatures for the wash and rinse cycles in the morning and in the evening, and that the dietary manager will spot check this log to assure temperatures are appropriate and staff are actually monitoring the dishwashing temperatures.",2020-09-01
61,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2017-10-19,500,D,1,1,PP4811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, and facility documentation, the facility failed to ensure that a urology appointment was scheduled in a timely manner for one resident (#173). Findings include: Resident #173 was admitted (MONTH) 19, (YEAR) with [DIAGNOSES REDACTED]. An interim care plan dated (MONTH) 19, (YEAR) revealed that the resident had a urinary catheter in place. A goal included the resident would be free of complications. Review of an Appointment/Transportation form dated (MONTH) 26, (YEAR) revealed the resident went to a follow up nephrology appointment. At the bottom of this form were progress notes from the nephrologist provider. The notes included for the resident to have a urology evaluation to assess bladder function and possibly remove the urinary catheter. A physician's orders [REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 26, (YEAR) revealed the resident scored a 9 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. The resident was also coded as having an indwelling urinary catheter. Review of the clinical record revealed no documentation of an attempt to schedule the urology appointment or that an appointment had been scheduled from (MONTH) 26-May 11. A nursing note dated (MONTH) 12, (YEAR) included that a family member voiced concerns about the resident's care. The note included that a nurse practitioner (NP) was present and wrote an order for [REDACTED].>A NP order dated (MONTH) 12, (YEAR) included for a urology consult related to [MEDICAL CONDITION]. Review of an Appointment/Transportation form dated (MONTH) 18, (YEAR) revealed the resident went to the urologist appointment. At the bottom of this form were progress notes from the urology provider. The notes included the resident had acute [MEDICAL CONDITION] requiring Foley catheter. The catheter was exchanged in the office today. Will need to come back in one month for a voiding trial attempt. Clinical record documentation showed that the resident was discharged from the facility on (MONTH) 18, (YEAR). During an interview conducted on (MONTH) 18, (YEAR) at 12:10 p.m. with the transportation coordinator (staff #156), staff #156 stated that the appointment may have been delayed because the resident was a new patient. Staff #156 stated she remembered the urologist wanted more information before scheduling the appointment. However, she was unable to provide any documentation of any attempts to schedule the urology consult during the time frame of (MONTH) 26-May 11. An interview was conducted with the Director of Nursing (DON/staff #64) on (MONTH) 18, (YEAR) at 12:15 p.m. She stated that there should be documentation if the appointment was delayed. She also stated they do not have a policy regarding appointments, but provided a protocol for setting up appointments. Review of the protocol for Setting up Appointments included that physician's orders [REDACTED]. The appointment form should be completed with the resident's name, date of birth, the doctor's name, address, and phone number and signed and dated by the nurse taking the order. The protocol also included to call the doctor's office to determine if the resident is an established patient or new patient and to input the appointment on the appointment calendar and print a copy for the nurses, so they are aware of the daily appointments.",2020-09-01
62,HAVEN OF SCOTTSDALE,35059,3293 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2019-01-25,600,G,1,1,NNTV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, resident and staff interviews, facility documents and policy and procedures, the facility failed to ensure one resident (#8) was free from neglect which resulted in harm, failed to ensure one resident (#284) was free from verbal abuse by a staff member and failed to ensure that one resident (#283) was free from physical abuse by another resident (#11). The resident census was 41. Findings include: -Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the fall care plan revised on 7/11/18 revealed the resident had an actual fall (guided to floor by staff) with no injury. The interventions included to anticipate and meet resident needs, encourage the resident to seek assistance with all transfers, ensure that call light and frequently used items are within reach before leaving the room, keep resident's room free of clutter and well lit, and resident is to be a two person transfer. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed to have severe cognitive impairment. The functional assessment of the MDS indicated the resident had no impairment with range of motion to her extremities. An Interdisciplinary Team (IDT) Fall Report dated 11/15/18 included that resident #8 had a fall on 11/14/2018 at 1:37 p.m. The events surrounding the fall included that a Certified Nursing Assistant (CNA/staff #67) called over the radio for assistance in the room of resident #8. Staff #67 was observed laying on the floor next to the resident who was also laying on the floor. The CNA was bleeding from his left orbital socket. Resident #8 was on her back with her head resting on the bed frame of her roommate's bed and was in distress and was crying. The note included the CNA was attempting to transfer the resident by himself from the wheelchair to the bed, and lost his balance due to the resident moving in the opposite direction of intended movement. The report included that the Registered Nurse (RN) requested the assistance of the Assistant Director of Nursing/Interim Director of Nursing (ADON/IDON). The resident was observed to have an injury to her right arm and possible injury to her head/neck. The resident was not moved off the floor, her neck was stabilized and 9-1-1 was called. The Fall Report further included that the fall was discussed with the Interdisciplinary Team (IDT) and that the resident had been a two person transfer since 7/2018. Per the report, staff #67 was not using his gait belt during the transfer, and he was transferring the resident by himself without another staff member. According to the fall investigation completed by the IDT, the resident had a witnessed fall with a major injury, which was directly correlated to the fact that the CNA was not following the resident's current plan of care for a two person transfer and was not in compliance with the facility's policy to use a gait belt with all transfers. The CNA was terminated as a result of the IDT investigation. The resident was placed on Alert Charting, the care plan was updated and a Fall Risk Assessment was completed. The physician and responsible party were notified. Review of the CNA task documentation revealed it was updated on 11/15/18 to reflect that resident #8 required the assistance of two staff with transfers. A physician hospital progress note dated 11/16/2018 included the resident was admitted due to being transferred from the wheelchair to standing, and while standing fell out of their grasp. Patient reports the staff person lost their balance while standing, and fell on to the patient. The hospital course included the resident had a humeral head fracture status [REDACTED]. The fall care plan was updated on 11/18/18 to reflect that the resident had a witnessed fall with major injury (right humeral head fracture) on 11/14/18. An observation was conducted on 1/23/19 at 8:46 a.m. of the resident in bed. With the assistance of a Spanish-speaking Certified Nursing Assistant, the resident was asked to move her right arm. The resident demonstrated severe limited ability with range of motion to the right shoulder, right elbow and right wrist. The resident was able to move all fingers on the right hand. An interview was conducted on 1/25/19 at 8:54 a.m. with a CNA (staff #19), who was observed with a gait belt around her waist. Staff #19 stated she always has it with her and it is required to be used for all resident assisted transfers. Staff #19 stated that she checks the Kardex and the Task List to see what specific care is needed for residents or she asks the therapist or nurse. Staff #19 stated if she doesn't feel comfortable transferring a resident, she will ask for help. Staff #19 stated that she remembered they were transferring resident #8 with one person and that she had transferred her by herself more than once, because there was nothing on the Kardex or on the task list to tell her that the resident needed to be transferred with two people. She stated that she doesn't have access to the care plan. An interview was conducted on 1/25/19 at 9:18 a.m. with the ADON (staff #29), who stated that ever since she had been working at the facility (8/08/17), she felt resident #8 was a two person transfer, but it was not determined for her to be a two person transfer until her first fall in (MONTH) (YEAR). Staff #29 stated when she was investigating the (MONTH) fall, the information regarding the need for two persons for transfers was not on the Kardex/Task list, so it was added then. Staff #29 stated she doesn't think the CNA's have access to the care plans, but she wasn't sure. An interview was conducted on 1/25/19 at 9:38 a.m. with the Administrator (Abuse Prohibition Officer/staff #40), who stated that staff are trained on physical, emotional, mental, sexual, financial and verbal abuse and neglect. Staff #40 stated that staff are made aware of what is included in the various types of abuse and that it was just reviewed along with resident rights at the all staff meeting. Staff #40 stated the leadership team will make a determination on whether or not an incident is abuse/neglect. Staff #40 stated neglect examples would include a resident demanding care and was purposely ignored or the provision of goods and services or types of care were not being provided. Staff #40 stated that the CNA (staff #67) was terminated, because of not following the resident's care plan and our policy for transfers. Another interview was conducted on 1/25/19 with ADON (staff #29), who stated she convened the IDT Fall team the day after the fall. She said the appropriate people (physician, responsible party) were notified and the resident was sent out to the hospital. Staff #29 further stated that based on the definition of neglect (as discussed above), she would now consider what occurred as neglect. An interview was conducted on 1/25/19 with the DON (staff #53), who stated that they looked at the fall as any other fall. She said resident #8 had a witnessed fall and sustained a fracture, and was sent to the hospital. She said for those reasons, she didn't feel it was neglect and it was not reported to the State Agency or other agencies. Staff #53 agreed that based on the definition of neglect as discussed, she would now consider what occurred as neglect. An interview was conducted on 1/25/19 at 11:45 a.m., with the CNA (staff #67). Staff #67 stated that he was provided training by the facility on how to do transfers and how to obtain information regarding transfer needs of residents from the computer system. Staff #67 stated the facility policy was to use a gait belt for all transfers and he used a gait belt for all transfers, except for one incident. Staff #67 stated the incident was when resident #8 fell . He said that he had taken the gait belt out of his pocket to use the restroom and didn't put it back and forgot about it. Staff #67 stated that Prior to that day we always used two people to transfer her, but that day I didn't call for help because I was just trying to get her laid down before the end of my shift and I had things to do. -Resident #284 was admitted on (MONTH) 16, 2019, with [DIAGNOSES REDACTED]. Review of the care plan initiated on (MONTH) 17, 2019, revealed the resident was on antidepressant medication related to depression. Interventions included redirection and activities of choice for crying, self-isolation or verbalization of sadness. Review of an activity of daily living (ADL) care plan revealed resident #284 has an ADL self-care performance deficit related to impaired mobility. Interventions included for PT/OT evaluation and treatment as per physicians orders and to encourage resident to participate to the fullest extent possible with each interaction. Review of the nurse's notes dated (MONTH) 19, 2019, revealed the resident was alert and oriented x 4, and has a right leg and left arm in an immobilizer. Per the note, the resident was extensive assist of one person for bed mobility and toileting, and a two-person extensive assist for transfers. The admission Minimum Data Set (MDS) assessment dated (MONTH) 23, 2019, revealed the resident scored a 15 on the Brief Interview for Mental Status (BIM's), indicating the resident was cognitively intact. The MDS also revealed the resident did not have any behaviors. Review of the facility's investigation dated (MONTH) 23, 2019, revealed that on (MONTH) 18, 2019, resident #284 was very upset about her therapy that day. She reported that the therapy staff (#68 and #21) were yelling and cussing at her. The resident reported that she wanted to work with physical therapy (PT), as she had already received a shower from occupational therapy (OT). She stated that when she went to the therapy gym, the therapist (Certified Occupational therapy assistant/COTA/staff #68) told her If you get your butt down here we can work. Resident #284 further reported that the therapists were yelling at her and told her that it took 30 minutes to get her out of bed and walk her and that was her therapy for the day. She stated it was not correct that it took her 30 minutes to get her out of bed. The resident stated that one of the therapists called her a name (B word), but she wasn't sure which one. She said that made her angry and she called the therapist the same name. Further review of the investigative report revealed a statement by the physical therapy assistant (PTA/staff #21). Staff #21 explained that it took 30 minutes for the resident to get out of bed, take a shower and walk 25 feet. After the shower, resident #284 came to the therapy gym and was upset, so she told the resident to sit down and she would explain it to her. Staff #21 reported that as she was explaining the issue regarding the therapy minutes, the resident started to escalate, so she backed off. Staff #21 stated that there were two other therapists in the room, one was an Occupational Therapist (OT/staff #23) and the other was staff #68 (COTA). She reported at that point, staff #68 tried to explain the situation to the resident. Staff #21's statement included that none of the therapists were yelling at the resident. Continued review of the investigative report revealed a statement from staff #23. Staff #23 said when resident #284 entered the gym, she was upset because it took 35 minutes to get her out of bed. Per staff #23, that time was included as part of her therapy and the resident did not understand that. Staff #23 reported that she saw staff #21 back down, when resident #284 started yelling and swearing. Staff #23 stated at that point, staff #68 started to jump in and started yelling If you want therapy get out of bed. Staff #23 stated that resident #284 and staff #68 were yelling at each other. She said that she did not hear anyone say the B word. Staff #23's statement also included that she could see how it was aggressive from the resident's point of view and she wouldn't talk to a patient like that. The investigative report also included a statement by a Certified Nursing Assistant (CNA/staff #51), who was present during the incident. Staff #51 reported that staff #21 was explaining to the resident about her physical therapy minutes and the resident was upset saying that it did not take her 30 minutes to get out of bed. Staff #51 reported that staff #68 was yelling at the resident, as she was trying to get the resident back to her room. Staff #51 stated the resident was strolling away when staff #68 kept at it and told the resident If you don't like it you can always go home. Staff #51 reported that she did not hear any cuss words from anyone. Per the report, a statement from staff #68 revealed that she tried to calm resident #284 down by trying to explain some items to her. Staff #68 reported the resident started wheeling out of the gym and she was trying to explain things to her, so she kept saying loudly Ma'am Ma'am. She stated that she did not think her actions were uncalled for. Review of staff #68's personal employee file revealed that staff #68 had a disciplinary warning on (MONTH) 13, (YEAR). Staff #68 was observed by a staff member talking to another staff member about a resident during a smoking break. It was reported that staff #68 was cussing and using profanity about a resident in front of other residents and a family member, who were a few feet away. Additional documentation via email included that based on their investigation the B word was never used. However, it was determined that staff #68 did yell at the resident even after the resident turned around to wheel herself out of the gym. Due to the previous warnings and this incident, staff #68 lacked the ability to provide good customer service and has demonstrated a pattern of behaviors, as a result staff #68 was terminated. The investigative report concluded that no staff witnessed staff #21 or staff #68 cussing at the resident, therefore the allegation was unsubstantiated. However, despite witnesses reporting that staff #68 was yelling at the resident, even as the resident was attempting to leave the area, the facility did not substantiate that verbal abuse had occurred. During an interview conducted with resident #284 on (MONTH) 23, 2019 at 8:28 a.m., she stated that on (MONTH) 18, 2019 she went to the physical therapy gym to talk to staff about her therapy. She said that a physical therapy assistant (PTA/staff #21) and a certified occupational therapy assistant (COTA/staff #68) were very rude to her. She stated that staff #21 and #68 were yelling at her and staff #68, who has never worked with her before continued to yell at her. She stated that staff #68 was yelling saying If you don't like it you can leave even as the Certified Nursing Assistant CNA (staff #51) was pushing her wheelchair out of the therapy gym. An interview was conducted on (MONTH) 25, 2019 at 8:38 a.m. with staff #21. She stated that on (MONTH) 18, 2019, she was working with resident #284. She stated that they used 30 minutes of therapy time getting the resident up from bed, giving her a shower and they walked the resident. She said the resident came to the therapy gym wanting the remaining minutes of her therapy later that day. Staff #21 said that she tried to explain to the resident that her 30 minutes of therapy was completed, as it had been used up when they got her up from bed to the shower and did some walking. She stated the resident was not happy when she heard this and started arguing in a loud voice, almost yelling. At this point, staff #21 stated that she backed down and said they could talk about it later and the resident was satisfied with that explanation. Staff #21 said that staff #68 was sitting in the corner of the room and tried to reiterate what she had just said, but by this time resident #284 and staff #68 were both yelling at each other. Staff #21 stated the resident was yelling and staff #68 was also yelling back at her. Staff #21 stated that staff #68 could have handled the situation differently and she felt that staff #68 was aggravating the situation further. She stated staff #68 has a tendency to get frustrated and escalates easily. An interview was conducted on (MONTH) 25, 2019, at 9:37 a.m. with the Director of Nursing (DON/staff #53), who stated that they conducted employee interviews during the investigation and based on the employee interviews they determined that it was not abuse, since there were no cuss words used. Staff #53 stated that during their investigation it was determined that only staff #68 was yelling. She stated that they fired staff #68, because she was yelling at a resident and did not provide good customer service. An interview was conducted with staff #51 on (MONTH) 25, 2019 at 11:09 a.m. Staff #51 stated that resident #284 went to the therapy room to speak to staff #21 to see if she was going to get therapy that day. Staff #21 told resident #284 that she already had her therapy for 30 minutes this morning. Staff #51 stated that staff #21 was telling the resident that it took her 30 minutes to get the resident out of bed to the shower, which was her total therapy time for the day. She said that is when staff #68 who was sitting in the far corner intervened and said that resident #284 only has 30 minutes allotted to her and she has used it all. Staff #51 stated that resident #284 turned around to leave and staff #68 started yelling at the resident stating she only gets 30 minutes and that's how much her insurance pays and if the resident does not like it she can leave. Staff #51 stated that there were no swear words used, but staff #68 was yelling at the resident. She stated that staff #68 should have let the other therapist finish her conversation with the resident and not interfere and it would have been easier to explain rather than start yelling. -Resident #11 was admitted on (MONTH) 29, 2003, with [DIAGNOSES REDACTED]. Review of the MDS assessment dated (MONTH) 21, (YEAR), revealed the Brief Interview for Mental Status (BIMS) was not conducted, however, the resident was assessed to have moderate cognitive impairment. The MDS also included the resident had difficulty focusing, was short-tempered and gets restless at times. Review of a care plan revealed that resident #11 displays behaviors of physical aggression. -Resident #283 was admitted on (MONTH) 23, (YEAR), with [DIAGNOSES REDACTED]. Review of the MDS assessment dated (MONTH) 8, (YEAR), revealed a BIMS interview was not attempted as the resident was rarely/never understood. The MDS included that resident #11 had moderate cognitive impairment. A nurse's weekly skin check and wound assessment dated (MONTH) 12, (YEAR) included resident was involved in a resident to resident altercation in which he was struck on the arm. No bruising, laceration, open skin or injury observed from residents altercation . Review of the facility's investigative report revealed that on (MONTH) 12, (YEAR) at approximately 7:00 p.m., resident #11 had been sitting next to resident #283 after dinner at the nurse's station. Resident #283 was talking/mumbling to himself quietly as he does most of the time. Staff observed resident #11 reach over and swing at resident #283's face. The first swing did not make contact, but resident #11 swung again immediately and resident #283 put his forearm in front of his face, so resident #11 made contact with resident #283's shoulder/upper arm. This incident was witnessed by facility staff who separated the residents just as resident #11 made contact with the second swing. An interview was conducted on (MONTH) 23, 2019 at 2:05 p.m., with a CNA (staff #3). She stated the residents were roommates and were seated in wheelchairs side by side at the nurses station. She said that resident #283 was talking to himself like he usually does and resident #11 thought he was talking about him. Staff #3 said that resident #11 is not very verbal and gave resident #283 an agitated look and then tried hitting him. She said when resident #11 missed, he swung again and this time he was able to punch resident #283 on his left arm. She stated that he did not hit him hard. Staff #3 stated they were quick in separating both residents and no injuries were noted on either resident. Staff #3 also stated that resident #11 has exhibited some aggressive behaviors in the past, but can easily be redirected and will calm down in a few minutes if removed from the situation. An interview was conducted on (MONTH) 24, 2019 at 9:52 a.m., with a Registered Nurse (staff #44). She stated that both resident's were sitting at the nurses station when she heard one of the CNA's yell no and that's when she turned and saw the CNA's in between the two residents. She said there were no injuries and they made sure both residents were safe. She said they kept them separated and placed them in separate rooms and did frequent checks (every 15 minutes for an hour then frequently). Staff #44 stated they notified the Administrator and the Director of Nursing. An interview was conducted on (MONTH) 25, 2019 at 9:38 a.m., with the Administrator (staff #40). He stated that abuse is covered in orientation and in staff meetings and is discussed on a weekly basis. He stated when there is a resident to resident altercation, employees should make sure the resident is safe and separate them from the situation. During an interview conducted on (MONTH) 25, 2019 with the Director of Nursing (staff #53), she said when there is a resident to resident altercation, staff should notify the nurse or charge nurse. She stated that staff are aware that they are mandated reporters of any kind of abuse. Review of the facility's Abuse policy revealed the facility will strive to prevent the abuse of all residents. Our objective is to provide a safe haven for our residents through preventative measures that protect every resident's right to freedom from abuse. We care for residents with a [DIAGNOSES REDACTED]. The policy included that by definition, abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Willful, as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Abuse includes verbal abuse, sexual abuse, physical abuse and mental abuse. Potential abusers can be residents, employees or family members. The policy also included that If abuse is witnessed or suspected, the resident's safety will immediately be secured. Prompt reporting and investigation will be utilized to identify the validity of findings and reasonable measures will be implemented to deter further incidents of abuse.",2020-09-01
63,HAVEN OF SCOTTSDALE,35059,3293 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2019-01-25,607,D,0,1,NNTV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to implement their abuse policy, by failing to identify an incident of neglect involving a staff member and a resident (#8), and by failing to report the incident of neglect to the State Agency and Adult Protective Services (APS). The resident census was 41. Findings include: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the fall care plan revised on 7/11/18 revealed the resident had an actual fall (guided to floor by staff) with no injury. The interventions included to anticipate and meet resident needs, encourage the resident to seek assistance with all transfers, ensure that call light and frequently used items are within reach before leaving the room, keep resident's room free of clutter and well lit, and resident is to be a two person transfer. An Interdisciplinary Team (IDT) Fall Report dated 11/15/18 included that resident #8 had a fall on 11/14/2018 at 1:37 p.m. The events surrounding the fall included that a Certified Nursing Assistant (CNA/staff #67) called over the radio for assistance in the room of resident #8. Staff #67 was observed laying on the floor next to the resident who was also laying on the floor. The CNA was bleeding from his left orbital socket. Resident #8 was on her back with her head resting on the bed frame of her roommate's bed and was in distress and was crying. The note included the CNA was attempting to transfer the resident by himself from the wheelchair to the bed, and lost his balance due to the resident moving in the opposite direction of intended movement. The report included that the Registered Nurse (RN) requested the assistance of the Assistant Director of Nursing/Interim Director of Nursing (ADON/IDON). The resident was observed to have an injury to her right arm and possible injury to her head/neck. The resident was not moved off the floor, her neck was stabilized and 9-1-1 was called. The Fall Report further included that the fall was discussed with the Interdisciplinary Team (IDT) and that the resident had been a two person transfer since 7/2018. Per the report, staff #67 was not using his gait belt during the transfer, and he was transferring the resident by himself without another staff member. According to the fall investigation completed by the IDT, the resident had a witnessed fall with a major injury, which was directly correlated to the fact that the CNA was not following the resident's current plan of care for a two person transfer and was not in compliance with the facility's policy to use a gait belt with all transfers. The CNA was terminated as a result of the IDT investigation. The resident was placed on Alert Charting, the care plan was updated and a Fall Risk Assessment was completed. The physician and responsible party were notified. A physician hospital progress note dated 11/16/2018 included the resident was admitted due to being transferred from the wheelchair to standing, and while standing fell out of their grasp. Patient reports the staff person lost their balance while standing, and fell on to the patient. The hospital course included the resident had a humeral head fracture status [REDACTED]. Further review of the investigative documentation revealed the facility had not identified this incident as neglect, therefore, did not notify the State Agency and APS. An interview was conducted on 1/25/19 at 9:38 a.m. with the Administrator (Abuse Prohibition Officer/staff #40), who stated the types of abuse staff are trained on include physical, emotional, mental, sexual, financial, verbal and neglect. Regarding allegations of abuse/neglect, he stated they initiate an investigation and the leadership team will make a determination on whether or not it is abuse. Staff #40 stated neglect examples would include a resident demanding care and was purposely ignored or the provision of goods and services or types of care were not provided. He stated the CNA (staff #67) was terminated, because he did not follow the resident's care plan and our policy regarding transfers. Staff #40 also stated that staff members have been educated that they have to call the State Agency, along with other agencies within 2 hours of becoming aware of the incident. An interview was conducted on 1/25/19 at 9:38 a.m. with staff #29, who stated that based on the definition of neglect as discussed (above), she would now consider what occurred as neglect. An interview was conducted on 1/25/19 with the Director of Nursing (DON/staff #53), who stated that they looked at the fall as any other fall. She said resident #8 had a witnessed fall and sustained a fracture, and was sent to the hospital. She said for those reasons, she didn't feel it was neglect and it was not reported to the State Agency or other agencies. Staff #53 agreed that based on the definition of neglect as discussed (above) she would now consider what occurred as neglect. An interview was conducted on 1/25/19 at 11:45 a.m., with the CNA (staff #67) who transferred the resident. He stated the facility policy was to use a gait belt for all transfers. He said that he used a gait belt for all transfers, except for one incident when resident #8 fell . Staff #67 stated he had taken the gait belt out of his pocket to use the restroom and didn't put it back and forgot about it. Staff #67 stated that Prior to that day we always used two people to transfer her, but that day I didn't call for help because I was just trying to get her laid down before the end of my shift and I had things to do. Review of the facility's Abuse policy revealed the facility will strive to prevent the abuse of all residents. Our objective is to provide a safe haven for our residents through preventative measures that protect every resident's right to freedom from abuse. We care for residents with a [DIAGNOSES REDACTED]. The policy included that by definition, abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Willful, as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Abuse includes verbal abuse, sexual abuse, physical abuse and mental abuse. Potential abusers can be residents, employees or family members. The policy included that if abuse is witnessed or suspected, reporting and an investigation will take place in this manner: 1. Executive Director (ED) will be notified. 2. ED and witness who is reporting will notify the following entities: a. Adult Protective Services b. Ombudsman 3. State Survey Agency d. Law Enforcement when applicable e. Facility Director of Nursing (DON) 3. DON will notify the following: a. Physician b. Responsible Party c. Corporate Clinical Team 4. ED will begin investigation immediately and complete within 5 days using the Abuse Investigation Packet. Suspected abuse will be reported in accordance with timeframes and standards required by the State Agency. If an employee is suspected of being the abuser, they will be suspended until the investigation is complete. If the investigation finds that abuse is substantiated and the abuser is an employee, they will be immediately terminated and licensure reporting as applicable will be done. The policy further included that If abuse is witnessed or suspected, the resident's safety will immediately be secured. Prompt reporting and investigation will be utilized to identify the validity of findings and reasonable measures will be implemented to deter further incidents of abuse.",2020-09-01
64,HAVEN OF SCOTTSDALE,35059,3293 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2019-01-25,608,D,0,1,NNTV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documents and policy and procedures, the facility failed to report a suspicion of a crime (neglect) to law enforcement involving a staff member and a resident (#8). Findings include: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the fall care plan revised on 7/11/18 revealed the resident had an actual fall (guided to floor by staff) with no injury. The interventions included to anticipate and meet resident needs, encourage the resident to seek assistance with all transfers, ensure that call light and frequently used items are within reach before leaving the room, keep resident's room free of clutter and well lit, and resident is to be a two person transfer. An Interdisciplinary Team (IDT) Fall Report dated 11/15/18 included that resident #8 had a fall on 11/14/2018 at 1:37 p.m. The events surrounding the fall included that a Certified Nursing Assistant (CNA/staff #67) called over the radio for assistance in the room of resident #8. Staff #67 was observed laying on the floor next to the resident who was also laying on the floor. The CNA was bleeding from his left orbital socket. Resident #8 was on her back with her head resting on the bed frame of her roommate's bed and was in distress and was crying. The note included the CNA was attempting to transfer the resident by himself from the wheelchair to the bed, and lost his balance due to the resident moving in the opposite direction of intended movement. The report included that the Registered Nurse (RN) requested the assistance of the Assistant Director of Nursing/Interim Director of Nursing (ADON/IDON). The resident was observed to have an injury to her right arm and possible injury to her head/neck. The resident was not moved off the floor, her neck was stabilized and 9-1-1 was called. The Fall Report further included that the fall was discussed with the Interdisciplinary Team (IDT) and that the resident had been a two person transfer since 7/2018. Per the report, staff #67 was not using his gait belt during the transfer, and he was transferring the resident by himself without another staff member. According to the fall investigation completed by the IDT, the resident had a witnessed fall with a major injury, which was directly correlated to the fact that the CNA was not following the resident's current plan of care for a two person transfer and was not in compliance with the facility's policy to use a gait belt with all transfers. The CNA was terminated as a result of the IDT investigation. Further review of the investigative documentation revealed the facility had not identified this incident as neglect and therefore, did not notify law enforcement. An interview was conducted on 1/25/19 at 9:38 a.m. with the Administrator (Abuse Prohibition Officer/staff #40), who stated that staff are trained on physical, emotional, mental, sexual, financial and verbal abuse and neglect. Staff #40 stated the leadership team will make a determination on whether or not an incident is abuse/neglect. Staff #40 stated neglect examples would include a resident demanding care and was purposely ignored or the provision of goods and services or types of care were not being provided. Staff #40 stated that the CNA (staff #67) was terminated, because of not following the resident's care plan and our policy for transfers. He further stated that staff members have been educated that the facility has to call the State Agency, along with other agencies, including law enforcement when appropriate, within the required time frames. An interview was conducted on 1/25/19 at 9:38 a.m. with staff #29, who stated that based on the definition of neglect as discussed (above), she would now consider what occurred as neglect. An interview was conducted on 1/25/19 with the DON (staff #53), who stated that they looked at the fall as any other fall. She said resident #8 had a witnessed fall and sustained a fracture, and was sent to the hospital. She said for those reasons, she didn't feel it was neglect and it was not reported to the State Agency or other agencies. Staff #53 agreed that based on the definition of neglect as discussed, she would now consider what occurred as neglect. An interview was conducted on 1/25/19 at 11:45 a.m., with the CNA (staff #67) who transferred the resident. He stated the facility policy was to use a gait belt for all transfers. He said that he used a gait belt for all transfers, except for one incident when resident #8 fell . Staff #67 stated he had taken the gait belt out of his pocket to use the restroom and didn't put it back and forgot about it. Staff #67 stated that Prior to that day we always used two people to transfer her, but that day I didn't call for help because I was just trying to get her laid down before the end of my shift and I had things to do. Review of the facility's Abuse policy revealed that the facility will strive to prevent the abuse of all residents. Our objective is to provide a safe haven for our residents through preventative measures that protect every resident's right to freedom from abuse. The policy included that by definition, abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Willful, as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Abuse includes verbal abuse, sexual abuse, physical abuse and mental abuse. Potential abusers can be residents, employees or family members. The policy included that if abuse is witnessed or suspected, reporting and an investigation will take place in this manner: 1. Executive Director (ED) will be notified. 2. ED and witness who is reporting will notify the following entities: a. Adult Protective Services b. Ombudsman 3. State Survey Agency d. Law Enforcement when applicable e. Facility Director of Nursing (DON) 3. DON will notify the following: a. Physician b. Responsible Party c. Corporate Clinical Team 4. ED will begin investigation immediately and complete within 5 days using the Abuse Investigation Packet. Suspected abuse will be reported in accordance with timeframes and standards required by the State Agency. If an employee is suspected of being the abuser, they will be suspended until the investigation is complete. If the investigation finds that abuse is substantiated and the abuser is an employee, they will be immediately terminated and licensure reporting as applicable will be done. The policy further included that If abuse is witnessed or suspected, the resident's safety will immediately be secured. Prompt reporting and investigation will be utilized to identify the validity of findings and reasonable measures will be implemented to deter further incidents of abuse.",2020-09-01
65,HAVEN OF SCOTTSDALE,35059,3293 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2019-01-25,609,D,0,1,NNTV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, facility documentation and policy and procedures, the facility failed to report an incident of neglect involving one resident (#8) to the State Agency and to Adult Protective Services (APS). The resident census was 41. Findings include: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the fall care plan revised on 7/11/18 revealed the resident had an actual fall (guided to floor by staff) with no injury. The interventions included to anticipate and meet resident needs, encourage the resident to seek assistance with all transfers, ensure that call light and frequently used items are within reach before leaving the room, keep resident's room free of clutter and well lit, and resident is to be a two person transfer. An Interdisciplinary Team (IDT) Fall Report dated 11/15/18 included that resident #8 had a fall on 11/14/2018 at 1:37 p.m. The events surrounding the fall included that a Certified Nursing Assistant (CNA/staff #67) called over the radio for assistance in the room of resident #8. Staff #67 was observed laying on the floor next to the resident who was also laying on the floor. The CNA was bleeding from his left orbital socket. Resident #8 was on her back with her head resting on the bed frame of her roommate's bed and was in distress and was crying. The note included the CNA was attempting to transfer the resident by himself from the wheelchair to the bed, and lost his balance due to the resident moving in the opposite direction of intended movement. The report included that the Registered Nurse (RN) requested the assistance of the Assistant Director of Nursing/Interim Director of Nursing (ADON/IDON). The resident was observed to have an injury to her right arm and possible injury to her head/neck. The resident was not moved off the floor, her neck was stabilized and 9-1-1 was called. The Fall Report further included that the fall was discussed with the Interdisciplinary Team (IDT) and that the resident had been a two person transfer since 7/2018. Per the report, staff #67 was not using his gait belt during the transfer, and he was transferring the resident by himself without another staff member. According to the fall investigation completed by the IDT, the resident had a witnessed fall with a major injury, which was directly correlated to the fact that the CNA was not following the resident's current plan of care for a two person transfer and was not in compliance with the facility's policy to use a gait belt with all transfers. The CNA was terminated as a result of the IDT investigation. The physician and responsible party were notified. However, the State Agency and APS were not notified of the incident of neglect within two hours. An interview was conducted on 1/25/19 at 9:38 a.m. with the Administrator (Abuse Prohibition Officer/staff #40), who stated that neglect examples would include a resident demanding care and was purposely ignored or the provision of goods and services or types of care were not provided. He stated that staff members have been educated that they have to call the State Agency, along with other agencies within two hours of becoming aware of the incident. An interview was conducted on 1/25/19 with the Director of Nursing (DON/staff #53), who stated that they looked at the fall as any other fall. She said resident #8 had a witnessed fall and sustained a fracture, and was sent to the hospital. She said for those reasons, she didn't feel it was neglect and it was not reported to the State Agency or other agencies. Staff #53 agreed that based on the definition of neglect as discussed, she would now consider what occurred as neglect. Review of the facility's Abuse policy revealed that if abuse is witnessed or suspected, reporting and an investigation will take place in this manner: 1. Executive Director (ED) will be notified. 2. ED and witness who is reporting will notify the following entities: a. Adult Protective Services b. Ombudsman 3. State Survey Agency d. Law Enforcement when applicable e. Facility Director of Nursing (DON) 3. DON will notify the following: a. Physician b. Responsible Party c. Corporate Clinical Team 4. ED will begin investigation immediately and complete within 5 days using the Abuse Investigation Packet. Suspected abuse will be reported in accordance with timeframes and standards required by the State Agency.",2020-09-01
66,HAVEN OF SCOTTSDALE,35059,3293 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2019-01-25,689,E,0,1,NNTV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, facility documents and policy and procedure, the facility failed to ensure safe water temperatures were maintained in eight resident rooms. The facility census was 41. Findings include: During an observation conducted on 1/22/19 at 2:35 p.m., the water temperature of the restroom sink in room [ROOM NUMBER]-1 was checked and was 135 degrees Fahrenheit (F). This resident was able to use the restroom sink. During an observation conducted on 1/22/19 at 2:58 p.m., the water temperature in room [ROOM NUMBER]-1 was 130 degrees F. This resident was able to use the restroom. At this time, a family member stated sometimes the water feels a little hot and we are just careful. Additional water temperatures were taken on 1/22/19 at 3:43 p.m. and the following was found: -room [ROOM NUMBER]: water temperature was 126.6 degrees F -room [ROOM NUMBER]: water temperature was 126.2 degrees F -room [ROOM NUMBER]: water temperature was 130 degrees F -room [ROOM NUMBER]: water temperature was 135 degrees F -room [ROOM NUMBER]: water temperature was 134 degrees F -room [ROOM NUMBER]: water temperature was 131.5 degrees F On 1/22/19 at 4:15 p.m., the Environmental Services manager (staff #5) tested the water temperatures and the following was observed: -room [ROOM NUMBER]: water temperature was 122 degrees F -room [ROOM NUMBER]: water temperature was 132 degrees F -room [ROOM NUMBER]: water temperature was 136 degrees F -room [ROOM NUMBER]: water temperature was 118 degrees F -room [ROOM NUMBER]: water temperature was 140 degrees F -room [ROOM NUMBER]: water temperature was 124 degrees F During this observation, an interview was conducted with staff #5, who stated that water temperatures are checked weekly and documented and there have not been any problems. He stated the water should be run for 3-5 minutes before checking the temperatures. The facility immediately turned down the water temperatures at least twice and monitored the water temperatures every hour throughout the night. Facility water temperature logs were reviewed with the following results: -January (YEAR): all temperatures were either 101, 102 or 103 degrees F. -February (YEAR) through (MONTH) (YEAR): all temperatures were either 101, 102 or 103 degrees F. -August (YEAR): all temperatures were either 103 or 104 degrees F. -September (YEAR) through (MONTH) (YEAR): all temperatures were either 101, 102 or 103 degrees F. Review of the facility temperature log for (MONTH) 2019 revealed the water temperatures were checked on 1/21/19 and all temperatures in every room were either 101, 102 or 103 degrees F. In an interview conducted on 1/23/19 at 8:00 a.m. with the Executive Director (staff #40), he stated that he did not know why the water temperatures were so consistent on previous temperature checks. He said the facility has monitored the water temperatures throughout the night and have made adjustments to the temperature settings to get them back in the required ranges. He stated that he takes this very seriously and understands residents could be easily burned with high water temperatures. Staff #40 further stated he has made sure the team checking the temperatures are using good thermometers (new ones were purchased) and are following the correct procedures to check the temperatures accurately. Follow-up water temperatures were conducted on 1/23/19 at 11:20 a.m. with the following results: -room [ROOM NUMBER]: water temperature was 113 degrees F -room [ROOM NUMBER]: water temperature was 109.2 degrees F -room [ROOM NUMBER]: water temperature was 110.2 degrees F -room [ROOM NUMBER]: water temperature 103.2 degrees F -room [ROOM NUMBER]: water temperature 104.2 degrees F -room [ROOM NUMBER]: water temperature 96.5 degrees F -Shower 1: water temperature 98 degrees F Follow up water temperatures were taken on 1/25/19 at 8:05 a.m. and revealed the following: -room [ROOM NUMBER]: water temperature was 110.9 degrees F -room [ROOM NUMBER]: water temperature was 105.9 degrees F -room [ROOM NUMBER]: water temperature was 104.9 degrees F -room [ROOM NUMBER]: water temperature was 106.6 degrees F -Shower 2: water temperature was 104.3 degrees F Review of the facility policy titled Accidents and Supervision - Water Temperatures (undated), revealed the purpose of recording water temperatures is to assure that the facility is remaining free from [MEDICAL CONDITION] scalds, and that issues are addressed in a prompt and consistent manner. The policy described the process which included: the dial thermometer should be calibrated on a regular basis; insert the step of the thermometer under the running water, while also holding your hand under the water to see how the water feels on skin and test water at various locations throughout the facility. The policy further included that patient water temperatures should be between 105 F and 115 F, and that State law should be followed with temperatures between 95 F to 120 F. Results of testing should be recorded, discrepancies noted, water setting adjusted as needed, and retest as necessary.",2020-09-01
67,HAVEN OF SCOTTSDALE,35059,3293 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2016-09-22,241,D,0,1,BZVV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and policy review, the facility failed to promote care for residents in a manner that maintains each residents dignity, by having one resident (#151) who was in their bed and their brief and lower extremities were exposed and were visible to others in the hallway. Findings include: Resident #151 was admitted on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) admission assessment dated (MONTH) 15, (YEAR) revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated that the resident had moderate cognitive impairment. A review of the admission nursing evaluation revealed the resident had bilateral weakness to the lower extremities. During an observation conducted on (MONTH) 19, (YEAR) at 6:30 a.m., resident #151 was observed inside the room sleeping. The resident was lying on his bed, with his lower legs and brief exposed. The privacy curtains were not pulled and the resident's door was wide open. The resident was visible from the hallway. Another observation was conducted on (MONTH) 19, (YEAR) at 7:35 a.m. The resident was in bed with his lower legs and brief exposed. The door was open and the resident was visible from the hallway. A later observation was conducted at 10:06 a.m. of the resident lying in bed asleep, with the door open. The resident was uncovered and his belly, lower legs and brief were exposed and he was visible from the hallway. This resident's room was directly across from the activity room. During this observation, there was an activity taking place in the activity room. Multiple staff, residents and visitors were observed passing by the resident's room. At 10:11 a.m., a certified nursing assistant (CNA/staff #7) entered the resident's room, but then quickly exited. The resident remained uncovered and his belly, lower legs and brief were still exposed. At 10:21 a.m., staff #7 looked inside the resident's room, but did not notice that the resident was still exposed. At 11:04 a.m., staff #7 entered the resident's room and placed a blanket over the resident covering his belly, legs and brief. In an interview with a CNA (staff #27) conducted on (MONTH) 20, (YEAR) at 2:49 p.m., she stated that she checks residents frequently and when she sees a resident with exposed body parts or brief, she will immediately enter the room and cover the resident. An interview with a licensed practical nurse (LPN/staff #60) was conducted on (MONTH) 21, (YEAR) at 11:04 a.m. She stated that when she sees a resident who is exposed, she will enter the room and cover the exposed area. In an interview with the Director of Nursing (DON/staff #6) conducted on (MONTH) 21, (YEAR) at 4:31 p.m., she stated that when a resident's body parts and undergarments are exposed, she expects staff to cover the resident immediately. A facility policy on Quality of Life-Dignity included that Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. It also included that staff shall promote, maintain, and protect resident privacy, including bodily privacy.",2020-09-01
68,HAVEN OF SCOTTSDALE,35059,3293 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2016-09-22,250,D,0,1,BZVV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documents and policy review, the facility failed to provide medically-related social services to maintain the highest practicable physical, mental, and psychosocial well-being of one resident (#144). Findings include: Resident #144 was admitted to the facility on (MONTH) 31, (YEAR), with [DIAGNOSES REDACTED]. Physician admission orders [REDACTED]. A care plan initiated on (MONTH) 1, (YEAR) included for the use of antianxiety medications related to an anxiety disorder. Interventions included to administer anxiety medications as ordered and to monitor and document side effects and effectiveness. A social service intervention included to educate the resident/family regarding the risks/benefits and side effects and/or toxic symptoms of antianxiety medication. Another care plan included the resident exhibited behavior problems related to hitting staff, throwing food, and poor safety awareness. Interventions included to administer medication as ordered after non pharmacological interventions are tried and ineffective, monitor side effects, approach resident calmly and provide activities. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 7, (YEAR) revealed the resident had a Basic Interview for Mental Status score of 13, which indicated the resident was cognitively intact. The mood section indicated the resident had not exhibited any symptoms of depression since arrival. Review of the behavior section revealed the resident had not exhibited any behaviors since admission. Nursing progress notes for (MONTH) 6 and 7, (YEAR) documented the resident complained of increased anxiety and requested the Alprazolam. Review of the Daily Skilled Notes from (MONTH) 8, 9 and 10, (YEAR) included the resident was experiencing confusion and anxiety, and received Alprazolam as ordered. A MAR note dated (MONTH) 10, (YEAR) documented the resident was trying to stand and remove her clothing and was yelling. The resident was medicated with Alprazolam for behaviors. A MAR note dated (MONTH) 11, (YEAR) at 1:08 a.m. included the resident stated that she was trying to leave and find her husband and was nervous, and was medicated with Alprazolam. Review of a fall report dated (MONTH) 11, (YEAR) at 7:34 a.m., the resident had been yelling and trying to get out of her chair. The report indicated the resident got away from the Licensed Practical Nurse, took off the tab alarm and jumped out of her chair onto the floor. The report also included the resident commented about not wanting to live anymore. A physician's orders [REDACTED]. Review of the MAR and a MAR note revealed the resident received the increased one time dose of Alprazolam. Further review of the MAR note dated (MONTH) 11, (YEAR) at 8:59 a.m. revealed the one time dose of Alprazolam was not effective. No additional interventions were documented. Review of the Alert Charting note dated (MONTH) 12, (YEAR) at 1:57 a.m. revealed the resident continuously attempted to get up unassisted during waking hours, was occasionally combative, and self propelled herself in her wheelchair into the medication cart, treatment cart, snack cart and attempted to open them. The note also indicated the resident self propelled herself into other resident's rooms and the resident remained intermittently argumentative. Despite the resident's behaviors, there was no clinical record documentation from social services regarding any services that were provided or interventions which were implemented to address the social service needs of the resident. A physician's orders [REDACTED]. A care plan was developed on (MONTH) 12, (YEAR) for feelings of loss of control and not wanting to live anymore. Interventions included to administer psychotropic medications as ordered, monitor for ineffective coping ability (e.g. verbalization of inability to cope, decreased problem solving, increased confusion, social withdrawal, insomnia, destructive behaviors toward self or others), psychiatrist to evaluate, and social service to visit and offer support as needed. Review of the MAR notes for (MONTH) 13 and 14 revealed the administered doses of Alprazolam were not effective. Review of physician progress notes [REDACTED]. Further review of the physician's orders [REDACTED]. Additional orders included to monitor the resident for target symptoms/behaviors every shift, which included yelling out and to monitor for side effects associated with the use of antianxiety medication. According to the Medication Administration Record (MAR), the resident received the Alprazolam for increased anxiety from one to four times each day between (MONTH) 1, and (MONTH) 20, (YEAR), with the exception of (MONTH) 12, when she did not receive any Alprazolam. Further review of the clinical record revealed that as of (MONTH) 20, (YEAR), the resident had not yet been evaluated by a psychiatrist as ordered on (MONTH) 12, (YEAR). In addition, there were still no social services notes addressing the resident's needs. In an interview conducted with the Director of Nursing (DON/staff #6) on (MONTH) 20, (YEAR), the DON stated that depending on what type of consult and the circumstances, the Social Worker will contact the physician to come out and see the resident. She further stated that the delay in getting this consult is not within the expected time frame and the consult should have been completed sooner. In an interview conducted with the Social Worker (staff #21) on (MONTH) 20, (YEAR) at 2:25 p.m., staff #21 stated that he called and requested for the psychiatrist to see the resident, but he won't see her until tomorrow. He stated that he did not know about her comment (of not wanting to live) and did not see any immediacy in getting the consult any faster. He stated that usually our psychiatrist comes once each month to see residents and if a consult is ordered, then it is requested. He stated he initially emailed the doctor and then talked with him by phone and they did not see any reason for him to see her any faster. He stated he does not have any social services notes regarding this resident. Shortly after the above interview the clinical record was reviewed. A social services progress note dated (MONTH) 20, (YEAR) at 2:51 p.m. now included that the social worker met with the resident regarding her previous statements of not wanting to live anymore and the resident indicated that she felt trapped in her body, due to Parkinson's disease. The note included the resident had been seeing a psychiatrist in the community prior to admission to the facility, and agreed to social services involvement. The note also included that the resident did not currently have any suicidal ideations. Review of a physician progress notes [REDACTED]. The resident states that the worst her suicidality becomes is when she has random thoughts to wheel herself in her wheelchair into traffic, but states she would never do that. Per the note, the resident also described feeling down, due to being away from home, family and her dogs, and due to having insomnia, Parkinson's disease, chronic pain and anxiety. The physician initiated treatment included for Remeron at bedtime for sleep, depression and anxiety. Review of a policy titled, Social Services revealed that the facility provides medically related social services to assure that each resident can attain or maintain his/her highest practicable physical, mental, or psychosocial well-being. The policy identified factors that have a potentially negative affect on the resident's dignity and sense of control that included disability or loss of function, the presence of a progressive, chronic, or disabling condition and behavioral problems (anxiety, confusion, depressed mood, anger, fear, wandering, psychotic episodes). The responsibilities of the social services department included obtaining pertinent social data, identifying social and emotional needs, assisting in providing corrective actions by developing and maintaining care plans, maintaining regular progress and follow-up notes, maintaining appropriate documentation of referrals and providing social services data summaries and making supportive visits to the resident.",2020-09-01
69,HAVEN OF SCOTTSDALE,35059,3293 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2016-09-22,278,D,0,1,BZVV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record review, staff interviews, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure one resident's (#136) Minimum Data Set (MDS) assessment was accurate. Findings include: Resident #136 was admitted to the facility on (MONTH) 25, (YEAR), with [DIAGNOSES REDACTED]. A pressure ulcer assessment dated (MONTH) 26, (YEAR) included the resident had a stage III pressure ulcer to the sacrum. The pressure ulcer care plan dated (MONTH) 27, (YEAR) included the resident had a stage III pressure ulcer to the sacrum. Review of the physician wound care note dated (MONTH) 28, (YEAR) also revealed that the resident had a stage III pressure ulcer located on the sacrum. However, review of the admission MDS assessment dated (MONTH) 1, (YEAR) revealed in Section I. that the resident was coded as having an active [DIAGNOSES REDACTED]. In an interview with the Director of Nursing (DON/staff #6) conducted on (MONTH) 22, (YEAR) at 9:00 a.m., she stated that Section I. of the MDS admission assessment was an error and the resident's pressure ulcer wound was a stage III. In an interview with the MDS Coordinator (staff #55) conducted on (MONTH) 22, (YEAR) at 9:31 a.m., he stated that he bases the MDS entries on therapy documentation, the certified nursing assistant (CNA) notes regarding activities of daily living, the daily assessments of the nurses and physician documentation. He stated that when there are discrepancies on the documentation regarding the stages and locations of pressure ulcers, he will verify it with the physician and the nurse, and will go with what the physician said and documents. He stated that he should have checked and clarified Section I. of the MDS to ensure that the stage of the pressure ulcer matched. Review of the RAI manual for the MDS revealed .the importance of accurately completing and submitting the MDS assessment cannot be over-emphasized. The MDS assessment is the basis for the development of an individualized care plan .",2020-09-01
70,HAVEN OF SCOTTSDALE,35059,3293 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2016-09-22,281,D,0,1,BZVV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy and procedures, the facility failed to ensure an interim care plan was developed to address one resident's (#43) needs related to contact isolation. Findings include: Resident #43 was admitted to the facility on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. A review of the Infection Surveillance Report dated (MONTH) 1, (YEAR) revealed Pt (patient) arrived to facility with infection .Type of isolation precautions:[MEDICAL CONDITION]-Contact . A physician's orders [REDACTED]. A nurses note dated (MONTH) 2, (YEAR) revealed Resident on isolation precautions related to DX (diagnosis):[MEDICAL CONDITION] of abdominal wound. Resident continues with PO (by mouth) antibiotics this shift without noted signs/symptoms of adverse or side effect. The admission Minimum Data Set assessment dated (MONTH) 8, (YEAR) also identified that the resident was on isolation. However, review of the clinical record revealed there was no interim care plan that was developed to address the residents needs related to contact isolation. During an interview conducted at 9:05 a.m. on (MONTH) 22, (YEAR), a LPN (Licensed Practical Nurse/staff #2) stated the admitting nurse was responsible for the development of the interim care plan. She stated that she would expect the need for contact isolation to be included in the interim care plan, when the resident has a [DIAGNOSES REDACTED]. During an interview conducted at 9:17 a.m. on (MONTH) 22, (YEAR), the DON (Director of Nursing/staff #6) also stated the nurse admitting the resident was responsible for developing the interim care plan. A review of the Care Plans - Preliminary policy and procedure revealed, A preliminary plan of care to meet the resident's immediate needs shall be developed for each resident within twenty-four (24) hours of admission. The policy also stated To assure that the resident's immediate care needs are met and maintained, a preliminary care plan will be developed within twenty-four (24) hours of the resident's admission.",2020-09-01
71,HAVEN OF SCOTTSDALE,35059,3293 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2016-09-22,314,D,0,1,BZVV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record review, staff interviews and policy review, the facility failed to ensure that one resident's (#136) pressure ulcer was accurately identified and documented. Findings include: Resident #136 was admitted on (MONTH) 25, (YEAR), with [DIAGNOSES REDACTED]. According to a hospital physician progress notes [REDACTED]. Review of the admission nursing evaluation dated (MONTH) 25, (YEAR) revealed the resident had a wound on the sacrum. However, there was no clinical record documentation of any description of the wound or any measurements. Review of the admission orders [REDACTED]. There were orders to apply EPC (Endothelial Progenitor Cell) to gluteal cleft/coccyx three times a day for skin impairment, however, there was no documentation that this order was clarified with the physician, in order to determine if this treatment was for the sacral pressure ulcer. An initial care plan dated (MONTH) 25, (YEAR) included that the resident had skin breakdown to the sacrum. Interventions included for weekly skin checks and to notify the charge nurse of skin issues. Review of the pressure ulcer assessment documentation dated (MONTH) 26, (YEAR), revealed the resident had a stage III pressure ulcer to the sacrum, which measured 2.1 cm x 2.0 cm x 0.2 cm. Per the documentation, the treatment included for the use of [MEDICATION NAME]. However, there were no wound treatment orders for the use of [MEDICATION NAME]. A physician's orders [REDACTED]. Review of the (MONTH) (YEAR) TAR (Treatment Administration Record) revealed the above order to the coccyx. However, there was no clinical record documentation that this order was clarified with the physician, in order to determine if the treatment order was for the sacral pressure ulcer or if it was a new wound to the coccyx which had developed. A pressure ulcer care plan dated (MONTH) 27, (YEAR) included the resident had a stage III pressure ulcer to the sacrum. Interventions included monitoring, documenting any changes in skin status and reporting to physician as needed. Review of the physician wound care notes dated (MONTH) 28, (YEAR) revealed the resident had an acute unhealed stage III pressure ulcer located on the sacrum, which measured 2.1 cm in length x 2 cm in width x 0.2 cm in depth. The plan included to cleanse the wound with NS or water, apply alginate with [MEDICATION NAME] and an island dressing, and to change the dressing every day and as needed. However, a physician's orders [REDACTED]. Further review of the (MONTH) (YEAR) TAR revealed this order was included for the coccyx. According to the weekly pressure ulcer report dated (MONTH) 29, (YEAR), the resident had a stage III pressure ulcer to the coccyx, which measured 2.1 cm x 2.0 cm x 0.2 cm. The documentation did not indicate whether this was a new pressure ulcer to the coccyx, or if it was the same wound to the sacrum which was present upon admission. Review of the Minimum Data Set (MDS) admission assessment dated (MONTH) 1, (YEAR), revealed in Section I. that the resident had a stage II pressure ulcer to the sacral area. However, in Section M. under skin conditions, the resident was assessed to have one unhealed stage III pressure ulcer that was present upon admission. The weekly pressure ulcer report dated (MONTH) 5, (YEAR) included the resident had a stage III pressure ulcer to the coccyx, which measured 2.0 cm x 2.0 cm x 0.2 cm. In an interview with a licensed practical nurse (LPN/staff #60) conducted on (MONTH) 21, (YEAR) at 11:04 a.m., she stated that wound care, treatment, measurement and documentation are done by a wound care nurse. She further stated that the floor nurses only apply barrier creams and ointments to wounds. An interview with another LPN (staff #24) was conducted on (MONTH) 21, (YEAR) at 4:48 p.m. The Director of Nursing (DON/staff #6) was also present during the interview. Staff #24 stated that she was the treatment nurse during the time when the resident was admitted and that the resident only had a stage III pressure ulcer to the coccyx. She stated that the resident did not have any pressure ulcer on the sacrum. In another interview with staff #24 on (MONTH) 22, (YEAR) at 9:00 a.m., she stated that when conducting a treatment, she documents what she sees. She said when the site of the wound is different from the physician's documentation, she will clarify it with the physician. Staff #6 was also present during the interview stated that she could not tell if the resident had two pressure ulcers, one on the sacrum and one on the coccyx, or if the physician and/or nurse just made a mistake in identifying the location of the wound. An interview with the wound care physician (staff #79) was conducted on (MONTH) 22, (YEAR) at 9:46 a.m. She stated that the resident only had one pressure ulcer and it's location and stage is whatever her documentation indicated. The policy regarding Wound Management included a comprehensive wound management program with a goal to promote the highest level of functioning and well-being of residents and to minimize the number of residents that develop in house acquired pressure ulcers. All residents with wounds receive treatment and services consistent with the resident's goals of treatment. The policy included that pressure ulcers are to be assessed weekly and that nursing staff shall describe and document a full assessment of the pressure sore, including the location, stage, length, width, depth and the presence of exudate or necrotic tissue.",2020-09-01
72,HAVEN OF SCOTTSDALE,35059,3293 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2016-09-22,514,D,0,1,BZVV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to maintain clinical records that were accurately documented, by failing to ensure a physician's orders [REDACTED].#5). Findings include: Resident #5 was admitted to the facility on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. Discharge orders from the hospital dated (MONTH) 9, (YEAR) included an order for [REDACTED]. However, review of the current physician's orders [REDACTED].>Review of the MAR (medication administration record) for (MONTH) and (MONTH) (YEAR) also revealed the order for [MEDICATION NAME] 27.5 mcg. In an interview with a Licensed Practical Nurse (LPN/staff #35) on (MONTH) 21, (YEAR) at 12:55 p.m., she reviewed the orders and acknowledged that the order for [MEDICATION NAME] 27.5 mcg was incorrect. In an interview on (MONTH) 21, (YEAR) at 1:00 p.m., the Clinical Operations Director (staff #76) reviewed the resident's chart regarding the original admission orders [REDACTED]. She stated somehow the order must have been entered incorrectly into the electronic clinical record. In an interview with the corporate resource nurse (staff #77) on (MONTH) 22, (YEAR) at 8:12 a.m., she stated that the night nurse is responsible for checking the electronic chart to ensure new orders are put in correctly. In addition, she stated that either herself and/or the Director of Nursing, review new orders in an audit report to ensure orders are transcribed correctly.",2020-09-01
73,HAVEN OF SCOTTSDALE,35059,3293 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2017-10-25,156,D,1,1,DB1811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews, and policy review, the facility failed to provide two residents (#s 13 and 18) with Notifications of Medicare Non-Coverage (NOMNC), prior to discharge. Findings include: -Resident #18 was admitted to the facility on (MONTH) 21, (YEAR), with [DIAGNOSES REDACTED]. A review of the Admission Record dated (MONTH) 21, (YEAR) revealed the resident's primary payer source was Medicare [NAME] Review of an undated and unsigned Case Management Activity note revealed DC (discharge) to group Home .will get house cleaned on 6/8 and wants to be home on that day to make sure all goes well. Review of the Physical Therapy Discharge Summary dated (MONTH) 7, (YEAR) revealed the resident's discharge destination was a group home, and the reason for discharge was Highest Practical Level Achieved. A review of the Occupational Therapy Discharge Summary dated (MONTH) 7, (YEAR) revealed the resident's discharge destination was a group home, and the reason for discharge was Highest Practical Level Achieved. Review of the clinical record revealed no documented evidence that a Notice of Medicare Non-Coverage was provided to the resident, prior to being discharged to the community on (MONTH) 8, (YEAR). -Resident #13 was admitted to the facility on (MONTH) 15, (YEAR), with [DIAGNOSES REDACTED]. A review of the Admission Record dated (MONTH) 15, (YEAR) revealed the resident's primary payer source was Medicare [NAME] Review of an unsigned and undated Case Management/Interdisciplinary Discharge Plan-Tier Two Active Inpatient Plan revealed Resident wants to return home on date/week of 6/5 for family reunion. Review of the Physical Therapy Discharge Summary dated (MONTH) 6, (YEAR) revealed the resident's discharge destination was Home, and the reason for discharge was Highest Practical Level Achieved. A review of the Occupational Therapy Discharge Summary dated (MONTH) 6, (YEAR) revealed the resident's discharge destination was Home, and the reason for discharge was Highest Practical Level Achieved. Review of the clinical record revealed no documented evidence that a Notice of Medicare Non-Coverage was provided to the resident, prior to being discharged to the community on (MONTH) 7, (YEAR). During an interview conducted at 12:35 p.m. on (MONTH) 25, (YEAR), the Administrator stated he was responsible for providing the Notice of Medicare Non-Coverage letters to the residents, prior to discharge. He stated that he had not provided these residents with the NOMNC letters, because the residents had told him they wished to go home and indicated the dates they wished to leave. During the survey, the facility provided undated Business Office Manager Auditor notes which included the following: .also discussed with .administrator, the importance of ensuring NOMNCs are done for all residents even if the resident chooses to leave on their own . Review of the facility's policy regarding Medicare Denial Notices revealed under the section Notice of Medicare Non Coverage that for residents currently under the Medicare A benefit in the facility, when the facility determined that Medicare A is no longer the appropriate payer for the resident or the resident is planning on discharging from the facility, the CMS NOMNC (Notice of Medicare Non Coverage) is to be issued to the resident and/or the appropriate Responsible Party two days before the resident is to come off Medicare A or be discharged . Once signed and dated appropriately, this is to be uploaded into the EHR (electronic health record).",2020-09-01
74,HAVEN OF SCOTTSDALE,35059,3293 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2017-10-25,281,D,1,1,DB1811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews and policy and procedures, the facility failed to ensure that medications were administered as physician ordered for two residents (#143 and #145). Findings include: -Resident #143 was admitted on (MONTH) 18, (YEAR), with [DIAGNOSES REDACTED]. A review of the (MONTH) (YEAR) physician's orders [REDACTED]. -[MEDICATION NAME] 325 mg (milligrams) by mouth every six hours PRN (as needed) for a pain level of 1-2. -[MEDICATION NAME] 325 mg two tablets by mouth every six hours PRN for a pain level of 3-4. -[MEDICATION NAME] (non steroidal anti [MEDICAL CONDITION]) 500 mg by mouth every 12 hours PRN for pain level of 5-6. -[MEDICATION NAME] (narcotic) 5-325 mg two tablets by mouth every four hours PRN for a pain level of 7-10. However, a review of the (MONTH) (YEAR) MAR (Medication Administration Record) revealed the resident had been administered [MEDICATION NAME] twice for a pain level of seven on (MONTH) 19, and once on (MONTH) 20 for a pain level of 7. Per the physician's orders [REDACTED]. An interview was conducted on (MONTH) 24, (YEAR) at 1:45 p.m., with the ADON (Assistant Director of Nursing/staff #55). Following a review of the physician's orders [REDACTED].#55 stated that the [MEDICATION NAME] was administered for a pain level of seven, which was not as ordered. He stated the physician's orders [REDACTED]. -Resident #145 was admitted on (MONTH) 10, (YEAR), with [DIAGNOSES REDACTED]. A review of the (MONTH) (YEAR) physician's orders [REDACTED]. -Tylenol 325 mg two tablets by mouth every four hours PRN for a pain level of 1-5. -[MEDICATION NAME] (narcotic) 15 mg by mouth every four hours PRN for a pain level of 6-10. A review of the (MONTH) (YEAR) MAR indicated [REDACTED]. There was no clinical record documentation that the physician was notified or additional orders were obtained. An interview was conducted on (MONTH) 24, (YEAR) at 10:20 a.m., with a LPN (Licensed Practical Nurse/staff #2). Following a review of the physician's orders [REDACTED].#2 stated that Tylenol was administered outside of the physician's prescribed pain scale parameters. Staff #2 stated that the physician's orders [REDACTED]. An interview was conducted on (MONTH) 24, (YEAR) at 10:30 a.m., with the DON (Director of Nursing/staff #5). Following a review of the physician's orders [REDACTED]. Staff #5 stated that if a resident requests a medication which is outside of the pain parameters, the physician should be notified and new orders obtained and documented. A facility policy titled, Administering Pain Medications included the following: 6. Administer pain medications as ordered.",2020-09-01
75,HAVEN OF SCOTTSDALE,35059,3293 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2017-10-25,322,D,0,1,DB1811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interviews and policy review, the facility failed to ensure one resident (#83) with a feeding tube was provided the appropriate treatment and services. Findings include: Resident #83 was admitted on (MONTH) 1, (YEAR) and readmitted on (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident had a percutaneous endoscopic gastrostomy (PEG) tube. A care plan dated (MONTH) 5, (YEAR) included the resident had a feeding tube related to poor nutritional intake. A goal included the resident would be free of aspiration. Interventions were for the nurse to check tube placement per facility protocol, and flush the PEG tube with water. Review of a Minimum Data Set (MDS) assessment dated (MONTH) 9, (YEAR) revealed the resident had severe cognitive impairment, was unable to speak, and had a feeding tube. A medication administration observation was conducted on (MONTH) 23, (YEAR) at 9:00 a.m., with a Registered Nurse (staff #4). During the observation, the nurse crushed nine medications together and mixed them with 60 cc of water in a cup. Without first checking placement of the PEG tube, the nurse then flushed the resident's PEG tube with 30 cc of water using a 60 cc syringe, by pushing the plunger on the syringe to administer the water, instead of using the gravity flow method. The nurse then drew up the medications which had been mixed with water into the syringe, and pushed the plunger on the syringe to administer the medications into the PEG tube, instead of using the gravity flow method. Next, the nurse flushed the PEG tube with 30 cc of water using a 60 cc syringe and pushed the plunger on the syringe to administer the water, instead of using the gravity flow method. Following the observation, an interview was conducted with staff #4, who stated that she had checked the placement of the tube by looking at a black line on the PEG tube. She stated that if the line is not visible, the PEG tube is not correctly placed and the tube cannot be used. Staff #4 stated that she did not need to use a stethoscope to check for correct placement of the tube, because the night shift nurse does that. Staff #4 also stated that the medications are usually pushed into the tube by depressing the plunger on the 60 cc syringe, and she was not sure if the gravity flow method was suppose to be use. She stated that she had mixed all of the medications together in the same cup, instead of giving them separately to prevent the resident from being disturbed. Staff #4 further stated that she was unsure what the facility policies were regarding medication administration through a PEG tube. An interview was conducted on (MONTH) 24, (YEAR) at 11:00 a.m., with the Director of Nursing (DON/staff #5). The DON stated that nurses are supposed to check the placement of the PEG tube, prior to flushing the tube. Staff #5 stated that this is done by injecting air into the tube, and at the same time, using a stethoscope to listen for air being injected into the stomach. The DON stated that the medications provided through a PEG tube are to be given separately and should not be mixed altogether. The DON further stated the nurses are supposed to remove the plunger from the 60 cc syringe, add the crushed medications which have been mixed with water, and allow the medications to flow by gravity into the PEG tube. The DON stated the nurses are not to administer the medications by depressing the plunger on the syringe. A facility policy for administering medications through an enteral (PEG) tube contained the following guidelines: The nurse is not to mix medications together prior to administering medications through an enteral tube, the nurse is to administer each medication separately; the nurse is to confirm placement of the feeding tube prior to flushing the tube; and that medications are to be administered by gravity flow.",2020-09-01
76,HAVEN OF SCOTTSDALE,35059,3293 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2017-10-25,371,E,1,1,DB1811,"> Based on observation, staff interview, review of the temperature logs and facility documentation, the facility failed to ensure one nourishment refrigerator temperatures were maintained at or below 41 degrees F. Findings include: During an observation conducted at 12:10 p.m. on (MONTH) 24, (YEAR), the nourishment refrigerator was observed to contain food and snacks for the residents. Review of the Refrigerator Temperature Log Audit for (MONTH) (YEAR) revealed the temperatures were to be checked daily. The log included that the temperature range should be between 35-46 degrees F, instead of at or below 41 degrees F, as required. Per the documentation, there were 12 of 24 days with documented temperatures between 42 to 46 degrees F. During an interview conducted at 1:00 p.m. on (MONTH) 24, (YEAR), the Dietary Manager (staff #35) stated the temperature range for the nourishment refrigerator should be between 35 and 41 degrees F. She stated this log was incorrect and was not the dietary refrigerator log which should be used. She stated she was not aware that the temperatures were often above 41 degrees F. Staff #35 stated that when the temperatures were not within the appropriate range, the food should have been discarded. She also said that snacks for residents are stored in the snack/nourishment refrigerator. Review of a facility's guideline regarding Resident Food Stored in Nourishment Refrigerators revealed that all nourishment refrigerators have a working thermometer and that the temperatures are to be maintained between 36-41 degrees F.",2020-09-01
77,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2020-01-08,609,D,1,0,DWKV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview and review of policies and procedures, and review of the State Agency data base, the facility failed to ensure that alleged violations involving abuse or mistreatment for [REDACTED].#1, 2, 3, 4) were reported to APS (Adult Protective Services) and failed to ensure that the results of investigation of alleged violations involving abuse or mistreatment for [REDACTED].#1, 3, 4, 5) were reported to the State Agency. The deficient practice could result in additional allegations of abuse or mistreatment not being reported to APS, and additional results of investigations of abuse or mistreatment not being reported to the State Agency. Findings include: -Resident #1 was admitted on (MONTH) 13, (YEAR) and readmitted on (MONTH) 5, 2019 with [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment dated (MONTH) 21, 2019 included a BIMS (Brief Interview for Mental Status) score of 15, which indicted the resident was cognitively intact. The assessment included that resident #1 had verbal behavioral symptoms directed at others, refused care and wandered. A Health Status Note dated (MONTH) 16, 2019 at 1:00 a.m. included that during a smoke break, a peer (resident #5) had grabbed the cigarette supply and that resident #1 had observed resident #5 grab the cigarettes. The note included that resident #1 tried to take the cigarettes from resident #5, and resident #5 then grabbed the sweater of resident #1, who slid to the floor. The note included that there were no injuries. A Behavior Note dated (MONTH) 21, 2019 at 3:30 p.m. included that the resident had hit another resident on the right cheek and pulled the other resident's hair while they were fighting over (pet) birds, in the other resident's room. The note included that the other resident had grabbed the arm of resident #1, and the resident's were separated. The note included that there were no injuries. Review of the plan of care for resident #1 revealed that it was updated on (MONTH) 21, 2019 to include that resident #1 had a confrontation with another resident over birds, and had hit the other resident on the cheek and pulled her hair. -Resident #5 was admitted on (MONTH) 31, 2019 with [DIAGNOSES REDACTED]. An admission MDS assessment dated (MONTH) 9, 2019 included that resident #5 had a BIMS score of 7 which indicated that resident #5 had severe cognitive impairment. The assessment included that resident #5 had verbal and physical behavioral symptoms directed towards others, no functional limitations in range of motion and used a wheelchair. An Incident Note dated (MONTH) 15, 2019 at 11:34 p.m. included that during a smoke break, resident #5 had grabbed all of the cigarettes, which caused an argument with a peer. The note included that resident #5 grabbed the peer by her sweater, which caused the peer to slide to the floor, and there were no injuries. An investigative report dated (MONTH) 20, 2019 included that on (MONTH) 15, 2019 at 7:10 p.m. as residents were headed to a smoke break, and when resident #1 noticed that resident #5 had the box of (resident) cigarettes, resident #1 became angry and confronted resident #5, and resident #5 grabbed the sweater of resident #1. The report included that when resident #5 grabbed the sweater of resident #1, this caused resident #1 to fall to the ground. The report included that the AZDHS (Arizona Department of Health Services), Phoenix Police, local Ombudsman and responsible parties were notified of the incident. Review of the facility investigation did not reveal a fax receipt, and review of the State Agency data base did not reveal any documented evidence that the facility sent a summary report of the incident on (MONTH) 15, 2019 to AZDHS. -Resident #2 was admitted on (MONTH) 29, 2019 with [DIAGNOSES REDACTED]. A quarterly MDS assessment dated (MONTH) 29, 2019 included that resident #2 had moderately impaired cognition and problems with short and long term memory, and behavioral symptoms not directed at others. The assessment included that the resident was short tempered, easily annoyed, and had trouble concentrating. A Behavior Note dated (MONTH) 21, 2019 at 4:01 p.m. included that resident #2 had grabbed another resident by the arm when the other resident tried to take her pet birds away from her. The note included that resident #2 said that the other resident hit her on the cheek and pulled her hair, and that the other resident was trying to take her pet birds away from her when she grabbed the other resident by the arm. The note included that there were no injuries. An investigative report dated (MONTH) 24, 2019 included that on (MONTH) 21, 2019 at 3:00 p.m. resident #1 entered resident #2's room and was observing pet birds that resident #2 keeps on her dresser, and resident #1 attempted to remove the birds in their cage from the room. The report included that resident #2 grabbed resident #1's arm, and resident #1 retaliated by pulling resident #2's hair and slapping her across the face. Staff separated the resident's and there were no injuries. The report included that the AZDHS (Arizona Department of Health Services), Phoenix Police, local Ombudsman and responsible parties were notified. However, there was no documentation that APS had been notified of the incident on (MONTH) 21, 2019. Review of the facility investigation revealed a form titled Desert Haven Care Center State Report File Folder. The form included multiple entries where staff recorded that the incident was reported on (MONTH) 21, 2019 to AZDHS, the Phoenix PD (Police Department), the resident's responsible party, and the State Ombudsman. However, the form did not include a space to record that APS had been notified of the incident. -Resident #4 was admitted on (MONTH) 8, 2019 with [DIAGNOSES REDACTED]. An Admission MDS assessment dated (MONTH) 20, 2019 included that resident #4 had a BIMS score of 3, which indicated that the resident had severely impaired cognition, difficulty focusing attention and physical behaviors directed at others. An Incident Note dated (MONTH) 7, 2019 at 10:36 a.m. included that resident #4 and resident #5 had engaged in a verbal altercation in the dining room, when resident #4 reached over and struck resident #5 on the right arm. The note included that he resident's were separated by staff, and there were no injuries. -Resident #3 was admitted on (MONTH) 6, 2014 with [DIAGNOSES REDACTED]. A Quarterly MDS assessment dated (MONTH) 9, 2019 included that the resident had speech that was unclear or slurred, and that he usually understands others. The assessment included that the resident had a BIMS score of 9, which indicated that the resident had moderately impaired cognition, and verbal behavioral symptoms directed at others. An Incident Note dated (MONTH) 17, 2019 at 10:31 a.m. included that resident #4 and resident #5 had engaged in a verbal altercation in the dining room, when resident #4 reached over and struck resident #5 on the right arm. The note included that he resident's were separated by staff, and there were no injuries. An investigative report dated (MONTH) 20, 2019 included that on (MONTH) 17, 2019 residents #4 and #3 were in the unit dining room, and began to have a verbal altercation, and that resident #4 reached over and hit resident #3 on the right arm. The report included that the residents were immediately separated and there were no injuries. Review of the facility investigation revealed a State Report File Folder form, which included that the incident was reported on (MONTH) 17, 2019 to AZDHS, the Phoenix PD (Police Department), the resident's responsible party, and the State Ombudsman. However, there was no documentation on the form that APS had been notified of the incident. Also, review of the facility investigation did not reveal a fax receipt, and review of the State Agency data base did not reveal any documented evidence that the facility sent a summary report of the incident to AZDHS. The following interviews were interviews conducted on (MONTH) 6, 2020 with the Director of Nursing/staff #120: -At 1:45 p.m. the Director stated that he tries to save fax receipts when he sends the 5 day summary report of the investigation to AZDHS. However, the fax machine had broken down and he was unable to print fax receipts. The Director also stated that the facility does report allegations of abuse to APS, and notifications to APS are sometimes done by the nurse on duty. However, the Director examined the Report File Folder forms, and stated that APS was not listed on the form to be notified of an allegation, which may have resulted in the nurse not notifying APS. -At 2:25 p.m. the Director stated that he had phoned APS to determine if APS had received reports of the incidents on (MONTH) 17, 2019 and (MONTH) 21, 2019, and stated that APS had never received notification of the incidents A policy and procedure titled Abuse Investigations included a statement that all allegations/signs of resident abuse, neglect and injuries of unknown source shall be immediately reported and thoroughly investigated by facility management. The policy included that the Administrator of designee will review and if incidents meet the elements of reporting within 2 hours, will ensure appropriate Regulatory Agencies, Law enforcement, Medical Director and Representative are notified. The policy also included that the Administrator or designee will provide a written report of the results of all abuse investigations and appropriate action taken to the State Survey and Certification Agency, the local police department, the Ombudsman and others as may be required by State or local laws, within 5 days of the incident.",2020-09-01
78,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2020-01-08,610,D,1,0,DWKV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interviews, record reviews and review of policies and procedures, the facility failed to ensure that an allegation of resident to resident abuse for two residents (#1, 2) was thoroughly investigated. The deficient practice could result in additional allegations of abuse not being thoroughly investigated by the facility. Findings include: -Resident #1 was admitted on (MONTH) 13, (YEAR) and readmitted on (MONTH) 5, 2019 with [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment dated (MONTH) 21, 2019 included a BIMS (Brief Interview for Mental Status) score of 15, which indicted the resident was cognitively intact. The assessment included that resident #1 had verbal behavioral symptoms directed at others, refused care and wandered. A Behavior Note dated (MONTH) 21, 2019 at 3:30 p.m. included that the resident had hit another resident on the right cheek and pulled the other resident's hair while they were fighting over (pet) birds, in the other resident's room. The note included that the other resident had grabbed the arm of resident #1, and the resident's were separated. The note included that there were no injuries. Review of the plan of care for resident #1 revealed that it was updated on (MONTH) 21, 2019 to include that resident #1 had a confrontation with another resident over birds, and had hit the other resident on the cheek and pulled her hair. -Resident #2 was admitted on (MONTH) 29, 2019 with [DIAGNOSES REDACTED]. A quarterly MDS assessment dated (MONTH) 29, 2019 included that resident #2 had moderately impaired cognition and problems with short and long term memory, and behavioral symptoms not directed at others. The assessment included that the resident was short tempered, easily annoyed, and had trouble concentrating. A Behavior Note dated (MONTH) 21, 2019 at 4:01 p.m. included that resident #2 had grabbed another resident by the arm when the other resident tried to take her pet birds away from her. The note included that resident #2 stated that the other resident hit her on the cheek and pulled her hair, and that the other resident was trying to take her pet birds away from her when she grabbed the other resident by the arm. The note included that there were no injuries. An investigative report dated (MONTH) 24, 2019 included that on (MONTH) 21, 2019 at 3:00 p.m. two CNA's (Certified Nursing Assistants) witnessed an altercation, and that the staff stated that resident #1 entered resident #2's room (located on the Magnolia Unit) and was observing pet birds that resident #2 keeps on her dresser, and resident #1 attempted to remove the birds in their cage from the room. The report included that resident #2 grabbed resident #1's arm, and resident #1 retaliated by pulling resident #2's hair and slapping her across the face. The report included that the staff who were present immediately separated the resident's, the residents were assessed for injuries, and there were no injuries present. Review of the facility investigation, did not incude any direct witness statements, or reveal the names of the two CNA's who witnessed the altercation, or identify the staff who separated residents #1 and #2. The following interviews were conducted on (MONTH) 7, 2020 with the following staff who were assigned to the Magnolia Unit on (MONTH) 21, 2019 when the incident occurred: -At 10:00 a.m. a CNA/staff #86 stated that when the incident occurred she was not present on the unit at that time because she was on a break and that she believed that two other CNA's (staff #173, and #71) and a nurse (staff #21) remained on the unit while she was on break. -At 10:09 a.m. a CNA/staff #143 stated that she did not witness what actually happened because she was in another room with another CNA (staff #71) providing care to a resident. Staff #143 stated she heard a commotion and when she went out of the room saw resident #1 placing resident #2's pet birds in the hallway, the two resident's were arguing and she helped to separate them. Staff #143 stated that another CNA was supposed to be monitoring the hallway while she and staff #71 were in another room providing care, and she did not know the location of the nurse at the time of the incident. -At 10:22 a.m. a CNA/staff #71 stated she did not observe what happened because she was assisting staff #143 to provide care in another room when the incident occurred. Staff #71 stated that there should have been a nurse and at least one of possibly two CNA's on the unit when she was in another room providing care. -At 11:35 a.m. an LPN/staff #21 stated that when the incident occurred she was off the unit on a break and did not witness the incident. The following interviews were conducted on (MONTH) 7, 2020 with the Director of Nursing/staff #120: -At 9:00 a.m. the Director identified 3 CNA's who were assigned to work on the Magnolia Unit on (MONTH) 21, 2019 at the time of the incident, and stated that witness statements had not been obtained from the CNA's. -At 10:26 a.m. the Director identified a nurse who was assigned to work on the Magnolia Unit on (MONTH) 21, 2019 at the time of the incident, and stated that witness statements had not been obtained for this investigation. A policy and procedure titled Abuse Investigations included a statement that all allegations/signs of resident abuse, neglect and injuries of unknown source shall be thoroughly investigated by facility management, and that the Administrator or his/her designee will appoint a member of management to investigate the alleged incident. The policy included that the individual conducting the investigation will, as a minimum interview the person(s) reporting the incident, interview any witnesses to the incident, interview the resident and the witness reports will be obtained in writing.",2020-09-01
79,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2020-01-08,689,E,1,0,DWKV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interviews, record reviews and review of policies and procedures, the facility failed to ensure that multiple residents with aggressive behaviors (#1, 2, 4, 5) were provided adequate supervision to prevent the residents from behaving in a physically aggressive manner towards other residents. The deficient practice could result in multiple residents behaving aggressively towards other residents. Findings include: -Resident #1 was admitted on (MONTH) 13, (YEAR) and readmitted on (MONTH) 5, 2019 with [DIAGNOSES REDACTED]. A written care plan initiated on (MONTH) 25, 2019 and updated on (MONTH) 8, 2019 included that resident #1 had a history of [REDACTED]. A Behavioral Plan dated (MONTH) 9, 2019 included that on admission the resident had a history of [REDACTED]. The behavioral plan included that currently, the resident makes false accusations of peers taking her belongings, and has a history of physical altercations with peers. The behavioral plan listed multiple interventions included to monitor resident #1 for her peer's safety, listen to her concerns and to remove peers for their safety. A quarterly MDS (Minimum Data Set) assessment dated (MONTH) 21, 2019 included a BIMS (Brief Interview for Mental Status) score of 15, which indicted the resident was cognitively intact. The assessment included that resident #1 had verbal behavioral symptoms directed at others, refused care and wandered. Review of the MAR (Medication Administration Record) for (MONTH) 2019 revealed that resident #1 had the following behaviors which were documented in sections of the record for daily behavioral monitoring: -Verbally abusive behaviors were recorded on (MONTH) 1, 3, 5, 9, 10, 12 and 15, 2019. -Angry outbursts were recorded on (MONTH) 3, 5, 9, 10, and 12, 2019. -Delusions were recorded on (MONTH) 1, 4, 6, 7, 8, 11, 14, and 15, 2019. -False accusations were recorded on (MONTH) 8, 10, and 15, 2019. A Health Status Note dated (MONTH) 16, 2019 at 1:00 a.m. included that during a smoke break, a peer (resident #5) had grabbed the cigarette supply and that resident #1 had observed resident #5 grab the cigarettes. The note included that resident #1 tried to take the cigarettes from resident #5, and resident #5 then grabbed the sweater of resident #1, who slid to the floor. The note included that there were no injuries. Review of the MAR for (MONTH) 2019 revealed that resident #1 had following behaviors which were documented in daily behavioral monitoring: -Verbally abusive behaviors were recorded on (MONTH) 5, 6, 8, 12, 14, 15, 17, 19, 20, and 21, 2019. -Angry outbursts were recorded on (MONTH) 8, 12, 14, 16, 17, 20, and 21, 2019. -Delusions were recorded on (MONTH) 1-5, 8, 9, 12, 14, 15, 16, and 18-21, 2019. -False accusations were recorded on (MONTH) 8, 9, and 19-21, 2019. -Combativeness was recorded on (MONTH) 17, 2019. A Behavior Note dated (MONTH) 21, 2019 at 3:30 p.m. included that the resident had hit another resident on the right cheek and pulled the other resident's hair while they were fighting over (pet) birds, in the other resident's room. The note included that the other resident had grabbed the arm of resident #1, and the resident's were separated. This note included that there were no injuries. Review of the plan of care for resident #1 revealed that it was updated on (MONTH) 21, 2019 to include that resident #1 had a confrontation with another resident over birds, and had hit the other resident on the cheek and pulled her hair. -Resident #5 was admitted on (MONTH) 31, 2019 with [DIAGNOSES REDACTED]. An admission MDS assessment dated (MONTH) 9, 2019 included that resident #5 had a BIMS score of 7 which indicated that resident #5 had severe cognitive impairment. The assessment included that resident #5 had verbal and physical behavioral symptoms directed towards others, no functional limitations in range of motion and used a wheelchair. A psychiatric evaluation dated (MONTH) 10, 2019 included that resident #5 had displayed intermittent irritability, impulsivity, agitation, demanding behavior and verbal aggression. A plan of care for resident #5 for impaired cognitive function related to dementia, had multiple interventions listed including to cue, re-orient and supervise the resident as needed. A plan of care of care for a history and [DIAGNOSES REDACTED]. Review of the MAR for (MONTH) 2019 revealed that resident #5 had demanding and verbally abusive behaviors recorded in daily behavioral monitoring for (MONTH) 1-5, 7, 8. 11. and 13-15, 2019. An Incident Note dated (MONTH) 15, 2019 at 11:34 p.m. included that during a smoke break, resident #5 had grabbed all of the cigarettes, which caused an argument with a peer. The note included that resident #5 grabbed the peer by her sweater, which caused the peer to slide to the floor, and there were no injuries. An investigative report dated (MONTH) 20, 2019 included that (MONTH) 15, 2019 at 7:10 p.m. as residents were headed to a smoke break, and when resident #1 noticed that resident #5 had the box of (resident) cigarettes, resident #1 became angry and confronted resident #5, and resident #5 grabbed the sweater of resident #1, The report included that when resident #5 grabbed the sweater of resident #1, this caused resident #1 to fall to the ground. -Resident #2 was admitted on (MONTH) 29, 2019 with [DIAGNOSES REDACTED]. A quarterly MDS assessment dated (MONTH) 29, 2019 included that resident #2 had moderately impaired cognition and problems with short and long term memory, and behavioral symptoms not directed at others. The assessment included that the resident was short tempered, easily annoyed, and had trouble concentrating. A written plan of care for resident #2 included a plan for impaired cognitive function related to dementia, that had multiple interventions including to cue, reorient and supervise the resident as needed. A Behavior Note dated (MONTH) 4, 2019 at 10:16 a.m. included that resident #2 was worried that resident #1 was getting into her closet when she was out out of her room. A Health Status Note dated (MONTH) 8, 2019 at 5:18 p.m. included that resident #2 had complained that resident #1 had been in her room and was afraid that resident #1 would take her possessions. The note included that staff would monitor the resident for any changes and safety. A Behavioral Plan dated (MONTH) 9, 2019 included that resident #2 grabs at other residents, and that she appears to be targeting a specific peer, and takes the peers belongings. The plan included to monitor and redirect her away from a specific peer. A Behavior Note dated (MONTH) 15, 2019 at 9:02 a.m. included that resident #2 and #1 had an argument and were redirected away from each other to de-escalate the argument. A Behavior Note dated (MONTH) 21, 2019 at 4:01 p.m. included that resident #2 had grabbed another resident by the arm when the other resident tried to take her pet birds away from her. The note included that resident #2 stated that the other resident hit her on the cheek and pulled her hair, and that the other resident was trying to take her pet birds away from her when she grabbed the other resident by the arm. The note included that there were no injuries. An investigative report dated (MONTH) 24, 2019 included that on (MONTH) 21, 2019 at 3:00 p.m. resident #1 entered resident #2's room and was observing pet birds that resident #2 keeps on her dresser, and resident #1 attempted to remove the birds in their cage from the room. The report included that resident #2 grabbed resident #1's arm, and resident #1 retaliated by pulling resident #2's hair and slapping her across the face. Staff separated the resident's and there were no injuries. During an interview with an LPN (Licensed Practical Nurse/staff #72) conducted on (MONTH) 6, 2020 at 2:45 p.m. the LPN stated that the staff circulate about the unit continuously to monitor resident's behavior and for safety. The LPN stated that the unit is usually staffed with 1-2 nurses and 3 CNA's (Certified Nursing Assistants). The following interviews were conducted on (MONTH) 7, 2020 with the following staff regarding the incident that occurred on (MONTH) 21, 2019: -At 10:00 a.m. a CNA/staff #86 stated that when the incident occurred she was not present on the unit at that time because she was on a break and that she believed that two other CNA's (staff #173, and #71) and a nurse (staff #21) remained on the unit while she was on break. -At 10:09 a.m. a CNA/staff #143 stated that she did not witness what actually happened because she was in another room with another CNA (staff #71) providing care to a resident. Staff #143 stated she heard a commotion and when she went out of the room saw resident #1 placing resident #2's pet birds in the hallway, the two resident's were arguing and she helped to separate them. Staff #143 stated that another CNA was supposed to be monitoring the hallway while she and staff #71 were in another room providing care, and she did not know the location of the nurse at the time of the incident. -At 10:22 a.m. a CNA/staff #71 stated she did not observe what happened because she was assisting staff #143 to provide care in another room when the incident occurred. Staff #71 stated that there should have been a nurse and at least one of possibly tow CNA's on the unit when she was in another room providing care. -At 11:35 a.m. an LPN/staff #21 stated that when the incident occurred she was off the unit on a break and did not witness the incident. The following interviews were conducted on (MONTH) 7, 2020 with the Director of Nursing/staff #120: -At 11:50 a.m. the Director stated that there should always be a staff present in the hallway on the unit and that the staff have scheduled break times to ensure there is staff coverage on the unit. The Director stated that there may have been a miscommunication which resulted in the nurse and a CNA being off the unit at the same when the incident occurred n (MONTH) 21, 2019. -At 1:30 p.m. the Director stated that one staff is assigned to assist the resident's with smoke breaks, and that one staff is sufficient to provide safety for the residents while they smoke. The Director stated that on (MONTH) 15, 2019 when the incident occurred between resident #1 and resident #5 during the smoke break, there was one staff present, however she was unable to reach the resident's quickly enough to prevent resident #5 from grabbing resident #1. -At 3:05 p.m. the Director stated that resident #5 was very compulsive about smoking from the time she was admitted and that interventions were not effective. The Director stated that resident #5 had grabbed a box of resident cigarettes, and resident #1 tried to take it from her to protect the cigarettes and that's when resident #5 pushed down resident #1. -Resident #4 was admitted on (MONTH) 8, 2019 with [DIAGNOSES REDACTED]. An Admission MDS assessment dated (MONTH) 20, 2019 included that resident #4 had a BIMS score of 3, which indicated that the resident had severely impaired cognition, difficulty focusing attention and physical behaviors directed at others. Review of the clinical record did not reveal that a written plan of care for physical behaviors directed at other residents had been initiated. An Incident Note dated (MONTH) 7, 2019 at 10:36 a.m. included that resident #4 and resident #5 had engaged in a verbal altercation in the dining room, when resident #4 reached over and struck resident #5 on the right arm. The note included that he resident's were separated by staff, and there were no injuries. -Resident #3 was admitted on (MONTH) 6, 2014 with [DIAGNOSES REDACTED]. A Quarterly MDS assessment dated (MONTH) 9, 2019 included that the resident had speech that was unclear or slurred, and that he usually understands others. The assessment included that the resident had a BIMS score of 9, which indicated that the resident had moderately impaired cognition, and verbal behavioral symptoms directed at others. A written plan of care included that resident #3 has a [DIAGNOSES REDACTED]. The plan of care included a goal that the resident would refrain from verbally or physically abusive behavior and listed multiple interventions including to intervene by speaking calmly and professionally and in a soft tome of voice. The plan of care also included a that the resident had a communication problem related to weak voice and that he whispers, and listed multiple interventions including to allow the resident adequate time to respond. An Incident Note dated (MONTH) 17, 2019 at 10:31 a.m. included that resident #4 and resident #5 had engaged in a verbal altercation in the dining room, when resident #4 reached over and struck resident #5 on the right arm. The note included that he resident's were separated by staff, and there were no injuries. An investigative report dated (MONTH) 20, 2019 included that on (MONTH) 17, 2019 residents #4 and #3 were in the unit dining room, and began to have a verbal altercation, and that resident #5 reached over and hit resident #3 on the right arm. The report included that the residents were immediately separated and there were no injuries. During an interview conducted on (MONTH) 8, 2020 at 10:00 a.m. with the Director of Nursing/staff #120, he stated that resident #4 had never behaved aggressively towards another resident before this incident. The Director stated that sometimes resident #3 says things under his breath that are insulting to other residents, and that may have been why resident #4 struck resident #3. The Director stated that there was a CNA in the dining room at the time of the incident. A policy and procedure titled Problematic Behavior Management-Clinical Guideline included a statement that as part of the initial assessment, the staff and physician will identify individuals with a history of impaired cognition, problematic behavior, or mental illness, and that nursing staff will document the nature, duration, and associated features of any changes over time in behavior, cognition, or mood. The policy included that if the resident is being treated for [REDACTED].",2020-09-01
80,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2017-02-03,154,D,0,1,TPN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident's (#88) representative was informed of the risks and benefits of an antipsychotic medication, prior to administering. Findings include: Resident #88 was admitted on (MONTH) 30, (YEAR), with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 7, (YEAR) and the quarterly MDS assessment dated (MONTH) 7, (YEAR), revealed the resident was rarely or never understood. Review of the clinical record revealed a physician's orders [REDACTED]. Review of the medication administration records for (MONTH) and (MONTH) (YEAR) and for (MONTH) and (MONTH) (YEAR) revealed the [MEDICATION NAME] was administered as ordered. Further review of the clinical record revealed no documentation that the resident's representative was informed of the risks and benefits of [MEDICATION NAME], nor had informed consent been obtained. During an interview conducted on (MONTH) 1, (YEAR) at 10:12 a.m., a Licensed Practical Nurse (staff #54) stated an antipsychotic medication should not be administered before obtaining consent. During an interview conducted on (MONTH) 1, (YEAR) at 10:43 a.m., the acting Director of Nursing (staff #1) stated before administering an antipsychotic medication, a consent is obtained from either the resident or the responsible person explaining the medication and the side effects. Staff #1 further stated there should have been consent for the [MEDICATION NAME]. Review of the policy titled, Antipsychotic Medication Use included the physician and staff will gather and document information to clarify a resident's symptoms and risks. However, the policy did not address the need to inform the resident/representative of the risks and benefits of an antipsychotic medication, prior to administering.",2020-09-01
81,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2017-02-03,225,D,0,1,TPN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, resident and staff interviews, and policy and procedures, the facility failed to ensure resident to resident altercations involving two residents (#57 and #97) were investigated and reported to the State agency. Findings include: Resident #57 was admitted to the facility in (MONTH) 2014, with [DIAGNOSES REDACTED]. The resident resided in the secured Behavioral Unit. Review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 4, (YEAR) revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Review of resident #57's Nurse's Notes dated (MONTH) 27, (YEAR) and (MONTH) 12, (YEAR) revealed resident #57 reported to staff that she was hit on the arm by resident #97 and no physical injury had occurred. Resident #97 was admitted to the facility in (MONTH) (YEAR), with [DIAGNOSES REDACTED]. The resident resided in the secured Behavioral Unit and was discharged in (MONTH) (YEAR). Review of the quarterly MDS assessment dated (MONTH) 18, (YEAR) revealed a BIMS score of 13, which indicated the resident was cognitively intact. In an interview on (MONTH) 31, (YEAR) at 9:19 a.m., resident #57 said yes that she was abused by a former roommate, who had hit her on the left arm multiple times. The resident stated these incidents had occurred sometime in the spring of last year and were reported to staff. Resident #57 stated staff had moved the roommate to the other side of the room and at a later date, resident #57 had changed rooms. Resident #57 further stated that the roommate was no longer in the facility and there were no further incidents. During interviews on (MONTH) 1, (YEAR) at 11:27 a.m. and on (MONTH) 2, 2012 at 10:12 a.m. with the Interim Director of Nursing (staff #1/former unit manager of the Behavioral Unit where residents #57 and #97 resided), investigations regarding the incidents were requested. Staff #1 stated the allegations had occurred between residents #57 and #97 in the spring of (YEAR). Staff #1 stated that management staff and the physician had discussed the incidents and had met with both residents. Staff #1 confirmed an investigation of these reported altercations was not done and stated the incidents were not reported to the State agencies as required. The facility's Abuse Investigations policy and procedures identified that All allegations/signs of resident abuse, neglect and injuries of unknown source shall be immediately reported and thoroughly investigated by facility management .The Administrator or Designee will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and others as may be required by state or local laws, within five (5) working days of the reported incident.",2020-09-01
82,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2017-02-03,226,D,0,1,TPN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, facility documentation and policy and procedures, the facility failed to implement their policy regarding an allegation of abuse for one resident (#57), and failed to ensure that two direct care staff's (staff #2 and #63) licenses were verified with the licensing board. Findings include: -Resident #57 was admitted to the facility in (MONTH) 2014, with [DIAGNOSES REDACTED]. The resident resided in the secured Behavioral Unit. Review of resident #57's Nurse's Notes dated (MONTH) 27, (YEAR) and (MONTH) 12, (YEAR) revealed resident #57 reported to staff that she was hit on the arm by another resident (#97). In an interview on (MONTH) 31, (YEAR) at 9:19 a.m., resident #57 said yes that she was abused by a former roommate, who had hit her on the left arm multiple times. The resident stated these incidents had occurred sometime in the spring of last year and were reported to staff. During interviews on (MONTH) 1, (YEAR) at 11:27 a.m. and on (MONTH) 2, 2012 at 10:12 a.m. with the Interim Director of Nursing (staff #1/former unit manager of the Behavioral Unit where residents #57 and #97 resided), investigations regarding the incidents were requested. Staff #1 stated the allegations had occurred in the spring of (YEAR). Staff #1 confirmed an investigation of these reported altercations was not done and stated the incidents were not reported to the State agencies as required. The facility's Abuse Investigations policy and procedures identified that All allegations/signs of resident abuse, neglect and injuries of unknown source shall be immediately reported and thoroughly investigated by facility management .The Administrator or Designee will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and others as may be required by state or local laws, within five (5) working days of the reported incident. -Review of the personnel file for staff #2 (Licensed Practical Nurse) revealed a hire date of (MONTH) 10, (YEAR). Further review revealed no documentation that staff #2's license had been verified with the licensing board. Review of the personnel file for staff #63 (Registered Nurse) revealed a hire date of (MONTH) 15, (YEAR). Further review revealed no documentation that staff #63's license had been verified with the licensing board. During an interview conducted on (MONTH) 1, (YEAR) at 2:07 p.m., administrative staff (#110) stated she did not know that verification of licenses was required. Staff #110 stated she thought having a copy of the license would meet the requirement. During an interview conducted on (MONTH) 3, (YEAR) with the Director of Nursing (staff #129), staff #129 stated that the New Hire Packet Check Off List was their policy for verifying licenses. Review of the New Hire Packet Check Off List revealed to verify the license.",2020-09-01
83,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2017-02-03,241,D,0,1,TPN311,"Based on observations, staff interviews and a review of policy, the facility failed to maintain an environment that enhanced each resident's dignity and respect. Findings include: A random observation was conducted on (MONTH) 1, (YEAR) at 12:30 p.m., on the secured male behavioral unit. During this observation, the lunch meal cart was observed to be positioned by the main dining room door and across from the assisted dining room. While conducting observations, a CNA (Certified Nursing Assistant/staff #123) was heard to tell the other CNA's to pull the Feeders trays. The same CNA was again heard to tell the other CNA's to take the Feeders trays into the assisted dining room. An interview was conducted on (MONTH) 1, (YEAR) at 1:50 p.m., with staff #123, who acknowledged that she had referred to the residents as, Feeders. Staff #123 stated that she probably should not have referred to those residents who required assistance with their meals as Feeders, because it was not appropriate. She said she could have called them, Assisted residents. A interview was conducted on (MONTH) 2, (YEAR) at 2:10 p.m., with the Director of Nursing (staff #129). He stated that referring to the residents as, Feeders would be a dignity issue and that they should be referred to as assisted residents. On (MONTH) 2, (YEAR), an interview was conducted with the Administrator (staff #48), who stated that calling a resident a Feeder, is not dignified and that he had just provided an inservice regarding dignity approximately six months ago. A facility policy titled, Assistance with Meals included the following: 3. Residents Requiring Full Assistance: Residents who can not feed themselves will be fed with attention to safety, comfort and dignity, for example: c. Avoiding the use of labels when referring to residents (e.g., feeders).",2020-09-01
84,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2017-02-03,248,E,0,1,TPN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and policy review, the facility failed to ensure that an individualized activities program was implemented for one resident (#71). Findings include: Resident #71 was admitted on (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. The resident resided on the male behavioral unit. According to the annual Minimum Data Set (MDS) assessment dated (MONTH) 23, (YEAR), the resident had severe cognitive impairment. Under the activity section, the documentation included that it was important to the resident to have books, newspapers and magazines available and to listen to music and to go outside for fresh air. A quarterly activities assessment dated (MONTH) 18, (YEAR), identified that the resident's favorite activities were one to one visits, coffee socials, music and conversing with family and friends. An activities care plan was developed and included as goals the following: -Resident will accept one to one visits at least twice a week. -Resident will attend group activity of interest once a week. The interventions included: -Invite to scheduled activities. -Offer to assist/escort the resident to activity functions. -Provide one to one visits twice weekly: conversation, outdoor leisure. -Socials 1-2 times weekly; cognitive games 1-2 times weekly; bingo 1-2 times monthly; education programs 1-2 times monthly; and exercise 1-2 times monthly. A review of the (MONTH) (YEAR) activity calendar revealed that 1:1 visits and coffee chats were scheduled daily, Bingo and a music program were scheduled weekly, and that fitness programs were scheduled several times a week. Review of the resident's one to one visit records from (MONTH) (YEAR) through (MONTH) (YEAR), revealed the following: July: five one to one visits were provided. August: seven one to one visits were provided. September: three one to one visits were provided. December: two one to one visits were provided January (YEAR): three one to one visits were provided. Further review of the activity records from (MONTH) (YEAR) through (MONTH) (YEAR) revealed the following: August: The resident attended only one group activity during the month. October: The resident attended two group activities during the month. November: The resident attended only one group activity during the month. December: The resident did not attend any group activities during the month. January (YEAR): The resident did not attend any group activities during the month. During multiple resident observations, the resident was observed either in his room or sleeping in his wheelchair and was not involved in any 1:1 visits, group activities or any other type of activities. An interview was conducted on (MONTH) 2, (YEAR) at 9:10 a.m., with the Activity Director (staff #109). She stated the resident was supposed to have 1:1 visits on Wednesdays and Saturdays and that those visits should last approximately 15 to 30 minutes. Staff #109 stated the 1:1 visits would consist of sensory activities, hand massages and reading a book about horses to the resident, since he use to keep horses. Following a review of the resident's activities records, she stated that she had not followed up with the activities staff to ensure that the 1:1 visits and invitations to other activities had been provided. She also stated the activities department was short a full time activities assistant and that she needed another part time employee. On (MONTH) 1, (YEAR) at 11:00 a.m., an interview was conducted with the Director of Nursing (staff #129), who stated that the facility did not had a written policy regarding 1:1 visits. At this time, he stated that if the resident's care plan indicated 1:1 visits as an intervention, then that should be provided and that would act as the facility policy. On (MONTH) 3, (YEAR) at 8:15 a.m., another interview was conducted with staff #109. She stated that the activities assistants keep the documentation for the month's attendance and provide them to her at the end of each month, so she can file them. Staff #109 stated that although she had looked over the activity records, she had not noticed that the activities were not provided as planned. Staff #109 stated if not documented then it was not done. Staff #109 further stated the activity program is a work in progress. An interview was conducted on (MONTH) 3, (YEAR) at 8:30 a.m., with an activity assistant (staff #93). She stated that she provides activities on the unit where the resident resides. She stated that she keeps the activity attendance records for each resident until the end of the month and then turns them in to the Activities Director. At this time, she stated that she may not have recorded all the activities that the resident was involved in. Review of the Activity Assessment policy revealed the following: In order to promote the physical, mental and psychosocial well-being of residents, an activity assessment is conducted and maintained for each resident. The assessment will be conducted to help develop an activities plan that reflects the choices and interests of the resident.",2020-09-01
85,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2017-02-03,253,E,0,1,TPN311,"Based on observations and staff interviews, the facility failed to ensure housekeeping and maintenance services were provided to maintain a sanitary, orderly and comfortable interior. Findings include: During the initial tour conducted on (MONTH) 30, (YEAR) at 10:46 a.m., the following was observed: -There was a strong urine odor in the hallway upon entering the Oak unit. -In multiple resident rooms, there were portable oxygen concentrators which had filters that were visible from the outside. The filters had a grayish dust like build up on them. -On all three units, the flooring in multiple resident rooms were stained with a brownish residue. -Multiple ceiling vents throughout the facility were dirty with a gray residue on the vent blades. Additional observations were conducted on (MONTH) 30, (YEAR) at 2:46 p.m. and revealed the following: -In room #7, there was a slight urine odor and there was a full urinal on the bed. -In room #8's bathroom, the flooring had several scuff marks and the floor boards were separated from the wall and there were several small holes in floor at the doorway. -In room #14, there was chipped paint on the walls and the floor boards had a dust build up and were stained. -In room #17, the bathroom door had a walnut sized hole, with jagged edges. The bathroom sink faucet was loose and moved freely. The sink vanity had multiple small gaps in the caulking, and the toilet ran continuously. -In room # 22's bathroom, one wall contained multiple small gouges and scrapes, and the bathroom door had small gouges with rough edges along the hinge side. -In room #26, the bathroom wall contained small gouges and peeling paint. The floor had missing tiles. The cove base was separating from the wall creating moderate sized gaps. There were multiple small gaps between the floor tile with an accumulation of gray/brownish dirt and debris in the gaps. Several window blinds were bent or had broken slats. -The window blinds in room #27 had several bent or broken slats. There was a hole in the bathroom wall over the toilet with exposed pipe, and there were small holes in the wall and unpainted surfaces from the removal of a dispenser, which was approximately 12 inches x 8 inches. The wood door had multiple small gouges and scrapes in the veneer. There was a hole in the wall at the head of the bed, which was approximately 3 x 1.5 inches. -In room #29, a closet drawer was missing, a section of the bathroom baseboard was missing and there was a large dark colored stain on the floor. -In room #31, there were multiple dark discolorations on the floor. -In room #32, there was floor tile that was missing which was approximately a 6 x 6 inch area. -In room #33, the bathroom walls were missing paint and the paint on the bathroom door frames paint were chipped. The window sill was missing approximately a 1 inch x 6 inch section of drywall, exposing the metal mesh. -In room #34, the bathroom door frame was rusted with a dark reddish/brown residue. The ceiling vent was stained with a dark reddish discoloration. -In room #39, the wall next to the bed was missing paint and the bathroom water faucet was missing a knob. -In room #42, the lower portion of the bathroom door frames had a dark reddish brown residue and there was extensive drywall deterioration around the sink and floor level. -In room #47, the ceiling was missing paint in several areas. An environmental tour was conducted on (MONTH) 1, (YEAR) at 11:30 a.m. with the Administrator (staff #48) and the maintenance/housekeeping supervisor (staff #41) present. Both staff were aware of the flooring issues, but both stated that they were not aware of the condition of the resident's rooms.",2020-09-01
86,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2017-02-03,279,D,0,1,TPN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews and policy review, the facility failed to ensure that comprehensive care plans regarding ADLs (Activities of Daily Living) were developed for two residents (#40 and #88). Findings include: -Resident #40 was admitted on (MONTH) 26, 2013, with [DIAGNOSES REDACTED]. A review of the quarterly MDS (Minimum Data Set) assessment dated (MONTH) 16, (YEAR), revealed in Section G, Functional Status that the resident required supervision-oversight/cueing with ADLS. An annual MDS assessment dated (MONTH) 18, (YEAR), included the resident now required limited to extensive assistance with ADLs. However, no care plan was developed regarding the resident's ADL needs. An interview was conducted on (MONTH) 1, (YEAR) at 12:50 p.m. with the MDS staff (staff #121), who stated that the MDS assessment was coded to reflect the resident's increased level assistance needed. A second interview was conducted in (MONTH) 1, (YEAR) at 1:30 p.m. with staff #121. Following a review of the (MONTH) 18, (YEAR) MDS assessment, staff #121 stated that although Section V. of the MDS assessment (CAA: Care Area Assessment) did not automatically trigger for initiation of an ADL care plan, she should have developed an ADL care plan, based on the documentation of the resident's increased level of assistance. -Resident #88 was admitted (MONTH) 30, (YEAR), with [DIAGNOSES REDACTED]. A admission MDS assessment dated (MONTH) 7, (YEAR), assessed the resident as requiring extensive assistance to total dependence, with ADLs. However, in Section V., the care area for ADLs did not trigger. A quarterly MDS assessment dated (MONTH) 7, (YEAR), also assessed the resident as requiring extensive assistance to total dependence, with ADLs. Review of the clinical record revealed no care plan was developed based on the resident's ADL needs. During an interview conducted on (MONTH) 1, (YEAR) at 10:48 a.m., the MDS coordinator (staff #121) stated she was unable to state why Section V. did not trigger for ADLs for care planning. Staff #121 stated ADLs should have triggered and ADLs should be care planned. During an interview conducted on (MONTH) 1, (YEAR) at 12:35 p.m., the Director of Nursing (staff #129) stated he would expect an ADL care plan be developed for this resident. A facility policy titled, Care Area Assessments included that Care Area Assessments will be used to help analyze data obtained from the MDS and to develop individualized care plans. The policy also included the following: 3. The IDT (Interdisciplinary Team) will employ tools and resources during the CAA process, including evidenced-based research and clinical practice guidelines, along with sound clinical decision making and problem-solving. Another facility policy titled, Care Plans Goals and Objectives included Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence.",2020-09-01
87,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2017-02-03,280,D,0,1,TPN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the clinical record, staff interviews and a review of facility policy, the facility failed to ensure that a comprehensive care plan was revised for one resident (#61). Findings Include: Resident #61 was admitted on (MONTH) 20, 2011, with [DIAGNOSES REDACTED]. Review of the clinical record revealed that the resident previously had been on a 960 cc (centimeter) fluid restriction, however, it had been discontinued on (MONTH) 24, (YEAR). Review of the current physician's orders [REDACTED]. However, according to a care plan for potential complications related to [MEDICAL TREATMENT], one of the interventions included for a 960 cc daily fluid restriction. An interview was conducted on (MONTH) 3, (YEAR) at 9:30 a.m., with the Assistant Director of Nursing (staff #45), who stated that care plans were suppose to be updated at the time of the care conference (the resident's last quarterly care plan conference was in (MONTH) (YEAR)). Another interview was conducted on (MONTH) 3, (YEAR) at 9:37 a.m., with the Director of Nursing (staff #129), who confirmed that the 960 cc fluid restriction was still included as a current intervention on the care plan. Staff #129 stated that licensed staff were responsible to update care plans whenever necessary, and that all of the resident's care plans were suppose to be reviewed and revised at the time of the resident's care conference. He stated that the care plan should have been revised to reflect the discontinuation of the fluid restriction. A facility policy titled, Care Plan Goals and Objectives included the following: 2 .Care plans will be modified accordingly and that 5. Goals and objectives are reviewed and/or revised .at least quarterly.",2020-09-01
88,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2017-02-03,314,E,0,1,TPN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record reviews, staff interviews, and policy review, the facility failed to consistently and thoroughly assess pressure ulcers for three residents (#22, #45 and #89). Finding include: -Resident #45 was admitted to the facility on (MONTH) 13, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident was admitted with an unstageable pressure ulcer to the left heel. The wound measured 5.9 cm x 6.3 cm, with a black wound bed, with moderate drainage and no tunneling or undermining. An admission MDS (Minimum Data Set) assessment dated (MONTH) 20, (YEAR) included the resident had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS also included that the resident was admitted with an unstageable pressure ulcer. Further review of the clinical record including the weekly wound reviews revealed the left heel pressure ulcer was assessed weekly from (MONTH) (YEAR) through (MONTH) (YEAR). A care plan dated (MONTH) (YEAR) included the resident had a pressure ulcer. An intervention included for weekly treatment documentation to include measurement of each area of skin breakdown (width, length, depth, type of tissue and exudate). According to the weekly pressure ulcer log dated (MONTH) 3, (YEAR), the left heel pressure ulcer was identified as a stage 3 and measured 4.5 cm x 4.3 cm. The next wound assessment which included measurements was not completed until (MONTH) 30, (YEAR). Per the wound note dated (MONTH) 30, the left heel measured 4.3 cm x 4.2 cm., however, there was no description of the wound bed. Continued review of the clinical record revealed the next thorough wound assessment was completed on (MONTH) 20, (YEAR). Per the Pressure Injury Log dated (MONTH) 20, the left heel wound was a stage 3 and measured 5 x 5 x 0.2 cm, and the wound bed was pink. There were no additional wound assessments which included the measurements of the pressure ulcer to the left heel, nor a description of the wound bed until (MONTH) 25. According to the Wound Weekly Observation Tool dated (MONTH) 25, (YEAR), the left heel was a stage 3 and measured 4.8 x 4.8 x 0.4 cm depth. The wound bed was described as having 50% [MEDICATION NAME] tissue and 50% slough. The wound edges were well defined and the wound was improving. A pressure ulcer treatment observation was conducted on (MONTH) 1, (YEAR) at 7:30 a.m., with the wound nurse (staff #25) present. The wound measured 4.5 x 4.4 cm, with no measurable depth. The wound edges were well approximated and the wound bed was brownish in appearance. -Resident #89 was admitted to the facility on (MONTH) 13, (YEAR), with [DIAGNOSES REDACTED]. Review of the Nursing Admission Screening assessment dated (MONTH) 13, (YEAR), revealed no documentation that the resident had a pressure ulcer to the left ankle. Review of an admission MDS assessment dated (MONTH) 20, (YEAR) revealed the resident had a BIMS score of 8, which indicated moderate cognitive impairment. The MDS also assessed the resident to have no pressure ulcers upon admission. A health status note dated (MONTH) 27, (YEAR) revealed that during a daily foot/leg assessment, the resident was noted to have an open area on the left ankle. The area was assessed by the wound nurse and identified as a stage 2 pressure ulcer. The note did not include any measurements or a description of the wound bed. A physician's orders [REDACTED]. Review of the Treatment Records revealed wound care was provided to the left ankle through (MONTH) (YEAR). Per the (MONTH) (YEAR) Treatment Record, the wound treatment to the left ankle was changed on (MONTH) 3, to three times a week. The wound care was provided through (MONTH) 13. A care plan identified that the resident was at risk for developing a pressure ulcer. A goal included that the resident would have intact skin. The care plan did not include that the resident had a pressure ulcer to the left ankle. Review of the clinical record revealed there were no thorough assessments of the left ankle wound which included measurements and a description of the wound bed from (MONTH) 27, (YEAR) through (MONTH) 15, (YEAR). Clinical record documentation revealed that on (MONTH) 13, (YEAR) orders were received to admit the resident to hospice care. The resident expired on (MONTH) 15, (YEAR). In an interview with the wound nurse (staff #25) on (MONTH) 1, (YEAR) at 11:20 a.m., she stated that during (MONTH) and (MONTH) there was no appointed wound nurse. She said that during that time, she was a floor nurse and she was responsible for administering treatment for [REDACTED]. She stated that she took over the wound nurse position in (MONTH) and the procedure now is to perform weekly assessments on wounds and document them in the electronic charting system. In an interview with the interim Director of Nursing (DON/staff #1) on (MONTH) 1, (YEAR) at 12:31 p.m., she stated that there were no wound assessments performed during the time period when there was no wound nurse. She stated that the floor nurses were responsible for administering treatments, but not doing a full wound assessment. She also stated that there were weekly wound meetings to discuss if the wounds were improving or if there were any concerns or changes, but measurements were not necessarily part of the discussion. -Resident #22 was admitted to the facility on (MONTH) 3, (YEAR), with [DIAGNOSES REDACTED]. The admission wound note dated (MONTH) 3, (YEAR) included the resident had a stage IV pressure ulcer on the sacrum. The documentation included the wound measurements and a description of the wound bed. Physician orders [REDACTED]. Review of the Braden Scale assessment dated (MONTH) 5, (YEAR) revealed the resident was at moderate risk for the development of pressure ulcers. Review of the admission MDS assessment dated (MONTH) 10, (YEAR) revealed a Brief Interview for Mental Status score of 11, which indicated that the resident had moderate cognitive impairment. The MDS also included the resident required the assistance of two persons with bed mobility and transfers, and was admitted with a stage IV pressure ulcer to the sacrum. Review of the clinical record revealed the sacrum wound was assessed on (MONTH) 10, (YEAR), per the Wound Care/Skin Integrity Evaluation. The sacral wound was identified as a full thickness, stage IV pressure ulcer. The documentation included measurements and a description of the wound bed. Further review of the clinical record revealed there were no additional assessments of the sacral wound which included measurements until (MONTH) 30. A nurse's note dated (MONTH) 30, (YEAR) documented that the measurements of the sacrum pressure ulcer, however, there was no description of the wound bed. A comprehensive care plan identified that the resident had a stage IV pressure ulcer. The goals included that the pressure ulcer would show signs of healing, there would be no signs of infection, and the skin will remain intact. Interventions included performing treatments as ordered and monitoring for effectiveness. The care plan did not address completing weekly wound assessments. Per the nurse's notes dated (MONTH) 3 and 4, (YEAR), the documentation included a description of the sacral wound bed and measurements. The next assessment of the sacral pressure ulcer was not completed until (MONTH) 16, (YEAR). A nurse's note dated (MONTH) 16, included a description of the sacral wound, however, there were no measurements of the length and width of the wound. Continued review of the clinical record revealed there were no other assessments of the sacral pressure ulcer from (MONTH) 17, through (MONTH) 30, which included the measurements and a description of the wound bed. The next thorough wound assessment was completed by the wound care physician on (MONTH) 10, (YEAR). The assessment included the resident had a stage IV pressure ulcer to the sacrum. The wound measurements and a description of the wound bed were also included. The next thorough wound assessment was done on (MONTH) 17, (YEAR) and was completed by the wound nurse. The next thorough wound assessment was completed eight days later on (MONTH) 25, (YEAR). Per the documentation, the wound was measured and included a description of the wound bed. An interview was conducted with resident #22 on (MONTH) 2, (YEAR) at 9:15 a.m. and the resident declined a wound care observation. An interview was conducted with the wound nurse (LPN/staff #25) on (MONTH) 2, (YEAR) at 9:56 a.m. She stated that she just started doing treatments in (MONTH) for this resident. She stated the wound doctor comes once a month to see the resident. Staff #25 stated that each resident should have a skin assessment on admission and for pressure ulcers, the wound assessments and documentation should be done weekly by the wound nurse, and the weekly skin assessments should be documented by the floor nurses. She stated the missing documentation for the wounds is related to the fact that they did not have a wound nurse for several months. Review of the Pressure Ulcer Risk Assessment policy revealed that nurses should conduct skin assessments at least weekly to identify changes, and document them in the resident's medical record. A policy titled, Pressure Ulcer Treatment included that the purpose was to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers. The pressure ulcer treatment program should focus on assessing the resident and the pressure ulcer. Per the policy, the following should be recorded in the medical record: all assessment data (i.e. color, size, pain, drainage etc.) when inspecting the wound. The policy did not address how often pressure ulcer assessments should be completed.",2020-09-01
89,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2017-02-03,323,D,0,1,TPN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and policy and procedures, the facility failed to ensure the environment was free from accident hazards, by failing to ensure a physical restraint was properly applied to one resident (#71) and by having resident door frames with exposed sharp edges. Findings include: -Resident #71 was admitted on (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. The resident resided on the behavioral unit. A review of the clinical record revealed a physician's orders [REDACTED]. A fall risk care plan included an intervention for the use of a lap buddy when in a wheelchair for poor safety awareness. The care plan also included to check the lap buddy for positioning and placement every shift. According to the CNA (Certified Nursing Assistant) care sheet, a lap buddy was to be used for this resident. The (MONTH) (YEAR) TAR (Treatment Administration Record) included the physician's orders [REDACTED]. An observation of the resident was conducted on (MONTH) 30, (YEAR) at 1:27 p.m. At this time, the resident was observed sleeping in a wheelchair, with a waist restraint on. The device was a non self-releasing cloth belt. The belt went around the front of the resident's waist and criss crossed behind the resident. The belt then went around the back of the wheelchair and one end was tied to the other end, which was then looped over the back rung of the wheelchair. An interview was conducted on (MONTH) 2, (YEAR) at 10:30 a.m., with the ADON (Licensed Practical Nurse/Assistant Director of Nursing/staff #45). She stated that she had also observed the resident on (MONTH) 30, with the non self-releasing waist restraint on. Staff #45 stated that after her observation, she replaced the non self-releasing waist restraint with a lap buddy. She stated that she had spoken with the staff on duty and they had reported that the night shift had gotten the resident up, and had put the non self-releasing waist restraint on the resident. She confirmed that the non self-releasing waist restraint was incorrectly applied and that the resident should have had a lap buddy applied. An interview was conducted on (MONTH) 2, (YEAR), with a LPN (staff #126). She stated that although the CNAs were responsible to apply the physician ordered devices, the nurses were responsible to ensure that they are being applied. A facility policy titled, Use of Restraints included the following: 9. Restraints shall only be used upon written order of a physician . 12. The following safety guidelines shall be implemented and documented while a resident is in restraints: a. Restraints shall be used in such a way as not to cause physical injury to the resident and to ensure the least possible discomfort to the resident. b. Physical restraints shall be applied in such a manner that they can be speedily removed in case of fire or other emergency. c. A resident placed in a restraint will be observed at least every thirty (30) minutes by nursing personnel and an account of the resident's condition shall be recorded in the resident's medical record. -An observation was conducted on (MONTH) 30, (YEAR) at approximately 2:46 p.m., of the bathroom in room #33 and #42. The bathroom metal door framing was observed to have extensive deterioration of the door frames, which had disintegrated through on the lower portions, exposing sharp metal edges. An environmental tour was conducted on (MONTH) 1, (YEAR) at 11:30 a.m., with the Administrator (staff #49) and the maintenance/housekeeping supervisor (staff #48). They both stated that they were not aware of the extensive deterioration of the door frames in the rooms. The Administrator stated the rooms identified would be prioritized, due to safety concerns.",2020-09-01
90,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2017-02-03,364,D,0,1,TPN311,"Based on observations, staff interviews and a review of facility policy, the facility failed to ensure that food was served at the proper temperature. Findings include: A lunch observation was conducted on (MONTH) 30, (YEAR), in the main dining room. During this observation the following issues were observed: -After the meal cart arrived in the dining room, 5 residents were served their meal. These residents sat with their covered food plate in front of them for 15 to 35 minutes, before a staff member assisted them to eat their meal. A second dining observation (breakfast) was conducted on (MONTH) 1, (YEAR), in the main dining room. The following issues were identified: -The breakfast meal was scheduled to be served at 7:30 a.m., however, the food cart was not delivered from the kitchen until 7:45 a.m. -The first meal tray was served to a resident at 7:55 a.m., which was 10 minutes after the food cart had arrived from the kitchen. -At this time, four residents were identified to require feeding assistance. The first resident was assisted with her breakfast at 8:10 a.m. and the second resident was assisted with his meal at 8:20 a.m. Although the breakfast plates were covered, the trays had been sitting on the residents' table from approximately 7:55 a.m. -At 8:30 a.m., a CNA (Certified Nursing Assistant) was observed to prepare to feed the third and fourth resident their breakfast. Although the breakfast plates were covered, they had been sitting on the dining room table since 7:55 a.m. At this time, the breakfast food temperature was obtained by the dietary manager. The pureed biscuits and gravy was at 79 degrees F. (Fahrenheit) and the oatmeal was at 113 degrees F. The dietary manager then instructed that another breakfast meal be provided to those residents. An interview was conducted on (MONTH) 1, (YEAR) at 8:40 a.m. with the dietary manager (staff #112). He stated that the covered foods would only stay hot for approximately 20 minutes after it was served. He stated that at the temperatures obtained, the food would not be considered hot and should not be served to a resident. He stated that the residents should be assisted with their meals when it comes out of the kitchen. Another interview was immediately conducted with a CNA (Certified Nursing Assistant/staff #32), who was preparing to assist the third and fourth resident with their meals. She stated that staff were not assigned to assist certain tables or residents, and that she had seen the residents sitting with the covered plates on the tables, while she was serving the beverages. The CNA stated that she should have realized that their food was getting cold and she should have obtained hot food for those residents. A facility policy titled, Assistance with Meals included the following: 5. For all residents, hot foods shall be held at a temperature of 136 degrees or above until served .Nursing and Dietary Services will establish procedures such that delivery of food to serving areas accommodates this requirement.",2020-09-01
91,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2017-02-03,371,E,0,1,TPN311,"Based on observations, staff interviews and policy review, the facility failed to ensure that ready to eat foods were handled properly, that food and beverages were properly labeled and that the nourishment refrigerator temperatures were consistently obtained and documented. Findings include: -A lunch observation was conducted in the main dining room on (MONTH) 30, (YEAR). During this observation a CNA (Certified Nursing Assistant) was observed to donn gloves, remove a resident's meal tray from the rack, carry the tray to the resident's table and place the food items in front of the resident. The CNA was then observed to butter the resident's bread, with the same gloves on. With the same gloves on, the CNA was then observed to reposition the meal cart in the dining room and removed another resident's meal tray from the rack. Again, the CNA removed the food items and placed them in front of the resident. The CNA then proceeded to butter the resident's bread, with the same gloves on. The CNA was not observed to change her gloves after touching the non-food items or in between assisting residents. An interview was conducted on (MONTH) 1, (YEAR) at 8:40 a.m., with a CNA (staff #32). She stated that gloves were suppose to be changed after touching a non-food item, like the meal cart and were suppose to be worn when handling food. A facility policy titled, Handling Ready to Eat Foods included Nursing staff and other dinning assistive personnel shall provide ready to eat foods while assuring sanitation guidelines are followed. The policy also included the following: 2. If a resident requires assistance with opening and handling of an item the associate assisting shall: a. Wash their hands. b. Caution to only touch the wrapper and avoid touching the food item. c. Wear gloves as appropriate if food item must be handled. d. Gloves shall be changed between service to each resident. 5. As gloves are changed between each resident the associate shall; a. Wash their hands. b. Use a hand sanitizer as indicated by the manufacturer's label. -An observation of three resident nourishment refrigerators was conducted on (MONTH) 31, (YEAR) at 2:15 p.m., with the Kitchen Manager (staff #112 ) present. The nourishment refrigerators contained unlabeled and undated beverages and foods. In addition, review of the refrigerator temperature logs revealed that the refrigerator temperatures were to be maintained between 38-41 degrees F, and if the temperatures were not in range, it was staff's responsibility to correct the issue (i.e. change temperature or write a work order.) Further review of the temperature logs from (MONTH) (YEAR) through (MONTH) (YEAR) revealed the following: -August: There were seven days with no documentation that the temperature was checked. The documentation included that on (MONTH) 13, a temperature reading of 50 degrees was documented and a note indicated that the unit needed defrosting. However, there was no documentation that the refrigerator was defrosted and there were no follow up temperatures which were recorded on (MONTH) 14, 15, or 16 to confirm that the temperatures were at the appropriate temperature. -September: There were five days with no documentation that the temperatures were checked. -October: There were five days with no temperatures documented. -November: There were eight days with no temperatures documented. -December: There were seven days with no temperatures documented. -January: There were five days with no temperatures documented. During the six month time frame, the documentation on the temperature logs showed that the refrigerator required adjustments or defrosting eight times to maintain safe operating temperatures. An interview was conducted on (MONTH) 31, (YEAR) at 2:18 p.m. with the Kitchen Manager (staff #112) who stated it was the floor nurses responsibility to monitor and record the refrigerator temperatures. Another interview was conducted on (MONTH) 31, (YEAR) at 2:31 p.m. with a LPN (Licensed Practical Nurse/staff #45) ). Staff #45 stated that the temperatures were to be checked and recorded by the night nurses and the Unit Managers review the logs to ensure compliance, and follow up on any pending work orders. Staff #45 stated that the Unit Manager position was eliminated a few months earlier and the task was not reassigned to anyone specifically to ensure it was being done. On (MONTH) 31, (YEAR) at 2:51 p.m., an interview was conducted with the acting DON (Director of Nursing/staff #31), who stated there were so many other problems to resolve that she missed it. Review of the Facility Nourishment Refrigerator Policy revealed the refrigerator temperatures were to be at or below 41 degrees F and at or above 38 degrees F, to prevent the spread of food borne illness. The policy included the following procedure: The night nurses (11 p.m.-7 a.m shift on weekends or 7 p.m.-7 a.m. shift on weekdays) will read the thermometer in the refrigerator and record the temperature on the refrigerator log nightly. Any temperature not in the range of 38-41 degrees F, must be reported to maintenance on a work order form and food thrown away.",2020-09-01
92,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2017-02-03,431,E,0,1,TPN311,"Based on observations, staff interviews, facility documentation, and policy review, the facility failed to ensure expired medications were not available for use and failed to consistently monitor and document medication refrigerator temperatures on the Oak unit. Findings include: -During a medication storage observation conducted on (MONTH) 2, (YEAR) at 2 p.m., three expired medications were found in the medication room on the Magnolia unit as follows: Calcitrate one bottle with an expiration date of (MONTH) of (YEAR), Vitamin B1 one bottle with an expiration date of (MONTH) of (YEAR), and Loperamide one bottle with an expiration date of (MONTH) (YEAR). An interview was conducted with a Licensed Practical Nurse (LPN/staff #27) on the Magnolia unit on (MONTH) 2, (YEAR) at 2:00 p.m. She stated that the nurses are the ones who check the medications to make sure they are not expired. She stated that she thought the night nurses do the medication room checks to ensure medications are not expired. Review of the facility's policy regarding the Storage of Medications revealed the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. -Review of the temperature logs for the medication refrigerator on the Oak unit revealed the following: No temperatures were recorded for nine days in (MONTH) (YEAR), for six days in (MONTH) (YEAR), for nine days in (MONTH) (YEAR), for ten days in (MONTH) (YEAR), for twenty days in (MONTH) (YEAR), and for fourteen days in (MONTH) (YEAR). An interview was conducted with an LPN (staff #28) on (MONTH) 2, (YEAR) at 1:45 p.m. He stated that the refrigerator temperatures are to be checked every night and recorded by night shift. An interview was conducted with a unit manager (Registered Nurse/staff #1) on (MONTH) 2, (YEAR) at 3:03 p.m. She stated that for the medication refrigerators, they keep a log of what the temperature is, and if a temperature is out of range, they have to document what their corrective action is. She stated they will notify maintenance right away, change the temperatures, and then check the temperatures again. She stated the temperatures are to be checked every night and recorded on the temperature log. Review of the facility's Refrigerator log policy and procedure revealed to maintain the medication refrigerators between 36 and 46 degrees Farenheit. Per the policy, the night shift nurses (working from 11 p.m. - 7 a.m.) will read the thermometer in the refrigerator and record it on the nightly refrigerator log.",2020-09-01
93,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2017-02-03,441,D,0,1,TPN311,"Based on observation, staff interviews, and policy review, the facility failed to ensure proper handwashing techniques were followed during a pressure ulcer treatment. Findings include: A pressure ulcer treatment observation was conducted on (MONTH) 1, (YEAR) at 7:30 a.m., with the wound nurse (staff #25). Prior to beginning the wound treatment, the nurse was not observed to wash her hands or use sanitizer gel. Following the wound treatment, the nurse removed her gloves and cleansed several items and then exited the room and placed the items back into the cart. The nurse was not observed to wash or sanitize her hands. In an interview with the wound nurse (staff #25) on (MONTH) 2, (YEAR) at 2:33 p.m., she stated her regular procedure is to wash her hands or use an antibacterial gel before, during and after treatment. In an interview with the Director of Nursing (staff #129) on (MONTH) 2, (YEAR) at 2:46 p.m., he stated that the expectation of staff during wound treatments is to wash or sanitize hands before, during, and after wound care. Included in a policy titled, Pressure Ulcer Treatment it stated to wash hands before treatment and to wash and dry hands thoroughly after performing ordered treatment.",2020-09-01
94,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2017-02-03,465,E,0,1,TPN311,"Based on observations, staff interviews and review of the safety data sheet, the facility failed to provide a safe environment, by failing to ensure the facility was free from chemical odors. Findings include: During a random observation conducted on (MONTH) 2, (YEAR) at 9:30 a.m. on the secured Oak nursing unit, a strong chemical odor was detected upon entry into the unit. The odor started at the entry door and proceeded 3/4 of the way down the hall. A small floor fan was on and positioned halfway down the hall. At this time, a resident who was self-propelling himself in a wheelchair to his room, which was located in the area of the chemical odor stated, What is that bad smell. Several other residents were observed in their rooms, which were also located in the area of the chemical smell. No windows or doors were observed to be opened to allow for more ventilation. The nursing staff on the unit were then interviewed and stated that they did not know what was causing the strong chemical odor. An environmental staff member (staff #13) was on the unit at this time and stated that her supervisor had instructed her to spray paint the ceiling air vent covers, in resident rooms. Staff #13 stated that she had just spray painted the ceiling air vent covers in six resident rooms. During this interview, another environmental staff person produced the spray paint can. The product was identified as Appliance Epoxy with warnings on the spray can which included: -Danger-extremely flammable liquid and vapor. -Vapor harmful. -Vapors may cause flash fires. Immediately following, an interview was conducted with the Administrator (staff #48), who was on the Oak unit. He agreed that a strong, chemical odor was present on the unit and directed staff to obtain another fan, to open the resident's room windows and doors, and to move those residents who were in their rooms to the dining room, which was farther away from the chemical odor. Staff #48 stated that the air vent covers should have been removed and spray painted outside. An interview was conducted on (MONTH) 2, (YEAR) at 10:30 a.m., with the Environmental Director (staff #41). He stated that he had purchased the product yesterday and had instructed his staff to spray paint the air vent covers. Staff #41 stated that he had not instructed his staff to remove the air vent covers and spray paint them outside. He acknowledged that he had not read the warnings on the spray paint bottle. He stated that the fumes could be toxic and that he would contact the manufacturer for further information regarding this product. On (MONTH) 2, (YEAR), staff #41 provided the manufacturer's safety data sheet for the Rust-Oleum product/Epoxy. The documentation included the following warnings: -Wear protective gloves/protective clothing/eye protection/face protection. -Use only in a well ventilated area. -Avoid breathing fumes, vapors, or mist. -Avoid contact with eyes, skin and clothing.",2020-09-01
95,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2017-02-03,520,E,0,1,TPN311,"Based on concerns identified during the survey, staff interview and policy and procedures, the facility failed to identify quality concerns through their QA (Quality Assurance) program regarding consistently and thoroughly assessing pressure ulcers. Findings include: During the survey, concerns were identified that pressure ulcers were not being thoroughly and consistently assessed to include measurements and a description of the wound bed. During the survey, interviews were conducted with the interim Director of Nursing (DON/staff #1) and the wound nurse (LPN/staff #25), and both stated that there were no wound assessments performed during the time period when there was no wound nurse. During an interview conducted with the Administrator (staff# 48) on (MONTH) 3, (YEAR) at 12:30 p.m., he stated that they had not identified any issues in QA regarding pressure ulcers. A review of the Quality Assessment and Assurance Committee policy and procedure revealed the committee shall serve as the final authority for implementing the facility's quality assessment and assurance programs. The policy included the committe shall meet as necessary, but at least quarterly to assure that the QA program is meeting the needs of the facility.",2020-09-01
96,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2018-03-30,567,B,0,1,WXKF11,"Based on observation, facility documentation, resident and staff interviews, and policy and procedures, the facility failed to ensure that residents have access to their personal funds on the weekends. Findings include: Review of facility documentation revealed that multiple residents had trust fund accounts through the facility. During the survey, an observation was conducted of a sign which was posted in the business office. The sign read that the resident trust fund bank was open Monday through Friday from 9:00 a.m. until 3:00 p.m., and that the bank was closed on the weekends and holidays. An interview was conducted with a resident at 9:45 a.m. on (MONTH) 26, (YEAR). She stated that she does not have access to her trust fund on the weekends, as the bank is closed. An interview with the business office manager (staff #113) was conducted at 11:20 a.m. on (MONTH) 29, (YEAR). She said that there are a lot of residents who have trust fund accounts in the facility. She stated that she manages these accounts and is the one who provides money for the residents at their request. Staff #113 stated that the banking hours that are posted are correct and are from 9:00 a.m. until 3:00 p.m., Monday through Friday. She said that this is the only time that residents can get their money. She stated that residents are not able to get money on the weekends or holidays. Staff #113 stated the residents and their families are aware of this and they make provisions to get money on Friday, before the bank closes. She said that she has never heard that residents should have access to their accounts on the weekends. Another interview was conducted with the same resident as above on (MONTH) 29, (YEAR) at 1 p.m. She stated that it is a pain that she cannot get money out of her trust fund on the weekends. She said that she has wanted to get money out of her account on the weekends at times, but is unable too. She said that it is hard for some residents because they may have relatives that come to the facility on the weekends and they will have no money to go out to eat with them. The resident stated that it is difficult not being able to get money on the weekends, because she does not have a safe place to keep it if she gets some out of her account on Friday, because she does not like having it on herself as it could get stolen. She also stated that staff do not like residents to have money on them, as it could be misplaced or stolen. During an interview with the Administrator (staff #45) on (MONTH) 30, (YEAR) at 1:00 p.m., he stated that he was not aware that the residents should have access to their trust fund accounts on the weekend, but has seen other facilities offer this to residents. Review of the facility's Resident Trust Account policy and procedure revealed that all nursing facilities are required to provide resident nursing home trust funds to their residents as requested, and that the funds managed by the facility on the resident's behalf must be held in a resident trust fund. The policy noted that the Administrator and the business office manager are accountable for the proper management and safeguarding of resident trust funds. The policy included that resident trust accounts will be managed in accordance with all federal and state regulations. The policy further included that residents will have reasonable and convenient access to the trust account and that petty cash should be available to meet the daily needs of the residents at the facility. The policy noted that trust fund hours of operation were Monday through Friday 9:00 a.m. to 3:00 p.m.",2020-09-01
97,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2018-03-30,600,D,1,1,WXKF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff and resident interviews, facility documentation and policy and procedures, the facility failed to ensure one resident (#74) was free from physical abuse by another resident (#49). Findings include: -Resident #49 was admitted on (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. An annual MDS (Minimum Data Set) assessment dated (MONTH) 21, (YEAR), included a BIMS (Brief Interview for Mental Status) score of 3, which indicated the resident had severe cognitive impairment. Review of resident #49's current care plan revealed the resident was exit seeking and displayed wandering, pacing, or roaming behaviors. The care plan included the resident required psycho-active medications to help manage mood and behavior symptoms which included hitting and combativeness. The care plan also included the resident utilized a wheelchair. -Resident #74 was admitted on (MONTH) 23, 2012, with [DIAGNOSES REDACTED]. An annual MDS assessment dated (MONTH) 27, (YEAR) identified the resident had been assessed with [REDACTED]. A review of the resident's current care plan revealed documentation that the resident demonstrates limited social interaction related to [DIAGNOSES REDACTED]. The care plan included the resident exhibited behaviors of yelling, verbal aggression towards staff and that the resident spends most of his time alone watching television and isolating self in his room. Review of the facility's investigative documentation revealed that on (MONTH) 20, (YEAR), resident #49 got up from his chair in the unit dining room and walked over to where resident #74 was seated, and slapped resident #74 on the face. An interview was conducted with a CNA (Certified Nursing Assistant/staff #35) on (MONTH) 27, (YEAR) at 11:30 a.m. Staff #35 stated that resident #74 and resident #49 were in the dining room during breakfast. Staff #35 stated she was assisting other residents in the dining room and heard resident #49 and #74 yelling at each other in Spanish. Staff #35 stated that she heard resident #74 tell resident #49 to leave him alone. She said she turned around and resident #49 hit resident #74 in the mouth. Staff #35 stated that she got between the residents and separated them. Staff #35 stated the nurse assessed the residents and the residents went back to their tables and finished their breakfast, with no further incidents. An interview was conducted on (MONTH) 27, (YEAR) at 12:00 p.m., with a LPN (Licensed Practical Nurse/staff #63). Staff #63 stated that staff #35 reported that resident #49 had left his table and wandered over to resident #49 and hit resident #49 in the mouth. Staff #63 stated she checked both residents and neither had sustained any injury. On (MONTH) 27, (YEAR) at 1:50 p.m., an interview was conducted with resident #74. Resident #74 stated that he remembered the incident that occurred on (MONTH) 20, (YEAR), in the dining room. Resident #74 stated that resident #49 came up to him and hit him in the face. Resident #74 stated he did not know why resident #49 had hit him and that he told resident #49 to leave him alone. Review of the Abuse policies revealed that the facility does not condone resident abuse by anyone, including staff members, physicians, consultants, volunteers, family members or other residents. The policy defined physical abuse as the willful infliction of injury, unreasonable confinement intimidation, or punishment with resulting physical harm, pain, or mental anguish.",2020-09-01
98,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2018-03-30,604,E,0,1,WXKF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, staff and resident interviews and policy and procedures, the facility failed to ensure that three residents (#68, #20 and #75) were assessed and/or monitored for the use of physical restraints. Findings include: -Resident #68 was readmitted to the facility on (MONTH) 21, (YEAR), with [DIAGNOSES REDACTED]. A physician's order dated (MONTH) 22, (YEAR) included for a Velcro self releasing belt when in wheelchair, due to poor safety awareness. A physical restraint informed consent was completed on (MONTH) 22, (YEAR). The documentation indicated that the restraint being used was a self releasing belt, when in the wheelchair. The documentation included specific target behaviors and that the resident had poor safety awareness. The form was signed by the resident's Power of Attorney (POA). However, an initial restraint evaluation could not be located in the resident's clinical record. There was no clinical record documentation that the resident was assessed for the use of the device, in order to determine if the device was a restraint. Review of a physical restraint evaluation dated (MONTH) 16, (YEAR) revealed the resident had an unsteady gait, agitated behavior, aggressive behaviors, attempts to self-transfer, and climbs out of bed. It was noted that the resident continues to ambulate and get out of bed, without assistance. The evaluation indicated that the restraint (self releasing belt) was effective and to continue it's use. The documentation did not include if the resident was assessed to be able to release the self releasing belt. Another physical restraint evaluation dated (MONTH) 18, (YEAR), included that the restraint (was considered to be effective and would be continued. The documentation did not include if the resident was assessed to be able to release the self releasing belt. Review of the nursing notes revealed that the resident was discharged on (MONTH) 24, (YEAR). The clinical record documentation showed that the order for the Velcro self releasing belt when in wheelchair had been discontinued on (MONTH) 28, (YEAR). The resident was then readmitted to the facility on (MONTH) 31, (YEAR). Review of a current care plan indicated that the resident was at risk for falls related to disease processes. One of the interventions was to apply the Velcro protective device, when up in wheelchair. A physical restraint evaluation was completed on (MONTH) 1, (YEAR). This assessment indicated the resident had an unsteady gait, aggressive behaviors, and attempts to self-transfer. The waist restraint (self releasing belt) was noted to be effective in the past. The assessment indicated that other alternative attempts had been tried prior to using the restraint including a recliner, a companion, one on one activities, a positioning device, regular toileting, and scheduled rest times. The assessment also included that a physician's order had not been obtained for the self releasing belt, but a message was left with the physician on (MONTH) 31, (YEAR) to obtain an order. Review of a quarterly Minimum Data Set (MDS) assessment dated (MONTH) 21, (YEAR), revealed the resident scored a two on the Brief Interview for Mental Status (BIMS), which indicated severe cognitive impairment. The MDS did not code the resident as using a physical restraint. Review of the current physician's orders for (MONTH) (YEAR) revealed there were no orders for the use of the Velcro self releasing belt upon the resident's return to the facility. In addition, there was no clinical record documentation of any direct monitoring and supervision which was done, when the self releasing belt was being utilized, and there was no documentation regarding the time and frequency of when the restraint should be released. An interview was conducted with a Licensed Practical Nurse (LPN/staff #101) at 2:22 p.m. on (MONTH) 27, (YEAR). She said that the resident has a Velcro belt on for safety, as he wheels around in his wheelchair and tends to slide down. She said that she did not think it was a restraint for him, because he is able to get up if he wants too. Staff #101 stated that if he tries to get up, the belt will eventually loosen and slide down as he gets up. She said there should be a physician's order for the belt. An interview was conducted with a Certified Nursing Assistant (CNA/staff #107) at 8:30 a.m., on (MONTH) 28, (YEAR). She said that she thinks the resident has the Velcro belt, because he is a fall risk as he tries to get up by himself. She said that he slides up and down in his chair and the belt helps him to stay in the chair. She said that the resident is able to remove it as needed, so she did not think it was a restraint. During an interview with the resident at 10:00 a.m. on (MONTH) 28, (YEAR), he said that he could remove the belt but when asked to remove it, he was unable. An interview was conducted with the unit manager (staff #36) at 11:40 a.m. on (MONTH) 28, (YEAR). She said the belt is not a restraint for the resident, because they only use them if residents are able to remove them. She said that he might have moments where he is angry or agitated and he will not display that he knows how to remove it, but removes it later. She stated that he has removed the belt from time to time and has fallen. She said that she checks the belt at least weekly to make sure it is applied correctly and is in good shape. She said if he tries to stand up the belt will loosen, but will do so slowly, so that staff are able to get to him before he falls. Staff #36 stated that the belt is helpful, because the resident constantly leans forward. She said the process for obtaining a device like the belt is to obtain a physician's order and then get consent from the family. After reviewing the chart, staff #36 stated that there was no order probably because he had gone out of the facility and come back. She said they do not use restraints in the facility. She said that she did not know much about the physical restraint assessments in the computer charting system. During an interview with the Director of Nursing (DON/staff #18) at 11:15 a.m. on (MONTH) 29, (YEAR), he said that the process regarding safety devices is that when the need for such a device arises, the interdisciplinary team will meet and discuss which device to use for a resident. He said they will talk about what they have done prior to using the device and the reason behind using a device. He said that once they decide to use a device, they will apply the device and then discuss it from time to time to determine if it should be discontinued. Staff #18 said that currently, they are not looking at devices such as this resident's Velcro belt as a restraint and they do not go through all of the documentation that is required for a restraint, including removing it every 2 hours and documenting the removal on the TAR. He said that this has changed in the facility, as they used to consider some of these devices as restraints. He said that he is not aware of an assessment to determine if a device is a restraint or not, but they do discuss this. Another interview was conducted with staff #18 at 10:00 a.m. on (MONTH) 30, (YEAR). He said the facility previously used a pre-restraint assessment to determine if a device was a restraint, but they stopped using this form since they no longer consider these devices as restraints. Staff #18 stated that he understands the facility should assess to determine if a device is a restraint, but currently they are not doing this. He said there should be an order for [REDACTED]. -Resident #20 was admitted (MONTH) 28, 2011, with [DIAGNOSES REDACTED]. A physician's order dated (MONTH) 29, (YEAR) included for a lap buddy when the resident is in the wheelchair for positioning, due to left-sided weakness related to a [MEDICAL CONDITION]. Review of the clinical record revealed there was no documentation that the resident was assessed for the use of the lap buddy, in order to determine if the device was a restraint for the resident. There was also no documentation that the resident/responsible party had been notified of the risks and benefits of the lap buddy. A quarterly MDS assessment dated (MONTH) 27, (YEAR), revealed the resident had a BIMS score of 9, which indicated the resident had moderate cognitive impairment. The MDS included the resident had been assessed to require extensive assisstance with bed mobility, transfers, locomotion on the unit and was totally dependent on staff for locomotion off the unit. The MDS further documented that the resident had limited range of motion to upper and lower extremities. The MDS did not code the resident as using a restraint device. Review of the current physician's orders for (MONTH) (YEAR) revealed orders for a lap buddy when the resident is in the wheelchair for positioning, due to left-sided weakness related to a [MEDICAL CONDITION]. A physician's order dated (MONTH) 25, (YEAR) included for an occupational therapy evaluation for her wheelchair. Review of the Occupational Therapy evaluation dated (MONTH) 26, (YEAR), revealed the resident was in a high back wheelchair and was not in a good position, which will cause falls. The evaluation included that the resident should be seen by a company that will fit the resident with a wheelchair which will put her in a good position to prevent falls and pressure ulcers. The evaluation did not address the use of a lap buddy. Observations were conducted of resident #20 on (MONTH) 26, (YEAR) at 10:00 a.m., on (MONTH) 28, (YEAR) at 11:32 a.m., and on (MONTH) 20, (YEAR) at 8:44 a.m. During these observations, the resident was observed to be in a high back wheelchair, with a lap buddy applied. Further review of the clinical record revealed there were no ongoing assessments which were completed, in order to determine if the lap buddy was a restraint and for the continued need for the lap buddy. In addition, there was no documentation regarding any direct monitoring and supervision which was provided during its use, nor the frequency of when to remove the device. An interview was conducted with a LPN (staff #27) on (MONTH) 28, (YEAR) at 11:46 a.m. Staff #27 stated that he had seen resident #20 attempt to remove the lap buddy but was unable too. An interview was conducted on (MONTH) 30, (YEAR) at 9:00 a.m. with a CNA (staff #70), who stated that he provided care to resident #20. Staff #70 stated that he applies the lap buddy, but has not seen the resident take it off. Staff #20 stated the resident has asked for staff to reposition her, as the lap buddy was pressing on her babies. Staff #70 stated the only time he has removed the resident's lap buddy was when he assisted the resident to bed. An interview was conducted with staff #18 on (MONTH) 30, (YEAR) at 9:56 a.m. Staff #18 stated that since the resident could not release the lap buddy, then it would be considered a restraint device that would need to be evaluated. -Resident #75 was admitted on (MONTH) 12, 2013, with [DIAGNOSES REDACTED]. A physician's order dated (MONTH) 5, (YEAR) included for a geri-chair as needed for safety and comfort. A review of the resident's care plan revealed the resident requires a geri-chair to promote functioning at the highest practicable level. The need for this level of intervention is related to [MEDICAL CONDITIONS] and bilateral lower extremity weakness. Interventions included to assess the resident to determine the most enabling, therapeutic and least restrictive treatment approaches. Consider factors such as behavioral symptoms, fall risk, medical symptoms, and ADL self-performance. Emphasize quality of life: confer with the attending physician and IDT members to evaluate alternative devices and least restrictive interventions; evaluate the resident's response to the restraint and share this evaluation with the IDT; advocate for increased quality of life through minimal use of restrictive devices; monitor and report to the physician the following restraint related issues (increased behavior/mood problems, decreased mobility, development of contractures, skin problems, increased incontinence; increased risk of falls) and offer sensory and social stimulation at intervals throughout the day with particular emphasis on the restraint release periods. This care plan was updated on (MONTH) 8, (YEAR). Review of the clinical record revealed there was no documentation of any evaluations which had been completed from (MONTH) 5, (YEAR) through (MONTH) (YEAR), in order to determine if the use of a geri-chair would be a restraint for the resident, and there was no documentation of any medical symptoms that warranted its use. There was also no documentation of the least restrictive measures which were utilized, prior to implementing a geri-chair and that the resident/responsible party had been notified of the risks and benefits of using a geri-chair. In addition, there was no documentation regarding any direct monitoring and supervision which was provided when utilizing the geri-chair, nor the frequency of when to remove the device. According to a quarterly MDS assessment dated (MONTH) 28, (YEAR), the resident was assessed with [REDACTED]. The MDS did not identify the use of a restraint device. Observations were conducted of the resident on (MONTH) 27, (YEAR) at 8:30 a.m., on (MONTH) 27, (YEAR) at 11:30 a.m., and on (MONTH) 29. (YEAR) at 11:30 a.m. During these times, the resident was observed to be seated in a geri-chair. During an interview with staff #18 on (MONTH) 28 (YEAR) at 12:03 p.m., staff #18 stated that any device could be considered a restrictive device and should be assessed as to whether or not it's a restraint and monitored on a regular basis for effectiveness and should be the least restrictive option. An interview was conducted on (MONTH) 29, (YEAR) at 12:18 p.m., with the unit manager (LPN/staff #22) regarding potential restraint devices. Staff #22 stated that the residents (#20 and #75) can't get up from their wheelchairs, so the devices are not restraints and therefore, they do not need assessments. A follow-up interview was conducted with staff #18 on (MONTH) 30, (YEAR) at 9:56 a.m. Staff #18 stated that upon receipt of a physician's orders for devices such as a geri-chair or lap buddy, the order needs to include a medical symptom, and the resident needs to be evaluated or screened by therapy to assess for the need and safety of a potential restraint device. Staff #18 stated that at least quarterly, the IDT teams should evaluate for the continued use of the device, and if the device was determined to be a restraint, then informed consent should be obtained after explaining the risks and benefits of the restraint to the resident/representative. Staff #18 said that staff would need to monitor the use of the devices at least every 2 hours for appropriate application and release of the restraint if appropriate. Regarding resident #75, staff #18 stated that the use of a geri-chair was the resident's choice, however, there was no documentation of that and there were no assessments or evaluations. Staff #18 further stated that the MDS assessments were not coded for residents having restraint devices, as staff had determined that there were no restraints in the building and that all the devices were to be considered mobility devices, even though a resident can not use a geri-chair or lap-buddy to assist with mobility. A review of the facility policy regarding physical restraints revealed to ensure that residents were using the least restrictive restraint and that residents have been assessed for the need of a restraint for safety. The policy stated the nursing staff will evaluate the need for a restraint by trying the least restrictive device possible. If nursing staff are unsure, they will consult with physical therapy and the medical doctor. The MDS coordinator will review physical restraints quarterly along with the care plan review. The policy further included that restraints include, but are not limited to the use of chair alarms, hand mitts, soft ties or vests, wheelchairs, geri-chairs, self-release seat belts, side rails and lap buddies. Practices that meet the definition of a restraint include but are not limited to using devices (e.g., trays, tray tables, bars or belts) that a resident can not remove easily and that prevent the resident from rising when used in conjunction with a chair or wheelchair. The policy also noted that restraints will only be used after alternative methods have been tried, unsuccessfully and upon the written order of a physician which specifies the circumstances (medical symptoms) for the use of the restraint. The order should also include the type of device and the length of time to be used. The need for restraints will be re-evaluated at least quarterly to determine if continued restraint use is necessary to treat the resident's medical symptoms.",2020-09-01
99,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2018-03-30,607,D,1,1,WXKF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews, facility documentation and policy review, the facility failed to implement their Abuse policy regarding four residents (#18, #49, #58 and #74). Findings include: -Resident #49 was admitted on (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. -Resident #74 was admitted on (MONTH) 23, 2012, with [DIAGNOSES REDACTED]. Review of the facility's investigative documentation revealed that on (MONTH) 20, (YEAR), resident #49 got up from his chair in the unit dining room and walked over to where resident #74 was seated, and slapped resident #74 on the face. Further review of the facility's investigative report revealed a statement from a staff member who had witnessed the incident, however, there were no statements from other staff and there was no documentation that resident #49 or #74 were interviewed regarding the incident. An interview was conducted with the DON (Director of Nursing/staff #18) on (MONTH) 27, (YEAR) at 12:42 p.m. Staff #18 stated that he did not interview other staff who may have witnessed the incident between resident #49 and resident #74. In a later interview on (MONTH) 27, (YEAR) at 2:16 p.m., staff #18 stated that he did not interview resident #49 or #74, due to the resident's having cognitive impairment. -Resident #18 was admitted to the facility on (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. Review of the facility's investigative documentation revealed that on (MONTH) 26, (YEAR), a Certified Nursing Assistant (CNA) was providing care to the resident in his room. The CNA called for help and staff assisted the CN[NAME] The resident was observed to be bleeding from a laceration above his eyebrow. When questioned, the CNA stated that the resident had started to become combative during care and was swinging and hit himself in the head, causing the laceration. Further review of the investigative documentation revealed it did not include interviews with other residents, who may have been cared for by this CN[NAME] An interview was conducted with staff #18 at 7:45 a.m. on (MONTH) 28, (YEAR). He said that he was involved in the investigation of this incident and that normally as part of the investigation, they will interview residents who may have received care by the alleged perpetrator. He stated that he thought this had happened for this incident. He said that sometimes the social worker conducts the interviews with the residents. In an interview with the social service director (staff #16) at 8:50 a.m. on (MONTH) 28, (YEAR), he said that he did not interview residents regarding this incident. He said that a few years ago, he used to be more involved in the investigations, but now he does not get very involved in them. During another interview with staff #18 at 1:00 p.m. on (MONTH) 29, (YEAR), he said that he did not locate any interviews with other residents and that this should have been done, as per facility policy. -Resident #58 was admitted to the facility on (MONTH) 31, (YEAR), with [DIAGNOSES REDACTED]. A behavior note dated (MONTH) 21, (YEAR) at 9:35 a.m. revealed this writer heard yelling down the hallway and entered the resident's room. The resident was squirming around in her bed, as a CNA (staff #33) was attempting to dress her following a shower. Per the note, the resident stated, she hit me in the face, she's going to be fired. There was no redness, swelling or any injury to the face. The note further included the CNA had stated that the resident hit her and she denied hitting the resident. Review of the facility's investigation revealed that on (MONTH) 21, (YEAR), a licensed practical nurse (staff #54) heard yelling from resident #58's room. Staff #54 entered the resident's room and staff #33 was inside. The resident told staff #54 that staff #33 had hit her in the face. Upon assessment, staff #54 reported that there were no signs of injury. Staff #33 denied striking the resident. Further review of the facility's investigative report revealed there was no documentation that resident #58 was interviewed or that other resident's were interviewed who may have been provided care by this CN[NAME] An interview was conducted with staff #18 on (MONTH) 28, (YEAR) at 12:45 p.m. He stated that he did not have any documentation that the resident was interviewed during the investigation. Review of the facility's Abuse policy revealed that all allegations and signs of resident abuse, neglect and injuries of unknown source shall be immediately reported and thoroughly investigated by facility management. The policy also included that the individual conducting the investigation at a minimum will interview the resident, the resident's roommate, interview other residents to whom the accused employee provides care or services, and interview all staff members who have had contact with the resident(s) during the period of the alleged incident.",2020-09-01
100,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2018-03-30,608,D,1,1,WXKF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews, facility documentation, and policies and procedures, the facility failed to ensure that staff reported a reasonable suspicion of a crime to law enforcement regarding a resident to resident altercation involving two residents (#49 and #74). Findings include: -Resident #49 was admitted on (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. An annual MDS (Minimum Data Set) assessment dated (MONTH) 21, (YEAR) included a BIMS (Brief Interview for Mental Status) score of 3, which indicated the resident had severe cognitive impairment. -Resident #74 was admitted on (MONTH) 23, 2012, with [DIAGNOSES REDACTED]. An annual MDS assessment dated (MONTH) 27, (YEAR) included the resident had been assessed with [REDACTED]. Review of the facility's investigative documentation revealed that on (MONTH) 20, (YEAR), resident #49 got up from his chair in the dining room and walked over to where resident #74 was seated, and slapped resident #74 on the face. Further review of the facility's investigative documentation revealed that there was no documentation that law enforcement had been notified. An interview was conducted with the DON (Director of Nursing/staff #18) on (MONTH) 27, (YEAR) at 12:42 p.m. Staff #18 stated that he did not call law enforcement, due to the residents' cognitive impairments and that resident #49 was not able to make informed intent to hit resident #74. Staff #18 stated he had informed staff to report to him and that he would make the determination as to whether a call needed to be made to law enforcement. During an interview with a LPN (Licensed Practical Nurse/staff #63) on (MONTH) 27, (YEAR) at 1:24 p.m., staff #63 stated that she had not witnessed the incident, but she did assess the residents and no injuries were found. Staff #63 stated she did not notify law enforcement, as there was no physical injuries and the incident was defused, immediately. Staff #63 stated she had received in-services regarding reporting of witnessed or suspected crimes to law enforcement, but was unsure of the time frames for reporting and thought reporting was only required if there was physical injury or a huge fight or altercation. An interview was conducted with a CNA (Certified Nursing Assistant/staff #35) on (MONTH) 27, (YEAR) at 2:00 p.m. Staff #35 stated that on (MONTH) 20, (YEAR) during the breakfast meal, she witnessed resident #49 hit resident #74 in the mouth. Staff #35 stated she reported the incident to the nurse. She said that she thought the incident was physical abuse, but did not call law enforcement. Staff #35 stated that the incident occurred on a behavior unit and hitting was one of resident #49's behaviors. Staff #35 stated she had received yearly in-services regarding the reporting of abuse to law enforcement. Review of the facility's policy regarding Reporting Abuse and Witnessed or Suspected Crimes revealed that it was the responsibility of employees, facility consultants, attending physicians, family members, visitors, etc., to immediately report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property, to facility management and all required outside agencies, such as the State Agency and local law enforcement. The policy further included that if staff had reasonable suspicion that a crime had occurred against a person receiving care at this facility, Federal law requires that you report your suspicion directly to both law enforcement and the State Survey Agency.",2020-09-01
101,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2018-03-30,609,D,1,1,WXKF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews and policy review, the facility failed to ensure that the State Agency was notified of an injury of unknown origin in a timely manner for one resident (#3). Findings include: Resident #3 was admitted to the facility on (MONTH) 12, 2012, with [DIAGNOSES REDACTED]. Review of a Minimum Data Set quarterly assessment dated (MONTH) 11, (YEAR) revealed the resident had severe cognitive impairment. Review of the nursing notes dated (MONTH) 30, (YEAR) revealed a CNA (Certified Nursing Assistant) who was providing care to the resident noticed that the resident's right elbow was swollen and discolored. This was reported to the nurse on duty. Per the notes, the resident was unable to communicate or respond to questions, but reacted with facial grimaces upon touching the right elbow. The right elbow was assessed to be red and swollen, and the posterior aspect of the elbow was discolored and was warm to the touch. The nurse informed his clinical manager who notified the on-call NP (Nurse Practitioner) and obtained an order for [REDACTED]. A nursing note dated (MONTH) 30, (YEAR) at 10:30 p.m. revealed the facility was informed of the x-ray results, which included that the resident had a displaced elbow fracture. Orders were received to splint the resident's arm with an arm sling, administer pain medication if needed and transfer the resident to the emergency room in the morning for an evaluation. Review of the facility's investigation revealed that on (MONTH) 30, (YEAR), the facility was notified that the resident had a displaced elbow fracture. The documentation included that the facility did not report the injury of undetermined origin to the State agency until (MONTH) 2, (YEAR). A review of the State Agency data base revealed the facility did not report the injury of undetermined origin until (MONTH) 2, (YEAR) at 3:22 p.m. An interview was conducted with the Director of Nursing (DON/staff #18) on (MONTH) 27, (YEAR) at 2:34 p.m., who stated that he did not recognize the incident with injury would have been considered possible abuse. He stated that they did not notify the State agency until (MONTH) 2, (YEAR). A review of the facility's policy on reporting abuse to outside agencies stated that it is the responsibility of our employees, facility consultants, Attending Physicians, visitors, etc., to immediately report any incident or suspected incident or suspected incident of neglect or resident abuse, including injuries of unknown source to facility management and all required outside agencies such as the State agency.",2020-09-01
102,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2018-03-30,610,D,1,1,WXKF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, resident and staff interviews, facility documentation, and policies and procedures, the facility failed to conduct thorough investigations into allegations of abuse involving four residents (#18, #49, #58 and #74). Findings include: -Resident #49 was admitted on (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. -Resident #74 was admitted on (MONTH) 23, 2012, with [DIAGNOSES REDACTED]. Review of the facility's investigative documentation revealed that on (MONTH) 20, (YEAR), resident #49 got up from his chair in the dining room and walked over to where resident #74 was seated, and slapped resident #74 on the face. Further review of the facility's investigative report revealed a written statement by a CNA (Certified Nursing Assistant), who had witnessed resident #49 hit resident #74. The CNA's statement included that coworkers and nurses also helped separate the residents. However, the investigative documentation did not include any statements from other staff and there was no documentation that resident #49 or #74 were interviewed regarding the incident. An interview was conducted on (MONTH) 27, (YEAR) at 12:42 p.m. with the Director of Nursing (staff #18), who stated that he only interviewed the CNA who witnessed the incident between resident #49 and resident #74, even though other staff had come to the dining room to assist in separating the residents. Staff #18 further stated that he had not interviewed resident #74, as he did not believe the resident was a good historian. An interview was conducted with resident #74 on (MONTH) 27, (YEAR) at 1:50 p.m. Resident #74 stated he remembered the incident in the dining room when resident #49 had hit him. Resident #74 stated he told resident #49 to leave him alone and that he did not know why resident #49 had hit him. A review of the facility's policy regarding Abuse investigations revealed documentation that All allegations of resident abuse, neglect, and injuries of unknown source shall be immediately reported and thoroughly investigated by facility management. The individual conducting the investigation would, as a minimum: interview the person(s) reporting the incident, interview any witnesses to the incident, interview the resident(s), and interview all staff members who have had contact with the resident(s) during the period of the alleged incident. -Resident #18 was admitted to the facility on (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. Review of the facility's investigative documentation revealed that on (MONTH) 26, (YEAR), a Certified Nursing Assistant (CNA) was providing care to the resident in his room. The CNA called for help and staff assisted the CN[NAME] The resident was observed to be bleeding from a laceration above his eyebrow. When questioned, the CNA stated that the resident had started to become combative during care and was swinging and hit himself in the head, causing the laceration. Further review of the investigative documentation revealed it did not include interviews with other residents, who may have been cared for by this CN[NAME] An interview was conducted with staff #18 at 7:45 a.m. on (MONTH) 28, (YEAR). He said that he was involved in the investigation of this incident and that normally as part of the investigation, the facility will interview residents who may have received care by the alleged perpetrator. He stated that he thought this had happened for this incident. He said that sometimes the social worker conducts the interviews with the residents. In an interview with the social service director (staff #16) at 8:50 a.m. on (MONTH) 28, (YEAR), he said that he did not interview residents regarding this incident. He said that a few years ago, he used to be more involved in the investigations, but now he does not get very involved in them. During another interview with staff #18 at 1:00 p.m. on (MONTH) 29, (YEAR), he said that he did not locate any interviews with other residents and that this should have been done, as per facility policy. -Resident #58 was admitted to the facility on (MONTH) 31, (YEAR), with [DIAGNOSES REDACTED]. A behavior note dated (MONTH) 21, (YEAR) at 9:35 a.m. revealed this writer heard yelling down the hallway and entered the resident's room. The resident was squirming around in her bed, as a CNA (staff #33) was attempting to dress her following a shower. Per the note, the resident stated, she hit me in the face, she's going to be fired. There was no redness, swelling or any injury to the face. The note further included the staff member had stated that the resident hit her and denied hitting the resident. Review of the facility's investigation revealed that on (MONTH) 21, (YEAR), a licensed practical nurse (staff #54) heard yelling from resident #58's room. Staff #54 entered the resident's room and staff #33 was inside. The resident told staff #54 that staff #33 had hit her in the face. Upon assessment, staff #54 reported that there were no signs of injury. Staff #33 denied striking the resident. Further review of the facility's investigative report revealed there was no documentation that resident #58 was interviewed or that other resident's were interviewed who may have been provided care by this CN[NAME] An interview was conducted with staff #18 on (MONTH) 28, (YEAR) at 12:45 p.m. He stated that he did not have any documentation that the resident was interviewed during the investigation. Review of the facility's Abuse policy revealed that all allegations of resident abuse, neglect, and injuries of unknown source shall be immediately reported and thoroughly investigated by facility management. The individual conducting the investigation would, at a minimum: interview the person(s) reporting the incident, interview any witnesses to the incident, interview the resident(s) and other residents to whom the accused employee provides care or services, and interview all staff members who have had contact with the resident(s) during the period of the alleged incident.",2020-09-01
103,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2018-03-30,641,E,0,1,WXKF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record reviews, resident and staff interviews, and policy review, the facility failed to ensure that the Minimum Data Set (MDS) assessments were accurate for two residents (#15 and #84). Findings include: -Resident #84 was admitted to the facility on (MONTH) 17, (YEAR) and discharged on (MONTH) 22, (YEAR). [DIAGNOSES REDACTED]. Review of a Skin Observation tool dated (MONTH) 28, (YEAR) revealed a new stage II pressure ulcer to the right gluteal fold, which measured 6 cm x 0.7 cm. Review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 25, (YEAR), revealed the resident had a stage I or greater pressure ulcer. However, in the section which asked Does this resident have 1 or more unhealed pressure ulcers Stage 1 or higher, the question was answered No. By indicating a no response, it disabled the ability to document wound detail such as; the actual stage or type of wound, the wound dimensions, the most severe type of tissue present, and if the pressure ulcer had worsened. Further review of the clinical record revealed documentation that the resident continued to have a stage II pressure ulcer, which then advanced to a stage III pressure injury to the right gluteal fold. The discharge MDS assessment dated (MONTH) 22, (YEAR) included the following: Does this resident have 1 or more unhealed pressure ulcers Stage 1 or higher? Per the MDS, the question was answered No, even though the resident had a documented stage III pressure ulcer at the time of this assessment. In an interview conducted with a Licensed Practical Nurse/MDS Coordinator (staff #119) on (MONTH) 28, (YEAR) at 10:24 a.m., staff #119 stated that she obtaines information regarding wounds from skin assessments, weekly wound assessments if present, weekly reports from the Weight/Wound meeting or the Quality meetings, and through record reviews and staff interviews. Staff #119 stated she clearly marked the wrong area and did not get the information correct. Staff #119 further stated if there is an assessment that is incorrectly completed, she would have to do the significant change MDS and document an error report, but she did not know what her recourse is after this period of time. -Resident #15 was admitted to the facility on (MONTH) 15, 2007 and readmitted on (MONTH) 16, 2013. [DIAGNOSES REDACTED]. Review of a quarterly MDS assessment dated (MONTH) 19, and (MONTH) 19, (YEAR), revealed documentation that the resident had no impairment to the upper extremities. A quarterly MDS assessment dated (MONTH) 20, (YEAR) included that the resident was assessed to have no impairment to both upper extremities. However, according to an Activity of Daily Living (ADL) care plan, the resident was identified to have a functional deficit with ADL's, related to a [DIAGNOSES REDACTED]. During an interview with resident #15 on (MONTH) 29, (YEAR) at 8:45 a.m., the resident was observed to have significant contractures to the fingers of her left hand and less contractures to the fingers of her right hand. At this time, the resident stated that her fingers have been that way for a long, long time. In an interview conducted with staff #119 on (MONTH) 29, (YEAR) at 9:07 a.m. Staff #119 stated that resident #15 is limited with her hands and has had surgeries to release some of the contractures. Staff #119 stated that she had incorrectly documented on the MDS assessments. The facility provided a document regarding MDS Completion Guidelines which included the signature on the MDS verifies the accuracy by the person completing the MDS.",2020-09-01
104,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2018-03-30,657,D,0,1,WXKF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy and procedures, the facility failed to revise one resident's (#6) care plan to include the use of a low bed. Findings include: Resident #6 was admitted on (MONTH) 16, 2009, with [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment dated (MONTH) 12, (YEAR) included the resident had been assessed with [REDACTED]. The resident was also assessed to have limited range of motion of bilateral lower extremities and had no falls, since the prior MDS assessment. An observation was conducted on (MONTH) 26, (YEAR) at 2:53 p.m. of the resident in a low bed. Review of the resident's care plans revealed they were not updated to reflect the use of a low bed. During an interview conducted on (MONTH) 30, (YEAR) at 9:56 a.m. with the DON (Director of Nursing/staff #18), staff #18 stated that a low bed should be included on the care plan with the identified need for the low bed. Staff #18 stated the care plan revision would be part of the IDT (Interdisciplinary Team) meetings. An interview was conduced on (MONTH) 30, (YEAR) at 11:10 a.m., with the MDS Coordinator (licensed practical nurse/staff #119). Staff #119 stated that care plan revisions were made based on quarterly assessments, weekly IDT meetings, physician's orders, and/or other assessments by staff. A review of the facility policy regarding assessments and care plans revealed documentation that the interdisciplinary assessment team, in coordination with the resident and his/her family or representative, will develop and update the comprehensive care plans for the resident.",2020-09-01
105,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2018-03-30,658,D,0,1,WXKF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and review of the Manual of Nursing Practice - 8th Edition, the facility failed to ensure a physician's orders [REDACTED]. Findings include: Resident #6 was admitted on (MONTH) 16, 2009, with [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment dated (MONTH) 12, (YEAR) revealed the resident had been assessed with [REDACTED]. The MDS further included that the resident had no falls since the prior assessment (June 11, (YEAR)). Review of the current physician's orders [REDACTED].>According to an ADL (activities of daily living) care plan, the resident had ADL deficits related to dementia. An intervention included for the use of a geri-chair with a tray table. An observation was conducted of resident #6 on (MONTH) 26, (YEAR) at 9:19 a.m. The resident was observed to be seated in a geri-chair, however, the geri-chair did not have a tray attached. Additional observations were conducted on (MONTH) 28, (YEAR) at 8:53 a.m., and on (MONTH) 29, (YEAR) at 12:18 p.m., of the resident in the geri-chair without a tray table attached. An interview was conducted on (MONTH) 29, (YEAR) at 12:30 p.m., with a CNA (Certified Nursing Assistant/staff #46), who stated that she provided care for the resident. Staff #46 stated she could not remember seeing a tray table, nor had she ever attached a tray table to the resident's geri-chair. An interview was conducted on (MONTH) 29, (YEAR) at 12:35 p.m., with a LPN (Licensed Practical Nurse/staff #22). At this time, staff #22 went to the resident's room to locate the tray table. Staff #22 was unable to locate the table and stated that the could not remember having seen it on the resident's geri-chair. A review of the Manual of Nursing Practice - 8th Edition by Lippincott,[NAME], and Wilkens, revealed that the standards of professional nursing practice included standards of care and standards of professional performance that included implementing a physician's orders [REDACTED].",2020-09-01
106,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2018-03-30,686,E,1,1,WXKF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews and policy review, the facility failed to consistently assess one resident's (#84) pressure ulcer and complete weekly skin assessments, as ordered. Findings include: Resident #84 was admitted to the facility on (MONTH) 17, (YEAR) and discharged on (MONTH) 22, (YEAR). [DIAGNOSES REDACTED]. Review of the Braden Pressure Ulcer Risk assessment dated (MONTH) 17, (YEAR) documented the resident had a score of 18, which indicated the resident was at risk for the development of a pressure injury. Physician orders [REDACTED]. The Skin Observation Tool (weekly skin assessment) dated (MONTH) 21, (YEAR) included the resident's skin was intact. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 24, (YEAR) revealed a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. The MDS included that the resident did not have a pressure injury, but was at risk for the development of a pressure injury. The Care Area Assessment (CAA) indicated to include Pressure Ulcer risk on the care plan. A physician's orders [REDACTED]. The Skin Observation Tool dated (MONTH) 28, (YEAR) documented the resident had a stage 2 pressure injury to the right gluteal fold, which measured 6 cm x 0.7 cm and that treatment was provided. A physician's orders [REDACTED]. A Wound Weekly Observation Tool dated (MONTH) 5, (YEAR) included the resident had a right buttock wound, which was identified on (MONTH) 27, (YEAR). A Wound Weekly Observation Tool dated (MONTH) 12, (YEAR) documented the wound was a stage 2 with granulation tissue present and that the wound was worsening. The wound measurements were 60 mm x 30 mm x 1 mm. A Wound Weekly Observation Tool dated (MONTH) 19, (YEAR) documented the stage 2 wound was improving with [MEDICATION NAME] tissue present and had well defined edges. The wound measured 56 mm x 27 mm x 2 mm. Per the note, the wound was discussed with the physician at the weekly meeting on (MONTH) 18, and staff are to continue with current treatment. A physician's orders [REDACTED]. Review of a care plan revealed the resident had a stage 3 pressure injury to the right buttocks, as resident continues to sit in wheelchair for hours at a time and is non compliant. One of the interventions included to complete weekly skin checks. Despite the physician's orders [REDACTED]. 2017 included documentation that the resident had a stage 2 pressure ulcer to the right buttock. Review of the clinical record revealed a weekly skin assessment was completed on (MONTH) 30, (YEAR), which indicated the resident had a wound on the buttock. However, the next weekly skin assessment was not completed until (MONTH) 14, over two weeks later. Further review of the Wound Weekly Observation Tools dated (MONTH) 13, 17, and 24, (YEAR), revealed the resident had a stage 2 pressure ulcer. The next weekly skin assessment was completed on (MONTH) 21, (YEAR), however, the next weekly skin assessment was not done until approximately 3 weeks later (on (MONTH) 11). A physician's orders [REDACTED]. A physician's orders [REDACTED]. However, review of a Wound Weekly Observation Tool dated (MONTH) 2, (YEAR) revealed documentation that the resident had a stage 2 pressure injury. The documentation further included that the wound measured 18 mm x 40 mm x 1 mm, with treatments in place. The Skin Observation Tool dated (MONTH) 11, 18, 25, and (MONTH) 1, (YEAR) included that treatment continued to the right gluteal fold. Further review of the clinical record revealed there was no documentation that the right buttock pressure ulcer was assessed from (MONTH) 3 through (MONTH) 22, (YEAR). According to the Discharge Summary dated (MONTH) 22, (YEAR), the resident had a stage 3 pressure ulcer on the right buttock. In an interview conducted with a Licensed Practical Nurse/Unit Manager (staff #22) on (MONTH) 27, (YEAR) at 2:45 p.m., staff #22 stated the staging and description of the wound is done by the wound doctor. Staff #22 stated that skin assessments should be done every week for every resident and that wound assessments are completed weekly by the Unit Manager. Staff #22 stated that she recalled this resident. She said that during the time when the wound assessments were missing from (MONTH) 3 to discharge on (MONTH) 22, the facility transitioned from having the wound nurse complete the weekly wound assessments to the Unit Managers who assumed this responsibility. Staff #22 stated that it looks like this resident fell through the cracks. In an interview conducted with the Director of Nursing (staff #18) on (MONTH) 28, (YEAR) at 10:06 a.m., staff #18 stated that in (MONTH) (YEAR), the wound program responsibilities transferred from the wound nurse to the unit managers. Staff #18 stated that staff #22 was previously a wound nurse and helped in teaching the unit managers the process for wound assessments. Review of a facility policy titled Pressure Ulcer Care/Treatment revealed the purpose is to provide guidelines for the care of existing pressure ulcers and prevention of additional pressure ulcers. The facility should have a system/procedure to assure that wound assessments are done timely. The policy also included to routinely assess and document the condition of the resident's skin per facility wound/skin care program. The policy stated that the resident's clinical record should include assessment data (i.e. color, size, pain, drainage etc.), when inspecting the wound.",2020-09-01
107,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2018-03-30,695,D,0,1,WXKF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure that oxygen was administered per physician orders for one resident (#11). Findings include: Resident #11 was readmitted on (MONTH) 23, (YEAR), with a [DIAGNOSES REDACTED]. The physician orders for (MONTH) (YEAR) included for oxygen at 2 liters per minute via nasal cannula, as needed for shortness of breath. The quarterly Minimum Data Set assessment dated (MONTH) (YEAR), revealed a Brief Interview for Mental Status score of 15, which indicated that the resident was cognitively intact. Review of the oxygen saturation vital sign report from (MONTH) 21-23, (YEAR) revealed the resident had oxygen saturations between 94-98%, while on oxygen at 2 liters per minute. An observation of the resident was conducted on (MONTH) 26, (YEAR) at 12:08 p.m. The resident was eating breakfast in the dining room and was wearing an oxygen nasal cannula which was connected to a portable oxygen tank. The regulator on the oxygen tank was set at 2 liters per minute. However, the oxygen tank pounds per square inch (PSI) level was reading in the red, which indicated the tank was empty. Immediately following this observation, an interview was conducted with a Registered Nurse (staff #122). She stated the resident is on PRN (as needed) oxygen and is usually on an oxygen concentrator, when in her room. She stated the resident is using oxygen because she has pneumonia. At this time, staff #122 checked the resident's oxygen saturation level. The resident's saturation level was 84%. Staff #122 went to turn up the oxygen regulator level and then observed that the portable oxygen tank was on zero. Staff #122 then asked a Certified Nursing Assistant to bring the resident's oxygen concentrator into dining room. After the oxygen concentrator was brought into the dining room, staff #122 connected the oxygen cannula to the oxygen concentrator, which was set at 2 liters per minute. She then re-checked the resident's oxygen saturation level which was 94%. An interview with a CNA (staff #116) was conducted on (MONTH) 26, (YEAR) at 12:20 p.m. She stated that she did not check the oxygen tank before she wheeled the resident to the dining room. Review of the facility policy regarding Oxygen Handling and Administration revealed that the oxygen tank must be checked to be sure that it is in good working order.",2020-09-01
108,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2018-03-30,697,D,0,1,WXKF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, facility documentation and policy review, the facility failed to ensure one resident (#284) received pain medication in a timely manner. Findings include: Resident #284 was admitted on (MONTH) 23, (YEAR) at 6:40 p.m., with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. The orders also included for [MEDICATION NAME] HCL (narcotic pain medication) 20 mg by mouth every 6 hours for pain management. Review of the nursing admission screen/history dated (MONTH) 23, (YEAR) at 6:40 p.m., revealed the resident was alert and oriented to person, place, time and situation. Per the documentation, the resident's pain was assessed to be a 10, indicating the worst possible pain. The documentation also included the resident had constant pain all over for the past 5 days, and had a history of [REDACTED]. Despite documentation that the resident's pain level was a 10, there was no clinical record documentation that pain medication was administered to the resident or that alternative measures were attempted on (MONTH) 23. A nursing pain assessment dated (MONTH) 24, (YEAR) included the resident had pain almost constantly for the past five days, and that the resident's pain level was a 10. Further review of the clinical record including the controlled substance countdown sheet, revealed the resident did not receive any pain medication until (MONTH) 24, (YEAR) at 6 p.m., when the [MEDICATION NAME] was administered. This was approximately 24 hours after being admitted . A nursing note dated (MONTH) 24, (YEAR) at 6:10 p.m. included that [MEDICATION NAME] had not been available, so the pharmacy was contacted and the medication was out for delivery. According to the controlled substance countdown sheet, the first application of the [MEDICATION NAME] was on (MONTH) 27, (YEAR) at 8:00 p.m. A review of the Narcotic Emergency box (E-Kit) inventory revealed that [MEDICATION NAME] 10/325 mg tablets and [MEDICATION NAME] 50 mcg patches were available on site. A resident interview was conducted on (MONTH) 26, (YEAR) at 11:40 a.m. She stated that she has a history of fibromylgia and chronic opiate dependency, and that her pain is not being adequately controlled. An interview was conducted on (MONTH) 28, (YEAR) at 2:04 p.m., with the RN clinical manager (Registered Nurse/staff #1). Staff #1 stated that the resident was admitted on Friday evening, and there was a delay in the order transmission of the resident's medications to the pharmacy, because the night RN did not know how to complete the transmission process, after inputting the orders into the computer. Staff #1 said that the nurse did not ask the management team for assistance until the following morning on how to complete this process. An interview was conducted with the DON (Director of Nursing/staff/#18) on (MONTH) 28, (YEAR) at 2:24 p.m. He stated if a resident is having severe pain and pain medication is not available, the physician should be notified within 30 minutes and an order obtained to give medications from the E-kit. He stated that [MEDICATION NAME] and [MEDICATION NAME]es were available in the E-Kit and should have been administered. Review of the facility's pain assessment and management guidelines revealed to effectively recognize the presence of pain and to address the under lying causes of pain. Staff are to report significant changes in the level of pain to the physician or practitioner. Review of a policy regarding medications revealed that a supply of drugs typically used in emergencies shall be maintained at each nurses station. An inventory listing is maintained of the contents of the kit.",2020-09-01
109,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2018-03-30,698,D,0,1,WXKF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and policies and procedures, the facility failed to ensure that pre/post [MEDICAL TREATMENT] assessments were consistently completed for one resident (#75). Findings include: Resident #75 was admitted on (MONTH) 12, 2013, with a [DIAGNOSES REDACTED]. A physician's order dated (MONTH) 5, (YEAR) included for the resident to receive [MEDICAL TREATMENT] every Monday, Wednesday and Friday at an outside [MEDICAL TREATMENT] provider, via stretcher van. A care plan included the resident was in [MEDICAL CONDITION] and received [MEDICAL TREATMENT] treatments. An intervention was for pre/post assessments to be completed on [MEDICAL TREATMENT] days. Review of the clinical record revealed documentation by nursing staff of pre/post [MEDICAL TREATMENT] assessments, which included the resident's blood pressure, pulse and weight. However, there was no clinical record documentation that pre/post [MEDICAL TREATMENT] assessments were completed five times in (MONTH) (YEAR) and four times in (MONTH) (YEAR) on [MEDICAL TREATMENT] days. An interview was conducted with the Director of Nursing (staff #18) on (MONTH) 28, (YEAR) at 2:04 p.m. Staff #18 stated that the floor nurses were to complete the pre/post [MEDICAL TREATMENT] assessments on residents before they leave for [MEDICAL TREATMENT] and upon return. Staff #18 stated the pre/post [MEDICAL TREATMENT] assessments were to be kept in the resident's clinical record. Staff #18 stated that the pre/post [MEDICAL TREATMENT] assessments which were missing in (MONTH) and (MONTH) (YEAR), could not be located. A review of the facility policy regarding [MEDICAL TREATMENT] Guidelines revealed that nursing staff are to assess and document vital signs, including blood pressure and weights. Nursing staff were also to provide direct visual monitoring of the access site before and after [MEDICAL TREATMENT], complete the required pre/post assessments and maintain the assessments in the resident's permanent record.",2020-09-01
110,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2018-03-30,761,D,0,1,WXKF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and policy review, the facility failed to discard an expired medication. Findings include: An observation of the Oak medication cart II was conducted with a Registered Nurse (staff #125) on (MONTH) 28, (YEAR) at 12:13 p.m. Inside the cart was one medication card containing twenty-two, 2 mg tablets of [MEDICATION NAME] (anxiolytic), with an expiration date of (MONTH) 16, (YEAR). An interview was conducted with (staff #125) immediately following this observation. He said that there should not be any expired medications in the medication cart. He stated that expired medications should be destroyed, per their facility policy. An interview was conducted on (MONTH) 28, (YEAR) at 1:19 p.m. with the Director of Nursing (staff #18). He said the nurses are supposed to check the medication cart daily for any expired medications. An interview was conducted on (MONTH) 28, (YEAR) at 1:39 p.m., with the facility's pharmacy provider (staff #137). Staff #137 stated the medication card containing twenty-two, 2 mg tablets of [MEDICATION NAME] had an expiration date of (MONTH) 16, (YEAR). Review of a policy regarding Storage of Medications revealed that the facility shall not use discontinued, outdated, or deteriorated drugs. All such drugs shall be returned to the dispensing pharmacy or destroyed.",2020-09-01
111,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2018-03-30,880,E,0,1,WXKF11,"Based on staff interviews, the facility failed to ensure that a water management system was developed and implemented to identify, monitor, and treat potential sources of Legionella and other waterborne pathogens. Findings include: During the survey, the facility's water management system plan to address Legionella and other waterborne pathogens was requested. An interview was conducted with a Licensed Practical Nurse (Infection Control Nurse/staff #36) on (MONTH) 28, (YEAR) at 10:52 a.m. Staff #36 stated that she was not aware of any plan for water safety for the facility. Staff #36 stated she would have to check with the Director of Maintenance or the Administrator. An interview was conducted with the Director of Maintenance (staff #82) on (MONTH) 28, (YEAR) at 1:22 p.m. Staff #82 stated that he had heard about this issue, but a plan had not been completed for the facility. In an interview conducted with the Administrator (staff #45) on (MONTH) 28, (YEAR) at 1:45 p.m., staff #45 stated he had heard about this at a conference and knew something had come out about this a few months ago, but it has not yet been completed for this facility.",2020-09-01
112,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2019-06-05,552,D,0,1,7VLE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one of eight sampled residents (#18) and/or their representative was informed of the risks and benefits of psychoactive medications, prior to administration. The deficient practice can result in the resident and/or the resident representative not being aware of the benefits and the potential adverse side effects of taking psychoactive medications. Findings include: Resident #18 was admitted on (MONTH) 27, (YEAR) with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated (MONTH) 3, (YEAR) revealed a Brief Interview for Mental Status (BIMS) score of 9 which indicated the resident had moderate impaired cognition. Review of the clinical record revealed a physician's orders [REDACTED]. The order was increased to 300 mg daily on (MONTH) 10, (YEAR). The Consultant Pharmacist's Medication Regimen Review dated (MONTH) 30, (YEAR) revealed documentation to ensure consent for [MEDICATION NAME] is obtained and scanned into the Electronic Medical Record. Review of the Medication Administration Record [REDACTED]. However, review of the clinical record did not reveal evidence the resident or the resident's representative had been informed of the risk and benefits of [MEDICATION NAME] prior to administration. Further review of the physician orders [REDACTED]. Review of the MARs for March, April, and (MONTH) 2019 revealed the resident was administered [MEDICATION NAME], and Klonopin as ordered. However, review of the clinical record did not reveal evidence that the resident or the resident's representative had been informed of the risk and benefits of these [MEDICAL CONDITION] medications prior to administration. Additional review of the clinical record revealed a Psychoactive Medication Consent for [MEDICATION NAME], and Klonopin that contained two Licensed Practical Nurses (LPN) witness signatures dated (MONTH) 22, 2019. However, the areas designated Resident/Resident representative Signature or Verbal consent obtained from was blank. An interview was conducted with a LPN (staff #97) on (MONTH) 3, 2019 at 1:32 PM. The LPN stated that informed consent is obtained from the resident or the resident's representative prior to administering [MEDICAL CONDITION] medications. She stated that resident #18 has a family member that is her Power of Attorney and that it is possible that the informed consent for this resident was overlooked. During an interview conducted with the Director of Nursing (DON/staff #84) on (MONTH) 3, 2019 at 1:37 PM, the DON stated the expectation is that an informed signed consent is obtained. The facility's policy titled Antipsychotic Medication Use revealed the resident or their representative will be notified of the need for antipsychotic medication, explain the risks and benefits to treatment, and a signed consent will be obtained prior to the first dose of medication being administered. The policy included if the resident's representative is unavailable to come to the facility to sign the form, a verbal consent may be obtained by two facility licensed personnel. The policy also included this verbal consent will remain in place for 30 days and that after 30 days the signature must be obtained or another verbal consent must be obtained.",2020-09-01
113,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2019-06-05,622,D,0,1,7VLE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure one sampled resident's (#80) clinical record included the information that was provided to the receiving provider. The deficient practice could result in an unsafe and ineffective transition of care. Findings include: Resident #80 was admitted on (MONTH) 8, (YEAR) with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A nursing progress note dated (MONTH) 12, 2019 at 12:52 PM revealed the resident left the facility that morning at 11:50 AM. The note also revealed narcotic and prescription medications were given to the family member and that report was given to the coordinator at the assisted living facility. However, further review of the clinical record revealed no documentation that the following information was provided to the receiving provider: -contact information of the practitioner responsible for the care of the resident, -the resident's representative information including contact information, -Advanced Directive information, -special instructions for ongoing care, -comprehensive care plan goals, -and other necessary information, including a copy of the resident's discharge summary, and any other documentation, as applicable, to ensure a safe and effective transition of care. After a request was made for the information that was provided to the receiving provider, a copy of the post-discharge plan of care obtained by fax from the receiving facility was provided. The document, dated (MONTH) 11, 2019, had been signed by the facility's social services director (staff #132), the activities director (staff #123), and the dietary manager (staff #77) indicating staff were aware of the plan to discharge. However, the document only provided contact information of the practitioner responsible for the care of the resident and stated that a medication list had been attached. A copy of the medication list was not included with the document provided. A discharge summary progress note dated (MONTH) 31, 2019, written by staff #132, revealed the resident was officially discharged from the facility on (MONTH) 12, 2019 around 11:50 AM. The note revealed the resident wanted to have a more independent living situation and that she was assessed to be capable and safe in an assisted living setting. The note included the resident and her family member had visited the assisted living facility prior to her move, and that her family member and a friend had come to the facility on (MONTH) 12 to help her move her belongings. The note also included the resident had become quite stable and pleasant during her stay at the facility, and that the resident was able to realize her goal of returning to the more independent setting. An interview was conducted on (MONTH) 4, 2019 at 2:33 PM with a Licensed Practical Nurse (LPN/staff #39). He stated that when a resident is discharged to another facility, the process includes completing a discharge summary, contacting the resident's case-worker to make them aware and gathering copies of pertinent documentation such as the resident's face-sheet and a list of their medications. He said he also calls the other facility and gives them report, and then documents a progress note with all the details and the time of discharge. The LPN stated he was involved in the discharge process of resident #80. The LPN stated that he remembered calling the facility she was transferred to. He said he thought he completed a discharge summary, but was unsure of where that information might be. The LPN also stated that the discharge happened very quickly and that he thought he had taken care of all the discharge requirements. The LPN said he usually follows the facility's discharge checklist. An interview was conducted on (MONTH) 5, 2019 at 8:56 AM with the Director of Nursing (DON/staff #84). The DON stated that his expectation is that the nursing discharge documentation include the date and time of discharge, the resident's general condition of health, any treatments the resident is receiving, the resident's destination, who they went with, that the belongings went with them, a list of essential individuals who had been notified, whether or not medications were sent, and whether education for medications were provided. He said that a copy of the discharge summary goes with the resident and one stays with the clinical record. The DON stated that the Interdisciplinary Team provides input to the discharge summary. He stated that resident #80's discharge summary may have been dropped due to the fact that it was a rapid discharge. The facility's policy regarding Discharging the Resident revealed that if the resident is being discharged to another facility, ensure that a transfer summary is completed and telephone report is called to the receiving facility. The policy included assessing and documenting the resident's condition at discharge, including a skin assessment. The policy also included recording other information in accordance with facility policy and professional standards of practice in the clinical record.",2020-09-01
114,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2019-06-05,660,D,0,1,7VLE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure discharge planning included developing a discharge care plan for one sampled resident (#80). The deficient practice has the potential to result in an ineffective transition to post-discharge care, and increases the risk factors leading to preventable readmission. Findings include: Resident #80 was admitted on (MONTH) 8, (YEAR) with [DIAGNOSES REDACTED]. An initial social service assessment dated (MONTH) 8, (YEAR) revealed the resident's expectation at admission was to probably remain at the facility. The handwritten document included the Social Service Director (SSD/staff #132) would continue to assess for needs and significant changes. Review of the comprehensive care plan dated (MONTH) 9, (YEAR), revealed no discharge care plan had been developed. The admission Minimum Data Set (MDS) assessment dated (MONTH) 16, (YEAR) revealed a score of 13 on the Brief Interview for Mental Status (BIMS) which indicated the resident had no cognitive impairment. The assessment included the resident expected to remain in the facility, but wanted to be asked on all assessments about returning to the community. A psychosocial progress note dated (MONTH) 25, 2019 revealed staff #132 continued to be involved with providing primary services to the resident which included compiling and sending referral packets to other facilities and the resident's case manager as well as coordinating discharge date s and discharge plan of care paperwork with the facility's management team. However, review of the clinical record revealed no discharge care plan had been initiated. The quarterly MDS assessment dated (MONTH) 15, 2019 revealed a score of 15 on the BIMS which indicated the resident was cognitively intact. The assessment also included there was no active discharge plan in place for the resident to return to the community. A physician's orders [REDACTED]. A discharge MDS assessment dated (MONTH) 12, 2019 revealed the resident's discharge was a planned discharge. A discharge summary progress note dated (MONTH) 31, 2019, written by staff #132, revealed the resident was officially discharged from the facility on (MONTH) 12, 2019 around 11:50 AM. The note revealed the resident wanted to have a more independent living situation and that she was assessed to be capable and safe in an assisted living setting. The note included the resident and her family member had visited the assisted living facility prior to her move, and that her family member and a friend had come to the facility on (MONTH) 12 to help her move her belongings. The note also included the resident had become quite stable and pleasant during her stay at the facility, and that the resident was able to realize her goal of returning to the more independent setting. An interview was conducted on (MONTH) 5, 2019 at 8:56 AM with the Director of Nursing (DON/staff #84). He stated the resident's discharge processes may have been dropped due to the fact that it was a rapid discharge. Review of the facility's policy titled Discharging the Resident revealed the discharge care plan was not addressed.",2020-09-01
115,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2019-06-05,661,D,0,1,7VLE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to develop a discharge summary for one sampled resident (#80) that included a recapitulation of the resident's stay and a final summary of the resident's status. The deficient practice could result in necessary information not being communicated at the time of discharge. Findings include: Resident #80 was admitted on (MONTH) 8, (YEAR) with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A nursing progress note dated (MONTH) 12, 2019 at 12:52 PM revealed the resident left the facility that morning at 11:50 AM. The note also revealed narcotic and prescription medications were given to the family member and that report was given to the coordinator at the assisted living facility. A discharge MDS assessment dated (MONTH) 12, 2019 revealed the resident's discharge was a planned discharge. A discharge summary progress note dated (MONTH) 31, 2019, written by the Social Service Director, revealed the resident was officially discharged from the facility on (MONTH) 12, 2019 around 11:50 AM. The note revealed the resident wanted to have a more independent living situation and that she was assessed to be capable and safe in an assisted living setting. The note included the resident and her family member had visited the assisted living facility prior to her move, and that her family member and a friend had come to the facility on (MONTH) 12 to help her move her belongings. The note also included the resident had become quite stable and pleasant during her stay at the facility, and that the resident was able to realize her goal of returning to the more independent setting. However, further review of the clinical record did not reveal a discharge summary that included a recapitulation of the resident's stay and a final summary of the resident's status at the time of discharge. An interview was conducted on (MONTH) 5, 2019 at 8:56 AM with the Director of Nursing (DON/staff #84). He stated the resident's discharge processes may have been dropped due to the fact that it was a rapid discharge. Review of the facility's policy titled Discharging the Resident revealed that if the resident is being discharged to another facility, ensure that a transfer summary is completed and telephone report is called to the receiving facility. The policy included assessing and documenting the resident's condition at discharge, including a skin assessment and documenting the assessment data.",2020-09-01
116,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2019-06-05,684,E,0,1,7VLE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interviews, and policy review, the facility failed to ensure one of eighteen sampled residents (#3) received treatment and care in accordance with professional standards of practice, by failing to conduct weekly skin assessments. The deficient practice could result in delayed identification and treatment of [REDACTED]. Findings include: Resident #3 was admitted to the facility on (MONTH) 5, 2019, with [DIAGNOSES REDACTED]. Review of the care plan dated (MONTH) 5, 2019, revealed the resident had a pressure ulcer to the coccyx related to decreased mobility. Interventions included completing weekly skin checks. A physician's orders [REDACTED]. The admission Minimum Data Set assessment dated (MONTH) 15, 2019, revealed the resident was severely cognitively impaired regarding cognitive skills for daily decision making, The assessment included the resident had a stage 3 pressure ulcer. Review of the Treatment Administration Record (TAR) for (MONTH) 2019, revealed initials that a skin assessment was conducted weekly except on (MONTH) 13. However, review of the Skin Observation Tool form only revealed skin assessments for (MONTH) 21 and 28, 2019. Review of the TAR for (MONTH) 2019, revealed initials that skin assessments were conducted weekly. However, review of the Skin Observation Tool form only revealed skin assessments for (MONTH) 14 and 21, 2019. Review of the TAR for (MONTH) and (MONTH) 2019, revealed initials that skin assessments were conducted weekly. However, review of the clinical record revealed no Skin Observation Tool forms for (MONTH) or (MONTH) 2019. An interview was conducted on (MONTH) 3, 2019 at 10:15 a.m., with a Licensed Practical Nurse (LPN/staff #39). The LPN stated that he attempts to conduct skin assessments on resident #3 on shower days because he knows the resident is at risk for skin breakdown. The LPN stated that although he regularly checks the resident's skin during shower time, he does not document the skin assessments because the scheduled weekly skin assessment is not on his shift. An interview was conducted on (MONTH) 3, 2019 at 12:44 p.m., with the Director of Nursing (DON/staff #84). The DON stated that nurses are responsible for conducting and documenting the weekly skin assessments according to the schedule on the TAR. He stated the results of the skin assessments are documented in the electronic record, and that if the results were not documented it meant the assessments were not conducted. The facility's policy regarding Resident Skin Assessments revealed the policy of the facility is to assess all residents weekly to identify risk for skin breakdown and assess current skin issues. The policy included all residents will be assessed for skin risk using the assessment available in the electronic medical record.",2020-09-01
117,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2019-06-05,727,E,0,1,7VLE11,"Based on facility documents, staff interviews, and policy review, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. Findings include: Review of the facility's daily staff posting records and the staff sign-in sheets for (MONTH) 2019 revealed there was no RN on (MONTH) 10, 2019 who provided services for at least 8 hours. Review of the daily staff posting records and the staff sign-in sheets for (MONTH) 2019 revealed that on (MONTH) 7, 21, and 28, there was no RN who provided services for at least 8 hours. Review of the daily staff posting records and the staff sign-in sheets for (MONTH) 2019 revealed that on (MONTH) 18, 25, and 26, there was no RN who provided services for at least 8 hours. An interview was conducted with the staffing coordinator (staff #119) on (MONTH) 4, 2019 at 1:23 PM. Staff #119 stated that on weekdays they have an RN on duty for at least 8 hours daily. She stated that on the weekends, they do not always have a RN who provides services for at least 8 hours. Staff #119 stated the lack of RN coverage was not due to call offs but that it is the regular schedule. An interview was conducted with the Director of Nursing (DON/staff #80) on (MONTH) 4, 2019 at 3:02 PM. The DON stated that they do not have a RN on the schedule for the weekends right now. He said RNs are hard to find. The facility's policy titled Staffing revealed the facility maintains adequate staffing on each shift to ensure that residents' needs and services are met. The policy also revealed licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services. The policy did not include the facility must use the services of a Registered Nurse for at least 8 consecutive hours a day, 7 days a week.",2020-09-01
118,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2019-06-05,757,E,0,1,7VLE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, clinical record review, and facility documentation and policy review, the facility failed to ensure that 3 of 5 sampled residents (#13, #3, and #18) were free from unnecessary medications, by failing to administer pain medications within the ordered parameters. This deficient practice could result in residents receiving medications which may not be necessary. Findings include: -Resident #13 was admitted (MONTH) 12, 2019 with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 22, 2019, revealed the resident had severely impaired cognitive skills for daily decision making. The MDS assessment also revealed the resident was receiving scheduled and as needed (PRN) pain medication and had frequent pain at a pain level of 7 on a scale of 0 to 10. The current care plan revealed the resident had pain related to chronic back and generalized pain. The goal was that the resident would be free of pain as evidenced by her subjective statement. Interventions included administering medications as ordered. Review of the Medication Administration Record (MAR) for (MONTH) 2019 revealed the resident was administered [MEDICATION NAME] 5 mg on (MONTH) 28 for a pain level of 0 and on (MONTH) 16 for a pain level of 4 and on (MONTH) 17, 18, 19, 22, 26, and 28 for a pain level of 5. Review of the MAR for (MONTH) 2019 revealed the resident was administered [MEDICATION NAME] 5 mg on (MONTH) 1 for a pain level of 0. Review of the MAR for (MONTH) 2019 revealed the resident was administered [MEDICATION NAME] 5 mg on (MONTH) 5, 7, and 20 for a pain level of 5 and on (MONTH) 27 for a pain level of 0. Review of the Consultant Pharmacist Medication Regimen Review for (MONTH) 2019 included [MEDICATION NAME] had been administered for pain rated at a 5. The review also included educating nursing on administering pain medications within the ordered parameters. However, review of the MAR for (MONTH) 2019 again revealed the resident was administered [MEDICATION NAME] 5 mg on (MONTH) 25 and 26 for a pain level of 5. Review of the clinical record revealed no documentation regarding administering [MEDICATION NAME] outside of the ordered parameters. During an interview conducted with a Registered Nurse (RN/staff #127) on (MONTH) 4, 2019 at 9:15 AM, the RN stated that the resident has Tylenol ordered for mild pain and [MEDICATION NAME] for severe pain. The RN further stated that she administers the [MEDICATION NAME] within the ordered parameters. -Resident #3 was admitted to the facility on (MONTH) 5, 2019, with [DIAGNOSES REDACTED]. Review of the care plan dated (MONTH) 5, 2019, revealed the resident had pain that appeared to be caused by musculoskeletal impairment. Interventions included utilizing a pain management flow sheet and administering pain strategies according to the MAR and Treatment Administration Record (TAR). The admission MDS assessment dated (MONTH) 15, 2019, revealed the resident had severe cognitive impairment for daily decision making. The assessment included the resident had daily non-verbal indicators of pain and received scheduled and PRN pain medication. Review of the physician orders [REDACTED]. Review of the MAR for (MONTH) 2019, revealed the resident was administered [MEDICATION NAME] 50 mg for a pain level of 0 on (MONTH) 10 and 14 and for a pain level of 4 on (MONTH) 22. A physician order [REDACTED]. Review of the MAR for (MONTH) 2019, revealed the resident was administered [MEDICATION NAME] 50 mg 2 tablets for a pain level of 6 on (MONTH) 8 and for a pain of 7 on (MONTH) 14. Review of the MAR for (MONTH) 2019, revealed the resident was administered [MEDICATION NAME] 50 mg 2 tablets for a pain level of 7 on (MONTH) 4 and 27, and for a pain level of 0 on (MONTH) 11. Review of the MAR for (MONTH) 2019, revealed the resident was administered [MEDICATION NAME] 50 mg 2 tablets for a pain level of 6 on (MONTH) 11 and 27. Review of a pharmacy consultant report dated (MONTH) 21, 2019, revealed that the resident's medications had been reviewed with the following recommendation: [MEDICATION NAME] has been given outside of parameters - please educate nursing staff that if medication is given outside of parameters, a progress note must indicate rationale for this. A handwritten note on the pharmacy review stated in-service/meeting 5/20/19. An interview was conducted on (MONTH) 3, 2019 at 12:29 p.m. with a Licensed Practical Nurse (LPN/staff #39). He stated that the resident had orders to administer [MEDICATION NAME] 50 mg 1 or 2 tablets depending on the resident's level of pain. The LPN stated that he has administered the [MEDICATION NAME] within the ordered parameters. The LPN also stated that he had never encountered a situation where he felt it was necessary to administer pain medications outside of the ordered parameters. An interview was conducted on (MONTH) 3, 2019 at 12:44 p.m. with the Director of Nursing (DON/staff #84). He stated that the expectation is that PRN pain medications be administered according to the pain parameters and the time frame ordered by the provider. The DON stated that all PRN pain medication orders should have pain parameters, and the administration of the medication should match the ordered parameters. -Resident #18 was admitted on (MONTH) 27, (YEAR) with [DIAGNOSES REDACTED]. A quarterly MDS assessment dated (MONTH) 26, (YEAR) revealed a Brief Interview for Mental Status (BIMS) score of 9 which indicated the resident had moderate impaired cognition. The assessment also included the resident received PRN pain medications. Review of the current care plan revealed the resident was on opioid medication therapy related to chronic pain. Interventions included administering [MEDICATION NAME] medications as ordered by the physician. Review of the active physician orders [REDACTED]. Review of the MAR for (MONTH) (YEAR) revealed [MEDICATION NAME] was administered for a pain level of 5 on (MONTH) 12, (YEAR). A Consultant Pharmacist's Medication Regimen Review dated (MONTH) 30, (YEAR) revealed the resident was administered PRN [MEDICATION NAME] (ordered for pain 6-10) for a pain level of 5 per the MAR for (MONTH) (YEAR). The pharmacist's recommendation was Please ensure that nursing staff is educated on importance of adhering to PRN pain scale parameters. Review of the MARs for (MONTH) (YEAR), and (MONTH) and (MONTH) 2019 revealed the PRN [MEDICATION NAME] was administered according to the ordered pain parameters. However, review of the MAR for (MONTH) 2019 revealed the resident was administered [MEDICATION NAME] on (MONTH) 4 and 9 for pain levels of 5. An interview was conducted on (MONTH) 3, 2019 at 1:32 PM with a LPN (staff #97). The LPN stated that before administering a PRN opioid pain medication, she would ask the resident to rate the pain on a scale of 1-10. She stated that if the resident's pain is below the ordered pain parameters, she would offer the resident a non-opioid [MEDICATION NAME]. An interview was conducted on (MONTH) 3, 2019 at 1:37 PM with the DON (staff #84). He stated that his expectation is for nurses to follow the physician's orders [REDACTED]. The facility's policy titled Medication Administration revealed medications must be administered in accordance with the orders. The policy also included PRN medications shall be administered per a physician's orders [REDACTED].",2020-09-01
119,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2019-06-05,758,D,0,1,7VLE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one of eight sampled residents (#39) received adequate monitoring for effectiveness of an antipsychotic medication, by failing to consistently monitor and accurately document target behaviors. The deficient practice could result in information that is not accurate regarding progress and/or decline towards the therapeutic goal. Findings include: Resident #39 was admitted on (MONTH) 26, (YEAR), with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired skills for daily cognitive decision making. The MDS assessment also included the resident had physical behaviors directed toward others such as hitting, kicking, scratching, etc. Review of the current care plan revealed the resident required [MEDICATION NAME] (antipsychotic medication) to help manage and alleviate agitation, physically aggressive, and exit seeking behavior. The goal was that the resident would be maintained on the lowest therapeutic medication dosage. Interventions included documenting any observed behavioral symptoms on the Behavior Tracking Form and reporting any untoward effects and abnormalities to the physician. The care plan also included the resident had behaviors related to dementia that included pacing or wandering the hallways into other residents' rooms and exit seeking. The goal was that the resident will have fewer episodes of exit seeking. Interventions included intervening as necessary to protect the rights and safety of other, approaching and speaking to the resident in a calm manner, diverting the resident's attention, and removing the resident from the situation. Review of the physician orders [REDACTED]. The orders included monitoring for combativeness, exit seeking, refusing care, agitation, physical aggression, wandering, and impulsivity and documenting the number of episodes observed. A review of the behavior monitoring on the Medication Administration Record [REDACTED]. Further review of the behavior monitoring on the MAR indicated [REDACTED]. However, review of the Certified Nursing Assistant (CNA) behavior note dated (MONTH) 23, 2019 at 5:45 AM, revealed the resident was very aggressive and refused to be directed when she wandered into other residents' rooms. The note included the nurse was notified and assisted the CN[NAME] Review of the CNA behavior note dated (MONTH) 26, 2019 at 7:24 PM, revealed the resident was wandering into resident rooms taking personal items and was unable to be redirected. Review of the CNA behavior note dated (MONTH) 27, 2019 at 9:48 PM revealed the resident was physically combative and rejected care. The note included the resident was punching, kicking, hitting, and grabbing staff. An interview was conducted with a Licensed Practical Nurse (staff #127) on 06/03/19 at 11:57 AM. Staff #127 stated that if behavior monitoring on the MAR indicated [REDACTED]. During an interview conducted with the Director Of Nursing (staff #84) on 06/03/19 at 1:47 PM, staff #127 stated that failure to properly monitor and document behaviors is not acceptable. The facility's policy regarding Antipsychotic Medication Use revealed nursing staff will document in detail a resident's target symptom(s). The policy also included the staff will observe, document, and report to the attending physician information regarding the effectiveness of any interventions, including antipsychotic medications. The policy further included that based on the assessing of the resident's symptoms and overall situation, the physician will determine whether to continue, adjust, or stop existing antipsychotic medication.",2020-09-01
120,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2019-06-05,880,E,0,1,7VLE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on personnel record review, observations, staff interviews, and policy review, the facility failed to ensure one of ten sampled employees (#24) had evidence of freedom from infectious [MEDICAL CONDITION] (TB) on or before the date the employee began providing services and failed to ensure containers of beverage thickener powder and protein powder were stored in a sanitary manner in four of five sampled medication carts. The deficient practice could result in the potential exposure of infectious TB and contamination of beverage thickener powder and protein powder. Findings include: -Review of the personnel file for employee #24, a Licensed Practical Nurse (LPN), revealed a hire date of (MONTH) 11, (YEAR). Review of the Employee Vaccine Record for annual TB testing revealed the LPN was administered a PPD (purified protein derivative) for TB on (MONTH) 7, (YEAR). However, the record did not reveal documentation whether the results of the test was positive or negative. An interview was conducted with the Director of Nursing (DON/staff #84) on (MONTH) 4, 2019 at 3:02 PM. After reviewing the vaccine record, the DON stated that staff #24 will have to be retested and that the LPN will be removed from the schedule until they have the results. The facility's policy regarding Employee Screening for [MEDICAL CONDITION] revealed each newly hired employee will be screened for TB infection and disease after an employment offer has been made but prior to the employee's duty assignment. The policy also included that if the skin test is negative, the employee may begin duty assignments. -During an observation conducted on (MONTH) 4, 2019 at 1:33 PM with a Licensed Practical Nurse (LPN/staff #39) of medication cart 1 on the Pine hall, a container of beverage thickener powder and a protein powder container were observed with a scoop inside with the scoop handle in contact with the powders. During an observation conducted on (MONTH) 4, 2019 at 1:42 PM with a Registered Nurse (RN/staff #127) of medication cart 1 on the Magnolia hall, a container of beverage thickener powder and a container of protein powder were observed with a scoop inside with the scoop handle in contact with the powders. During an observation conducted on (MONTH) 4, 2019 at 1:50 PM with a LPN (staff #141) of medication cart 1 on the Oak hall, a container of beverage thickener powder and a container of protein powder were observed with a scoop inside with the scoop handle in contact with the powders. During an observation conducted on (MONTH) 4, 2019 at 2:00 PM with a LPN (staff #141) of medication cart 2 on the Oak hall, a container of beverage thickener powder was observed with a scoop inside with the scoop handle in contact with the powder. An interview was conducted on (MONTH) 4, 2019 at 2:33 PM with staff #141. He stated that he keeps the scoops inside the containers because the scoops are not going to be in the container long. An interview was conducted with the Director of Nursing (DON/staff # 89) on (MONTH) 4, 2019 at 2:45 PM. He stated his expectation is that the scoops be stored separate from the containers of powders for infection control. The facility's policy titled Administering Medications revealed staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable.",2020-09-01
121,FOOTHILLS REHABILITATION CENTER,35064,2250 NORTH CRAYCROFT ROAD,TUCSON,AZ,85712,2018-06-05,645,E,0,1,9O9Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy, the facility failed to ensure two residents (#16 and #96) had a PASARR (Pre-admission Screening and Resident Review) Level II completed. Findings include: -Resident #16 was admitted on (MONTH) 16, (YEAR), with [DIAGNOSES REDACTED]. Review of the quarterly MDS (Minimum Data Set) assessment dated (MONTH) 20, (YEAR), revealed a BIMS (Brief Interview for Mental Status) score of 15 which indicated the resident was cognitively intact. Review of the PASARR Level I evaluation dated (MONTH) 22, (YEAR), revealed that if a resident's primary [DIAGNOSES REDACTED]. However, review of the clinical record did not reveal any documentation that a PASARR Level II was conducted. An interview was conducted with the social worker (staff #100) on (MONTH) 22, (YEAR) at 11:00 a.m. She stated a PASARR level I was conducted and that a PASARR Level II should have been completed due to the resident's mental illness diagnoses. She stated that a PASARR Level II had not been conducted. -Resident #96 was admitted to the facility on (MONTH) 31, (YEAR), with [DIAGNOSES REDACTED]. Review of the annual MDS (Minimum Data Set) assessment dated (MONTH) 4, (YEAR), revealed a BIMS (Brief Interview for Mental Status) score of 15 which indicated the resident was cognitively intact. The quarterly MDS assessment dated (MONTH) 29, (YEAR), revealed a BIMS score of 6 which indicated the resident's cognition was severely impaired. Review of the PASARR level I screening document revealed a PASARR level II evaluation needed to be completed for a [DIAGNOSES REDACTED]. Further review of the clinical record revealed no PASARR level II screening documentation. An interview was conducted with the social worker (staff #100) on (MONTH) 24, (YEAR) at 1:52 p.m. She stated that she had identified that the previous social worker had not been completing the PASARR screening process appropriately. She stated that when the prior staff member completed a level 1 screening and identified the need for a level II screening; the paperwork was not forwarded to the State PASARR Coordinator. The social worked stated that she called the state coordinator and was notified that the paperwork was never received on resident #96. She stated that once it is identified that a resident will need a level II screening, the paperwork must be sent promptly to the state coordinator. An interview was conducted with the Administrator (staff #161) on (MONTH) 24, (YEAR) at 2:05 p.m. He stated that he expects the PASARR screening to be completed correctly at admission and forwarded to the State PASARR Coordinator if a level II screening is identified upon admission. He stated that the staff member completing the form did not follow the facility's policy. The facility's policy's regarding PASARR revealed that if required by the State Medicaid Program, a PASARR screen for Mental Illness or Developmental Disabilities must be completed on all potential residents. If the Level I screen is referred for a Level II screen, a referral will be made to the appropriate agency for determination and recommendations for care.",2020-09-01
122,FOOTHILLS REHABILITATION CENTER,35064,2250 NORTH CRAYCROFT ROAD,TUCSON,AZ,85712,2018-06-05,658,D,0,1,9O9Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy and procedure, the facility failed to ensure one resident (#72) received pain medications as ordered by the physician. Findings include: Resident #72 was readmitted to the facility on (MONTH) 06, (YEAR), with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. The admission Minimum Data Set assessment dated (MONTH) 13, (YEAR), revealed a Brief Interview of Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact. Review of the Medication Administration Record [REDACTED] April 12, (YEAR): [MEDICATION NAME] 650 mg was administered for a pain level of 5. April 14, (YEAR), [MEDICATION NAME] 650 mg was administered for a pain level of 8. April 15, (YEAR), [MEDICATION NAME] 650 mg was administered for a pain level of 8. April 17, (YEAR), [MEDICATION NAME] 650 mg was administered for a pain level of 8. April 18, (YEAR), [MEDICATION NAME] 650 mg was administered for a pain level of 8. April 20, (YEAR), [MEDICATION NAME] 650 mg was administered for a pain level of 6. April 21, (YEAR), [MEDICATION NAME] 650 mg was administered for a pain level of 8. May 2, (YEAR), [MEDICATION NAME] 650 mg was administered for a pain level of 7. May 7, (YEAR), [MEDICATION NAME] 650 mg was administered for a pain level of 5. May 10, (YEAR), [MEDICATION NAME] 650 mg was administered for a pain level of 6. May 13, (YEAR), [MEDICATION NAME] 650 mg was administered for a pain level of 6. May 14, (YEAR), [MEDICATION NAME] 650 mg was administered for a pain level of 6. An interview was conducted on (MONTH) 24, (YEAR) at 1:23 p.m. with a Licensed Practical Nurse (LPN/staff #251). The LPN stated before administering a pain medication to a resident, she asks the resident their pain level, the location of the pain, and the type of pain. She stated that if the resident has two different pain medications ordered, she will administer the medication based on the resident's pain level per the physician order. Staff #251 stated that if the pain level does not match the order, she cannot administer the medication. During an interview conducted with the Director of Nursing (DON/staff #175) on (MONTH) 24, (YEAR) at 2:07 p.m., the DON stated that the expectation is that a pain assessment be completed every shift. Staff #175 stated that if multiple as needed pain medications are ordered, the pain medication is administered per the physician's orders [REDACTED]. The facility's policy and procedure regarding administering pain medications included to administer pain medications as ordered.",2020-09-01
123,FOOTHILLS REHABILITATION CENTER,35064,2250 NORTH CRAYCROFT ROAD,TUCSON,AZ,85712,2018-06-05,690,D,0,1,9O9Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and staff interviews, the facility failed to ensure the tubing of an indwelling urinary catheter was correctly secured within the locking mechanism to prevent pulling at the insertion site for one resident (#79). Findings include: Resident #79 was readmitted to the facility (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. The significant change minimum data set (MDS) assessment dated (MONTH) 21, (YEAR), revealed a Brief Interview of Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The assessment also included the use of an indwelling urinary catheter and a [DIAGNOSES REDACTED]. Review of the care plan dated (MONTH) 4, (YEAR), revealed that the resident had a indwelling urinary catheter related to a [MEDICAL CONDITION] bladder. Review of the quarterly MDS assessment dated (MONTH) 15, (YEAR), revealed the resident had a indwelling urinary catheter and a [DIAGNOSES REDACTED]. An observation of the indwelling urinary catheter care was conducted on (MONTH) 23, (YEAR) at 8:53 a.m. with certified nursing assistants (CNA/staff #'s 59 and 238). The resident was observed supine in bed with the indwelling urinary catheter tubing pulled to the right side of the bed, connected to the drainage bag. When staff lifted the penis to perform care, the penis was noted to be eroded over half way down the shaft and the tubing was pulling at a right angle. A locking mechanism for the tubing was observed to be adhered to the resident's right thigh, however, the tubing was not properly secured within the unit and continued to pull and thread back and forth within the ring. The Y of the tubing was observed between the lock and the drainage bag and not within the lock. There was no tubing slack between the lock and the penis. The resident's incontinence pad was removed by turning the resident from side to side. No support was provided by staff to keep the indwelling catheter tubing from pulling during provision of care. An interview was conducted with CNA/staff #238 on (MONTH) 23, (YEAR) at 9:29 a.m. She stated that she had received training on proper indwelling urinary catheter (Foley) care. She stated that the indwelling urinary catheter tubing needs to be secured on the resident's leg to keep the tubing from pulling. The CNA stated that the Y connection of the tubing should be secured into the lock to prevent pulling. She stated that if the tubing is moving around within the lock and the Y connection is between the lock and the bag then it is not appropriately applied. The CNA stated that she noticed that there was no slack in the tubing when she was assisting with care and that she should have repositioned the tubing in the lock. An interview was conducted with a Registered Nurse (RN/staff #11) on (MONTH) 23, (YEAR) at 9:35 a.m. She stated that the indwelling urinary catheter lock should be on the Y part of the tubing so that the tubing does not pull. She stated that the tubing should not be pulling on the penis because that could cause bleeding, skin irritation, blood in the urine, pain, and skin breakdown. The RN stated that the CNAs should have seen that the tubing was incorrectly secured in the lock and should have corrected the tubing placement. During an interview conducted with a Licensed Practical Nurse (LPN/staff #159) on (MONTH) 23, (YEAR) at 9:46 a.m., she stated that the CNAs should correct a tubing placement in the Foley lock that is incorrectly placed. She stated that if the indwelling urinary catheter tubing is not placed correctly in the (Foley) lock, it can cause pulling which could cause damage to the penis. An interview was conducted with the Director of Nursing (DON/staff #175) on (MONTH) 24, (YEAR) at 1:12 p.m. She stated that the CNAs receive training on indwelling urinary catheter care upon hire and annually. The DON stated that if the tubing is incorrectly applied into the locking mechanism and there is no slack in the tubing; the CNAs should correct the placement of the tubing. She stated that if the indwelling urinary catheter tubing is pulling it can cause irritation and erosion at the entry site.",2020-09-01
124,FOOTHILLS REHABILITATION CENTER,35064,2250 NORTH CRAYCROFT ROAD,TUCSON,AZ,85712,2017-08-24,157,D,1,0,B1LU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical review, staff interviews, and review of facility policies and procedures, the facility failed to immediately notify one resident's (#1) physician following a fall which resulted in a change of condition. The sample size was three. Findings include: Resident #1 was readmitted to the facility on (MONTH) 18, (YEAR) with [DIAGNOSES REDACTED]. Review of an Event Report dated (MONTH) 20, (YEAR) revealed the resident sustained [REDACTED]. this resident's room. Upon arrival this writer found patient lying on the floor on his left side. The Event Report further documented .What appears to be the root cause of the fall? Altered mental status from baseline . Review of the clinical record revealed a Neurological Flow Sheet dated (MONTH) 20, (YEAR). The Neurological Flow Sheet revealed that a neurological assessment was completed at the time of the fall and that the resident refused further neurological assessments. There was no documented evidence in the clinical record that the resident's physician was notified that the resident refused further neurological assessments. A Respiratory Therapy Note dated (MONTH) 20, (YEAR) at 3:40 a.m. documented LPN (licensed practical nurse) came to get me for assessment. Patient confused awake and would not keep oxygen on. Patient stated he didn't want oxygen and refused all oxygen and physically took oxygen off when I tried. SAT (oxygen saturation level) was at 60-78%. I attempted many times to place oxygen on patient then asked LPN what he wanted me to do, He said he would call me if patient got any worse and someone would be in the room with him. There was no documented evidence in the clinical record that the resident's physician was notified of the low oxygen saturation levels and the refusal of oxygen. Resident Progress Notes dated (MONTH) 20, (YEAR) at 4:20 a.m. documented A loud sound was heard of 'HELP' coming from this resident room shortly after midnight, Upon arrival this writer found patient lying on the floor on his left side. Resident unable to explain what happened when asked. Complete body assessment was done that revealed no visible injury. Resident denies pain. He was assisted by the 3 person (transfer) to get back to bed. Neuro checks were initiated, that resident refused. Made several attempts to have oxygen on but refused. Provider, case manager, and DON will be notified. There was no documented evidence in the clinical record that the resident's physician was notified of the resident's fall, refusal of neurological assessments, and the refusal of oxygen. Resident Progress Notes dated (MONTH) 20, (YEAR) at 5:30 a.m. documented Upon entering the room patient was found. Patient was unresponsive, no carotid pulse present, no radial pulses present, no apical pulse present, no blood pressure auscultated, no respirations nor chest movement noted. Pupils fixed dilated. Patient had 'passed' and is a DNR (do not resuscitate). Placed a call to provider service and notified them that resident had passed. Left message to the case manager also. An interview was conducted with an RN (registered nurse), staff #74 (this staff member was a LPN at the time of the incident) on (MONTH) 18, (YEAR) at 8:45 a.m. Staff #74 stated that if a resident has a fall without injury, the resident's physician is notified the next day. Staff #74 stated that if a fall is unwitnessed, a neurological assessment should be done right after the fall. Staff #74 stated that the resident allowed him to complete the first neurological assessment but refused further assessments. Staff #74 stated he was going to call the resident's physician at the end of his shift (approximately 6:00 a.m.) of the resident's fall and the refusal of neurological assessments. An interview was conducted with another RN, staff #93 on (MONTH) 23. (YEAR) at 8:00 a.m. Staff #93 stated that he was working on another unit at the time of the resident's fall. Staff #93 stated that staff #74 asked him to assess the resident when he noticed that the resident's oxygen saturation levels were low. Staff #93 stated that the resident's oxygen saturation levels were about 91% and the resident did not appear to have any injuries from the fall. An interview was conducted with the DON (director of nursing) staff #266 on (MONTH) 24, (YEAR) at 11:30 a.m The DON stated that it was facility policy if a resident sustained [REDACTED]. The DON stated that the licensed nurse did not feel the resident sustained [REDACTED]. A review of the facility's policy Post Fall Protocol documented .When a fall results in a significant injury or condition change, nursing staff will notify the practitioner immediately by phone .",2020-09-01
125,FOOTHILLS REHABILITATION CENTER,35064,2250 NORTH CRAYCROFT ROAD,TUCSON,AZ,85712,2017-08-24,309,D,1,0,B1LU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, and review of facility policies and procedures the facility failed to ensure that one resident (#1) was provided the necessary care and services following a fall. The sample size was three. Findings include: Resident #1 was readmitted to the facility on (MONTH) 18, (YEAR) with [DIAGNOSES REDACTED]. Review of an Event Report dated (MONTH) 20, (YEAR) revealed the resident sustained [REDACTED]. this resident's room. Upon arrival this writer found patient lying on the floor on his left side. The Event Report further documented .What appears to be the root cause of the fall? Altered mental status from baseline . Review of the clinical record revealed a Neurological Flow Sheet dated (MONTH) 20, (YEAR). The Neurological Flow Sheet revealed that a neurological assessment was completed at the time of the fall and that the resident refused further neurological assessments. A Respiratory Therapy Note dated (MONTH) 20, (YEAR) at 3:40 a.m. documented LPN (licensed practical nurse) came to get me for assessment. Patient confused awake and would not keep oxygen on. Patient stated he didn't want oxygen and refused all oxygen and physically took oxygen off when I tried. SAT (oxygen saturation level) was at ,[DATE]%. I attempted many times to place oxygen on patient then asked LPN what he wanted me to do, He said he would call me if patient got any worse and someone would be in the room with him. Resident Progress Notes dated (MONTH) 20, (YEAR) at 4:20 a.m. documented A loud sound was heard of 'HELP' coming from this resident room shortly after midnight, Upon arrival this writer found patient lying on the floor on his left side. Resident unable to explain what happened when asked. Complete body assessment was done that revealed no visible injury. Resident denies pain. He was assisted by the 3 person (transfer) to get back to bed. Neuro checks were initiated, that resident refused. Made several attempts to have oxygen on but refused. Provider, case manager, and DON will be notified. Review of the clinical record revealed a neurological assessment was done at 12:40 a.m. when the resident fell . There was no evidence that the resident had been monitored after the time of the fall except for the assessment by the respiratory therapist at 3:40 a.m. Resident Progress Notes dated (MONTH) 20, (YEAR) at 5:30 a.m. documented Upon entering the room patient was found. Patient was unresponsive, no carotid pulse present, no radial pulses present, no apical pulse present, no blood pressure auscultated, no respirations nor chest movement noted. Pupils fixed dilated. Patient had 'passed' and is a DNR (do not resuscitate). Placed a call to provider service and notified them that resident had passed. Left message to the case manager also. Resident Progress Notes dated (MONTH) 20, (YEAR) at 5:43 a.m. documented At 1:00 a.m. charge nurse on unit 300 reported patient fell at approximately 12:00 a.m. Upon entering room patient was sleeping, no grimacing, nor any other signs and symptoms of pain/discomfort. Unit 300 nurse reported no apparent injuries from the fall. An interview was conducted with a respiratory therapist, staff #217 on (MONTH) 18, (YEAR) at 8:25 a.m. The respiratory therapist stated that when the resident continued to refused his oxygen, he reported it to the LPN (licensed practical nurse), staff #74 and that a CNA (certified nursing assistant) went in to the resident's room. An interview was conducted with a CNA, staff #110 on (MONTH) 18, (YEAR) at 1:00 p.m. The CNA stated that after the resident fell , he and the LPN, staff #74 were going into the resident's room all the time to monitor for changes in the resident's condition. The CNA further stated that he did not document this. An interview was conducted with an RN (registered nurse), staff #74 on (MONTH) 18, (YEAR) at 8:45 a.m. Staff #74 was a LPN at the time of the incident. Staff #74 stated that the resident did not appear to have any injuries after the fall. Staff #74 stated that the resident allowed him to complete the first neurological assessment after the fall but refused further assessments. Staff #74 stated that the resident went back to sleep after the fall. Staff #74 stated that he was going to call the resident's physician at the end of his shift (approximately 6:00 a.m.) to notify him of the resident's fall, refusal of neurological assessments, and refusal of oxygen. When asked what monitoring was done after the resident fell prior to being deceased , staff #74 stated that he checked on the resident every 30 minutes but did not document this. Staff #74 further stated that the CNA (staff #110) checked on the resident every two hours. An interview was conducted with the DON (director of nursing) staff #266 on (MONTH) 24, (YEAR) at 11:30 a.m. The DON stated that the staff #74 did not feel the resident sustained [REDACTED]. A review of the facility's Post Fall Protocol documented .Nursing staff will observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall, and will document findings in the medical record. Documentation will include any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in level of responsiveness/consciousness and overall function. It will note the presence or absence of significant findings .",2020-09-01
126,FOOTHILLS REHABILITATION CENTER,35064,2250 NORTH CRAYCROFT ROAD,TUCSON,AZ,85712,2017-08-24,387,D,1,0,B1LU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interview, and review of facility policies and procedures, the facility failed to ensure that one resident (#1) was seen by a physician at least every 60 days. The sample size was three. Findings include: Resident #1 was readmitted to the facility on (MONTH) 18, (YEAR) with [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed a Physician's Progress Note dated (MONTH) 20, (YEAR). Further review of the clinical record revealed the resident was not seen by a physician again until (MONTH) 8, (YEAR). The clinical record revealed no evidence that the resident was seen by his physician in (MONTH) (YEAR). An interview was conducted with the director of nursing (DON), staff #266 on (MONTH) 24, (YEAR) at 9:00 a.m. The DON stated that on (MONTH) 17, (YEAR), when the facility identified the resident was not seen by his physician as required, the facility audited all resident clinical records to ensure compliance. The DON further stated that the facility is currently conducting monthly audits to ensure continued compliance. A review of the facility's policy Physician Services documented .Physician visits, frequency of visits .are provided in accordance with OBRA (Omnibus Budget Reconciliation Act of 1987) regulations and facility policy .",2020-09-01
127,PUEBLO SPRINGS REHABILITATION CENTER,35068,5545 EAST LEE STREET,TUCSON,AZ,85712,2017-05-25,225,D,1,1,NL7T12,Deficiency Text Not Available,2020-09-01
128,PUEBLO SPRINGS REHABILITATION CENTER,35068,5545 EAST LEE STREET,TUCSON,AZ,85712,2017-05-25,226,D,1,1,NL7T12,Deficiency Text Not Available,2020-09-01
129,PUEBLO SPRINGS REHABILITATION CENTER,35068,5545 EAST LEE STREET,TUCSON,AZ,85712,2017-05-25,323,D,1,1,NL7T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, resident and staff interviews, and policies and procedures, the facility failed to provide adequate supervision to one resident (#67) with behaviors, in order to prevent a resident to resident altercation with one resident (#160). Findings include: -Resident #160 was admitted to the facility on (MONTH) 3, (YEAR), with a [DIAGNOSES REDACTED]. Review of the quarterly MDS (Minimum Data Set) assessments dated (MONTH) 21, (YEAR) and (MONTH) 15, (YEAR), revealed a BIMS (Brief Interview for Mental Status) score of 15, which indicated the resident was cognitively intact. The resident was also identified to require extensive assistance with bed mobility and transfers. Review of an ADL (Activities of Daily Living) care plan revealed the resident had limited ability with ADLs. An approach included to provide extensive assist of two with toileting, transfers and bed mobility. -Resident #67 was admitted to the facility on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. A review of an admission MDS assessment dated (MONTH) 16, (YEAR) revealed a BIMS score of 6, which indicated that the resident had severe cognitive impairment. Under the behavior section, it was documented that the resident had no physical or verbal behaviors toward others. Review of a facility's Reportable Event Record/Report dated (MONTH) 18, (YEAR) revealed a resident (#80) reported to the social services director that her roommate (resident #67) verbally threatened her by saying, I'm going to kick your a---. The Social Services Director and the Director of Nursing spoke with resident #67, who admitted that she had made the above statement to resident #67. The resident (#80) agreed to and transferred to another room. Review of the clinical record revealed there were no additional interventions which were implemented for resident #67. There was also no care plan which was initiated at this time, with any additional interventions to address this behavior. According to a nurses note dated (MONTH) 30, (YEAR), the resident (#67) had a mental breakdown around 2:30 p.m. The resident was yelling at people and telling them to get out of her house. She also attacked a resident, pulling on the resident's gown. The resident was trying to hit anyone walking by. Review of the facility's Reportable Event Record/Report dated (MONTH) 30, (YEAR) revealed the following incident: Resident #67 began yelling at people and was then observed attempting to pull a gown off of another resident (#310). This incident occurred in the West unit dining room. Resident #67 was separated from other residents and was transported out of the facility for a psych evaluation. Per the clinical record documentation, the resident was readmitted back to the facility on (MONTH) 6, (YEAR). However, there were no additional interventions or any increased supervision which was implemented to prevent further altercations. In addition, there was no care plan which was developed upon readmission to address the resident's verbal and physical aggression. A quarterly MDS assessment dated (MONTH) 16, (YEAR) included that the resident did not have any verbal or physical behaviors toward others. According to another Reportable Event Record/Report dated (MONTH) 23, (YEAR), resident #67 was in the dining room at approximately 7:15 p.m. and began punching another resident (#149) on the right shoulder. Staff immediately intervened and separated both residents. When resident was asked why she began hitting the resident, she responded that she did not know why. Interventions implemented after the incident included the following: resident was removed from the dining room and moved to another dining room; care plan initiated for physical/aggressive behaviors and staff were to monitor resident for signs/symptoms of aggression. Review of a care plan dated (MONTH) 23, (YEAR) revealed the resident had a recent episode of being physically/combative/abusive and was striking out at peers. The goal was that the resident would not harm self or others, secondary to socially inappropriate and/or disruptive combative behaviors. Approaches included the following: Ensure distance in seating other residents around resident; observe whether the behavior endangers the resident and/or others; intervene if necessary removing others from the surrounding area; and when resident is noted with aggressive mood provide direct simple reminders. The goal is to protect resident and others. Another care plan dated (MONTH) 23, (YEAR) addressed the resident had episodes of verbal aggression such as threatening, screaming and cursing at others. Approaches included to monitor whether the behavior endangers the resident or others and intervene; redirect conversation when the resident becomes verbally abusive; and remove resident from group activities when behavior is unacceptable. Although, the care plans included for behavior monitoring to be done, the care plans nor the clinical record reflected that any additional interventions or any increased supervision was provided, despite the resident having three episodes of aggressive behaviors toward residents. Review of a Reportable Event Record/Report revealed that on (MONTH) 6, (YEAR) in the early morning., resident #160 was resting in her bed when resident #67 went into her room and grabbed her neck and scratched the left side of her face, knocking off her glasses. The resident sustained [REDACTED]. Further review of the report revealed a licensed practical nurse (LPN/staff #125) was called down to resident #67's room. Resident #67 had a CNA (staff #5) by her arms and was cursing and striking out at staff. Resident #67 was removed from the area. Staff #125 then heard resident #160 calling out from her room. Staff #125 entered her room and resident #160 was upset, because resident #67 had grabbed her by the neck. 911 was called and resident (#67) was sent out for psychiatric care and would not be returning to the facility. A social services note dated (MONTH) 8, (YEAR) included .Due to (resident #67's) dementia and aggressive behavior, resident requires more specialized services such as a dementia unit or behavioral unit and did not return to the facility. An interview was conducted with resident #160 on (MONTH) 25, (YEAR) at 10:30 a.m. The resident stated that she never met resident #67 before. The resident stated that she was in her bed when resident #67 came in her room and told her to get the f--- out of my home and pulled on her face. She said she was lying in bed and was unable to do anything to stop resident #67. An interview was conducted with a LPN (staff #125) on (MONTH) 25, (YEAR) at 10:46 a.m. Staff #125 stated that on (MONTH) 6, she heard a CNA (staff #5) yelling help, help, help. Staff #125 stated that resident #67 had staff #5 against the wall near resident #160's room. Staff #125 stated that she separated the CNA and resident #67. Staff #125 stated she then heard resident #160 yell out, so she went into her room. Staff #125 stated that resident #160 told her that resident #67 attacked her. She said the resident's glasses were broken and she had scratches and bruises on her neck. An interview was conducted with another LPN (staff #10) on (MONTH) 25, (YEAR) at 11:10 a.m. Staff #10 stated that if residents are involved in a resident to resident altercation, the DON (Director of Nursing), the Administrator, physician and social worker are notified. Staff #10 stated that a meeting is then held to evaluate new interventions to prevent further incidents. An interview was conducted with the social worker (staff #21) on (MONTH) 25, (YEAR) at 11:25 a.m. Staff #21 stated that if residents are involved in an altercation, a care plan is initiated regarding new interventions. Staff #21 stated that he thought the situation was building. Staff #21 stated that resident #67 was involved in a verbal incident in (MONTH) (YEAR). He stated that resident #67 was examined by a psychiatric nurse practitioner on (MONTH) 20, (YEAR), and there were no new recommendations. Staff #21 further stated that resident #67's first physical altercation occurred on (MONTH) 18, (YEAR) (however, an episode occurred on (MONTH) 30, (YEAR)). Staff #21 stated that the facility thought this incident was a one time incident. An interview was conducted with a CNA (staff #5) on (MONTH) 25, (YEAR) at 11:50 a.m. Staff #5 stated that on (MONTH) 6, (YEAR), resident #67 was acting like she was having a psychotic breakdown and was acting deranged. Staff #5 stated that after resident #67 attacked resident #160, she pushed her up against the wall. Staff #5 stated that resident #67 was screaming if you don't get the f---out of my house, I am going to kill you. An interview was conducted with the DON (staff #91) on (MONTH) 25, (YEAR) at 1:46 p.m. The DON stated that if a resident is involved in an altercation, the facility attempts to find out the root cause and make adjustments to the resident's environment and medications. Regarding the (MONTH) incident, the DON stated they believed it was more of a reaction, as the other resident bumped into resident #67. The DON further stated that the facility never thought that the resident would attack staff and resident #160. The facility was unable to provide any documentation that additional interventions including increased supervision were provided to resident #67, prior to the (MONTH) 6 episode. Review of a policy regarding Safety and Supervision of Residents revealed .Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .Resident supervision is a core component of the system approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs .The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased .if there is a change in the resident's condition .",2020-09-01
130,PUEBLO SPRINGS REHABILITATION CENTER,35068,5545 EAST LEE STREET,TUCSON,AZ,85712,2019-06-13,607,D,1,0,M0NY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interview, review of facility documentation, and review of facility policies and procedures, the facility failed to implement their abuse policy regarding reporting and investigating an allegation of physical abuse for one resident (#3). The deficient practice could result in the potential for abuse to be ongoing, unreported and uninvestigated. Findings include: Resident #3 was readmitted to the facility on (MONTH) 10, 2019 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated (MONTH) 17, 2019 revealed the resident's BIMS (Brief Interview for Mental Status) score was a 12 (moderately impaired cognition). Review of a Social Services Note dated (MONTH) 7, 2019 at 4:01 p.m. documented This morning writer was in hallway by patient's room when she started to yell repetitive 'she hit me with her hand' when LNA (licensed nursing assistant) and LPN (licensed practical nurse) walked out of the room after finishing her care. Writer asked what happened? Patient stated 'aide hit me with her hand.' A few minutes later therapists arrived to get her up. Patient then stated 'the nurse hit me with a clip board.' Patient is a two person care given past allegations. It was noted staff did not have a clip board when in the room. Executive director, director of nursing, and assistant director of nursing notified of the above. Review of facility documentation revealed no evidence that the allegation of abuse was reported to the State Survey Agency and adult protective services. Further review of facility documentation revealed no evidence that the facility conducted a thorough investigation regarding the allegation of abuse. An interview was conducted with the administrator (staff #18) on (MONTH) 12, 2019 at 12:40 p.m. Staff #18 stated that it was facility policy to report all allegations of abuse to the State Survey Agency and adult protective services. Staff #18 stated that it was also facility policy to thoroughly investigate all allegations of abuse. Staff #18 further stated that the reason why he did not report and investigate the allegation of abuse was because two staff were in the resident's room at the time the allegation was made. Review of the facility's policy Abuse: Prevention of and Prohibition Against dated (MONTH) 28, (YEAR) documented .All allegations of abuse .will be promptly and thoroughly investigated by the Administrator or his/her designee .Allegations of abuse .will be reported outside the Facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations .",2020-09-01
131,PUEBLO SPRINGS REHABILITATION CENTER,35068,5545 EAST LEE STREET,TUCSON,AZ,85712,2019-06-13,609,D,1,0,M0NY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, review of facility documentation, and review of facility policies and procedures, the facility failed to ensure that an allegation of physical abuse for one resident (#3) was reported to the State Survey Agency and adult protective services. The deficient practice could result in the potential for abuse to be ongoing, unreported and uninvestigated. Findings include: Resident #3 was readmitted to the facility on (MONTH) 10, 2019 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated (MONTH) 17, 2019 revealed the resident's BIMS (Brief Interview for Mental Status) score was a 12 (moderately impaired cognition). A care plan dated (MONTH) 21, 2019 revealed the resident had an anxiety disorder. An intervention documented was Monitor/record occurrence of for target behavior symptoms pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others . Review of a Social Services Note dated (MONTH) 7, 2019 at 4:01 p.m. documented This morning writer was in hallway by patient's room when she started to yell repetitive 'she hit me with her hand' when LNA (licensed nursing assistant) and LPN (licensed practical nurse) walked out of the room after finishing her care. Writer asked what happened? Patient stated 'aide hit me with her hand.' A few minutes later therapists arrived to get her up. Patient then stated 'the nurse hit me with a clip board.' Patient is a two person care given past allegations. It was noted staff did not have a clip board when in the room. Executive director, director of nursing, and assistant director of nursing notified of the above. A Nursing Note dated (MONTH) 7, 2019 at 4:15 p.m. documented Approximately 11:00 a.m. this writer heard loud yelling from room. This writer knocked and entered room, noted patient lying on bed turned on left side, as CNA (certified nursing assistant) doing peri-care. Patient yelling out at CNA while doing peri-care. This nurse assisted with task. CNA explained to patient to keep right hand off buttock, due to patient scratching buttock. CNA explained she cleaned patient's hand due to BM (bowel movement) on hand and under fingernails. Patient at that time stated CNA hit her hand. Hand checked and no bruise and no swelling/bump noted. CNA explained to patient that she had to clean her hand and at that time, swung at CNA with right hand. Patient yelled at CNA swearing that she is a 'b----' and 'lies.' Stated 'I want to file a report.' Social services, director of nursing made aware. Patient continued to yell out loudly from room, reassured patient. Patient stated that CNA hit her with a 'clipboard.' This nurse explained to patient that CNA did not have a clipboard during pericare and stated 'you are taking her side.' Reassured patient that nurse supervisor is aware. Transferred out to [MEDICAL TREATMENT] as scheduled. Another Nursing Note dated (MONTH) 7, 2019 at 4:44 p.m. documented Received call from [MEDICAL TREATMENT] staff and reported that patient stated she wants to file a complaint on '(staff #103) for hitting her hand with a clipboard.' [MEDICAL TREATMENT] given information that assistant director of nursing and social services are aware of report. Will follow up with patient's concern. Social services aware. Review of a Nursing Note dated (MONTH) 7, 2019 at 9:15 p.m. documented Received a call earlier from [MEDICAL TREATMENT] waiting to be picked up. Called assistant director of nursing for transport arrangements. 9:45 p.m. received a call from (name of hospital) case manager. Patient is in emergency room with same allegation as earlier. Placed a call to administrator and assistant director of nursing for updates. Further review of the clinical record revealed no evidence that the allegation of physical abuse was reported to the State Survey Agency and adult protective services. A written statement by the administrator (staff #18) dated (MONTH) 7, 2019 documented This writer spoke with CNA (staff #103) and LPN (staff #37) on (MONTH) 7, 2019 at approximately 10:00 a.m. This writer was across the hall when hearing patient screaming for help, and witnessed (staff #103) exiting the room to get assistance from (staff #37). (Staff #103) had indicated she was trying to assist in cleaning (resident #3), but kept putting her hand near her butt to scratch at wound, and feces would continue to be on her hand. She was throwing her arms everywhere.[NAME]needed assistance to help redirect (resident #3) and went and got (staff #37). Once (staff #37) entered the room they both assisted her in getting changed. (Resident #3) then stated 'you just hit me with a clipboard', when neither employee had a clipboard in the room. After speaking with (staff #37), (staff #37) indicated the same. She entered the room to help calm down and re-direct (resident #3). During that time in the room is when she stated one of them hit her with a clipboard. This writer then spoke to (resident #3) around 10:45 a.m. to further look into her complaint of someone hitting her with a clipboard. (Resident #3) was hard to follow in conversation. I asked her if she knew who hit her with the clipboard, and she couldn't name an employee. I asked when it occurred, and she stated it occurred when 'those two women were trying to clean me in my room.' I followed up and said 'so while the nurse and the CNA were in the room together is when one of them hit you with a clipboard, and she said yes'. Review of a written statement by a CNA (staff #103) dated (MONTH) 10, 2019 documented I (staff #103) walk in to the room. (Resident #3) was yelling loud I need to be changed. She said I will help in a little bit. Got my stuff ready to change her but still yelling at me. Put her head (of the bed) down to start changing her so I took her brief off. She was full of BM .was very dirty with BM. So she puts her right hand to scratch herself. Ask her not put her hands in because of the BM but she didn't care. Trying to clean her and starts swinging at me. Trying to hit me with her hand all full of BM. I moved and she kept swinging at me. Open the door and call my charge nurse to come help me finish changing her and all this time she was still yelling and saying stop hitting me and told charge nurse that I was hitting her . Review of a written statement by a occupational therapist (staff #34) dated (MONTH) 10, 2019 documented I entered (resident #3's) room for occupational therapy session. Upon entering patient screaming 'It hurts!' 'She hit me and my hand hurts.' I did not witness patient being hit, just heard her repeatedly yell about it and the pain she was in. Patient repeatedly stated it was the nurse who hit her because she was angry at patient for not being able to get out of bed. I attempted to look at patient's hand and noticed redness over knuckles. Patient insisted she would file a report. I informed patient I would notify nurse on duty. All of this time the director of social services was in the room, trying to calm down resident. A written statement by a therapy aide (staff #24) dated (MONTH) 10, 2019 documented On (MONTH) 7, 2019 I the rehabilitation technician for therapy walked in (resident #3's) room because she was screaming it hurts. I then asked her what was hurting. She said her hand, don't recall which one. (Resident #3) said the nurse hit her with a clipboard. I asked her which nurse, then she said she hit me which was the therapists. It was was clear that (resident #3) didn't know who hit her as she kept saying different people hit her .(Resident #3) also said CNA (staff #103) hit her. An interview was conducted with an LPN (staff #8) on (MONTH) 12, 2019 at 12:00 p.m. Staff #8 stated that if she received an allegation of abuse no matter if she thought it was credible or not it was her responsibility to report the allegation to the State Survey Agency. Staff #8 stated that she would also report the allegation to the administrator immediately. An interview was conducted with another LPN (staff #63) on (MONTH) 12, 2019 at 12 :12 p.m. Staff #63 stated that if she received an allegation of abuse she would immediately notify the administrator and director of nursing because they have two hours to report the allegation to the State Survey Agency. An interview was conducted with the social worker (staff #47) on (MONTH) 12, 2019 at 12:16 p.m. Staff #47 stated that if the DON and the administrator were not available that she would report an allegation of abuse to the State Survey Agency. Staff #47 stated that she was outside the resident's room when the allegation was made but the door to the resident's room was closed because care was being provided. Staff #47 stated that she reported the allegation to the administrator immediately. An interview was conducted with the administrator (staff #18) on (MONTH) 12, 2019 at 12:40 p.m. Staff #18 stated that the reason why he did not report the allegation of abuse is because two staff were with the resident at the time the allegation was made. Staff #18 also stated that there was not a clipboard in the resident's room. Staff #18 further stated that he felt the allegation was unsubstantiated because of two staff being with the resident at the time the allegation was made. A review of the facility's policy Abuse: Prevention of and Prohibition Against dated (MONTH) 28, (YEAR) documented .Allegations of abuse .will be reported outside the facility and to the appropriate State or Federal agencies in the applicable timeframes .",2020-09-01
132,PUEBLO SPRINGS REHABILITATION CENTER,35068,5545 EAST LEE STREET,TUCSON,AZ,85712,2019-06-13,610,D,1,0,M0NY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interview, review of facility documentation, and review of facility policies and procedures, the facility failed to ensure that an allegation of physical abuse for one resident (#3) was thoroughly investigated. The deficient practice could result in the potential for abuse to be ongoing and uninvestigated. Findings include: Resident #3 was readmitted to the facility on (MONTH) 10, 2019 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated (MONTH) 17, 2019 revealed the resident's BIMS (Brief Interview for Mental Status) score was a 12 (moderately impaired cognition). Review of a Social Services Note dated (MONTH) 7, 2019 at 4:01 p.m. documented This morning writer was in hallway by patient's room when she started to yell repetitive 'she hit me with her hand' when LNA (licensed nursing assistant) and LPN (licensed practical nurse) walked out of the room after finishing her care. Writer asked what happened? Patient stated 'aide hit me with her hand.' A few minutes later therapists arrived to get her up. Patient then stated 'the nurse hit me with a clip board.' Patient is a two person care given past allegations. It was noted staff did not have a clip board when in the room. Executive director, director of nursing, and assistant director of nursing notified of the above. A written statement by the administrator (staff #18) dated (MONTH) 7, 2019 documented This writer spoke with CNA (staff #103) and LPN (staff #37) on (MONTH) 7, 2019 at approximately 10:00 a.m. This writer was across the hall when hearing patient screaming for help, and witnessed (staff #103) exiting the room to get assistance from (staff #37). (Staff #103) had indicated she was trying to assist in cleaning (resident #3), but kept putting her hand near her butt to scratch at wound, and feces would continue to be on her hand. She was throwing her arms everywhere.[NAME]needed assistance to help redirect (resident #3) and went and got (staff #37). Once (staff #37) entered the room they both assisted her in getting changed. (Resident #3) then stated 'you just hit me with a clipboard', when neither employee had a clipboard in the room. After speaking with (staff #37), (staff #37) indicated the same. She entered the room to help calm down and re-direct (resident #3). During that time in the room is when she stated one of them hit her with a clipboard. This writer then spoke to (resident #3) around 10:45 a.m. to further look into her complaint of someone hitting her with a clipboard. (Resident #3) was hard to follow in conversation. I asked her if she knew who hit her with the clipboard, and she couldn't name an employee. I asked when it occurred, and she stated it occurred when 'those two women were trying to clean me in my room.' I followed up and said 'so while the nurse and the CNA were in the room together is when one of them hit you with a clipboard, and she said yes'. Review of facility documentation revealed that the facility obtained written statements from a CNA, an occupational therapist, and a therapy aide. Further review of facility documentation revealed no evidence that the facility initiated an investigation regarding the allegation of abuse. An interview was conducted with the administrator (staff #18) on (MONTH) 12, 2019 at 12:40 p.m. Staff #18 stated that an investigation was not conducted because two staff were with the resident at the time the allegation was made. Staff #18 further stated that he felt the allegation was unsubstantiated because two staff were with the resident. A review of the facility's policy Abuse: Prevention of and Prohibition Against dated (MONTH) 28, (YEAR) documented .Investigation .The investigation will include the following: .Interviews with other residents to whom the accused employee provides care or services or who may have information regarding the alleged incident. An interview with staff members having contact with the accused employee. A review of all circumstances surrounding the incident .The investigation, and the results of the investigation, will be documented .",2020-09-01
133,PUEBLO SPRINGS REHABILITATION CENTER,35068,5545 EAST LEE STREET,TUCSON,AZ,85712,2019-06-13,684,D,1,0,M0NY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, and review of facility policies and procedures, the facility failed to contact hospice staff when one resident (#2) sustained a fall with injury resulting in a transfer to the hospital for evaluation. The deficient practice could result in other resident's hospice care not being coordinated with the facility. Findings include: Resident #2 was admitted to the facility on (MONTH) 17, (YEAR) with [DIAGNOSES REDACTED]. A physician order [REDACTED].hospice for a [DIAGNOSES REDACTED]. Review of a hospice care plan dated (MONTH) 23, (YEAR) revealed the following intervention: Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs are met. A Change of Condition Note dated (MONTH) 30, 2019 documented Staff responding to loud noise heard from room .Patient noted standing in front of sink/mirror in bathroom with blood on his face. Patient stated 'I fell and hit my head on the toilet.' Face cleaned. Patient has a gash 2 centimeters long, depth unknown, sutures needed. Bleeding stopped and pressure dressing applied. Ice also applied. Patient also has a .5 centimeter long abrasion to right cheek bone. Patient transported to (name of hospital) emergency room for evaluation. Review of the clinical record revealed no evidence that the facility had notified the resident's hospice agency of his fall or transfer to the hospital. An interview was conducted with a licensed practical nurse (LPN/staff #8) on (MONTH) 12, 2019 at 10:00 a.m. Staff #8 stated that if a resident fell and sustained an injury that she would notify the resident's physician and family. Staff #8 also stated that hospice and everyone involved with the resident's care needed to be notified. Staff #8 further stated that she would document who was notified in the nursing progress notes. An interview was conducted with another LPN (staff #63) on (MONTH) 12, 2019 at 10:15 a.m. Staff #63 stated that if she had to transfer a resident to the hospital she would notify the physician, the director of nursing and the resident's family. Staff #63 stated that she would also contact hospice because they would need to know where the resident was. Staff #63 further stated that she would document in the clinical record who was contacted. An interview was conducted with the assistant director of nursing (ADON/staff #94 on (MONTH) 12, 2019 at 10:45 a.m. Staff #94 stated that staff should document on the hospital transfer form or progress note who was notified of the resident's transfer to the hospital. An interview was conducted with an administrator of the facility's sister facility (staff #113) on (MONTH) 12, 2019 at 11:45 a.m. Staff #113 stated that the facility did not notify hospice when the resident was transferred to the hospital. Staff #113 further stated that the hospice agency stated that they were notified by the resident's family member the following day that the resident was transferred to the hospital. Review of the facility's policy Change of Condition Reporting dated (MONTH) 2019 did not reveal that hospice should be notified if the resident had a change in condition.",2020-09-01
134,PUEBLO SPRINGS REHABILITATION CENTER,35068,5545 EAST LEE STREET,TUCSON,AZ,85712,2018-08-23,552,E,0,1,EXE711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to inform one resident (#67) of the risks/benefits of psychoactive medications. Findings include: Resident #67 was admitted on (MONTH) 7, (YEAR), with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 17, (YEAR), revealed the resident scored a 13 on the Brief Interview for Mental Status (BIMS), which indicated the resident was cognitively intact. The MDS also included the resident received antidepressant and antianxiety medications during the assessment period. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. However, review of the clinical record revealed no evidence that the risks and benefits of [MEDICATION NAME] or [MEDICATION NAME] were explained to the resident until (MONTH) 25, (YEAR). According to a signed consent dated (MONTH) 25, (YEAR), the risks and benefits of the medications were included. Another physician's orders [REDACTED]. Review of the MARs from (MONTH) 20, (YEAR) through (MONTH) 22, (YEAR) revealed the resident was administered the [MEDICATION NAME] as ordered. However, there was no clinical record documentation that the risks and benefits of [MEDICATION NAME] were explained to the resident/responsible party. An interview was conducted on (MONTH) 23, (YEAR) at 8:26 a.m., with a License Practical Nurse (LPN/staff #9). Staff #9 stated that consent for [MEDICAL CONDITION] drugs are signed right away as part of the admission process. He stated the risks/benefits must be explained before the drug is administered. An interview was conducted with the Director of Nursing (DON/staff #104) on (MONTH) 23, (YEAR) at 9:26 a.m. The DON stated that documentation of the risks/benefits of [MEDICAL CONDITION] drugs are documented on the signed consent. She stated it must be signed within 24 hours of the medication being ordered. She further stated that [MEDICAL CONDITION] medication cannot be administered, without consent. The DON was unable to find a signed consent for [MEDICATION NAME] for resident #67.",2020-09-01
135,PUEBLO SPRINGS REHABILITATION CENTER,35068,5545 EAST LEE STREET,TUCSON,AZ,85712,2018-08-23,578,D,0,1,EXE711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy and procedures, the facility failed to ensure that physician orders were obtained for one resident's (#121) advance directive wishes per policy and that the electronic record reflected the resident's DNR wishes. Findings include: Resident #121 was admitted to the facility on (MONTH) 15, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed a Prehospital Medical Care Directive Do Not Resuscitate (DNR) form. This document stated that in the event of cardiac or respiratory arrest, the resident refuses any resuscitation measures, including cardiac compressions or the administration of cardiac life support drugs and related emergency medical procedures. This document was signed by resident #121 and dated (MONTH) 15, (YEAR). However, review of the electronic medical record regarding the section to document code status revealed that this field was left blank for resident #121. Further review of the clinical record revealed there were no physician's order for a Do Not Resuscitate status, per the resident's advance directive wishes. An interview was conducted on (MONTH) 21, (YEAR) at 11:57 a.m., with a CNA (Certified Nursing Assistant/staff #86). Staff #86 stated that the resident's advance directive status can be found in the computer. She then pulled up resident #121 on the computer, and no code status was listed for this resident. Staff #86 then stated that in the event of cardiac or respiratory arrest, she would definitely start CPR (cardiopulmonary resuscitation) on this resident. An interview was conducted on (MONTH) 22, (YEAR) at 8:41 a.m., with a Licensed Practical Nurse (staff #9). He stated that it is not our policy to have a doctor's order for a DNR just a doctor's signature, but 99.9% of the time we have an order. Staff #9 also stated that there is a field in the computer which tells if the resident is a DNR. Staff #9 then brought up resident #121 on the computer and it did not show a code status. He then stated that in the absence of a DNR status, the resident would be a Full Code. An interview was conducted on (MONTH) 22, (YEAR) at 10:08 a.m., with the Director of Nursing (DON/staff #104). The DON stated the facility must have a doctor's order to identify them as a DNR. A review of the Advance Directive policy revealed that a resident's choice about advance directives will be respected. Procedures included that the facility will notify the attending physician of advance directives, so the appropriate orders can be documented in the resident's medical record and plan of care.",2020-09-01
136,PUEBLO SPRINGS REHABILITATION CENTER,35068,5545 EAST LEE STREET,TUCSON,AZ,85712,2018-08-23,584,D,0,1,EXE711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and policy review, the facility failed to ensure that one resident's (#13) wheelchair was clean and free of odors. Findings include: Resident #13 was admitted to the facility on (MONTH) 28, (YEAR), with [DIAGNOSES REDACTED]. An observation of the resident was conducted on (MONTH) 20, (YEAR) at 10:39 a.m. The resident was seated in his wheelchair in the hallway, outside of his room. A thick, dark substance was observed to be adhered to both wheelchair brakes and the metal bars under the seat of the wheelchair. Another observation of the resident's wheelchair was conducted on (MONTH) 22, (YEAR) at 1:15 p.m. The thick, dark substance was again observed on both wheelchair brakes and the metal bars under the seat of the wheelchair. Also, when the wheelchair cushion was removed, a strong odor of urine was detected. An interview was conducted with the maintenance director (staff #109) on (MONTH) 22, (YEAR) at 1:20 p.m. Staff #109 stated that he cleaned wheelchairs when they needed to be repaired and that the plant operations director (staff #14) cleaned wheelchairs as well. He further stated that he was not sure, but thought housekeeping might do routine cleaning of wheelchairs also. An interview was conducted with staff #14 on (MONTH) 22, (YEAR) at 1:25 p.m. The plant operations director stated that he cleans all of the wheelchairs in the facility once a month, but he does not maintain a log of when the wheelchairs are cleaned. When asked when the last time resident #13's wheelchair had been cleaned, staff #14 stated that he had not done it yet. An interview was conducted with a LNA (licensed nursing assistant/staff #68) on (MONTH) 22, (YEAR) at 1:30 p.m. Staff #68 stated that she wiped the cushion on the resident's wheelchair earlier. She stated that the resident gets a little messy. Review of the facility's policy for Wheelchair Cleaning Equipment Maintenance revealed It is the policy of this facility to establish procedures for routine and non-routine care and cleaning of wheelchairs to verify the equipment remains in good working order for resident and staff safety .The Maintenance Supervisor will carry out routine cleaning schedules in conjunction with housekeeping and maintain cleaning records from survey to survey .",2020-09-01
137,PUEBLO SPRINGS REHABILITATION CENTER,35068,5545 EAST LEE STREET,TUCSON,AZ,85712,2018-08-23,692,G,1,1,EXE711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on closed clinical record review, staff interviews, hospital records and policies and procedures, the facility failed to ensure that one resident (#120) received sufficient fluid intake to prevent dehydration. Findings include: Resident #120 was admitted from the hospital on (MONTH) 13, (YEAR), with [DIAGNOSES REDACTED]. Review of a hospital visit summary dated (MONTH) 13, (YEAR) revealed that resident #120 was admitted after suffering a fall, with pain in the left hip. Laboratory values included the following: Creatinine = 1.5 (normal range 0.9-1.3; Blood Urea Nitrogen (BUN) = 36 (normal range 6-20); Chloride level = 105 (normal range 101-111) and Sodium Level = 140 (normal range 136-145). A hospital physician's discharge summary included that resident #120 had acute pain secondary to a fracture, leukocytosis, coronary [MEDICAL CONDITION] and dementia. Per the summary, the resident was adequately nourished but mildly dehydrated, and that an indwelling urinary catheter had been placed in the hospital, due to complications from the pubic fracture. An initial nursing admission record dated (MONTH) 13, (YEAR), included the resident was admitted for status [REDACTED]. The documentation included the resident was alert to time and person but was confused, and was able to follow simple commands. Also noted was that the resident had difficulty swallowing, oral mucosa was pink and moist, and the resident had an indwelling urinary catheter in place, due to a pelvic fracture and pain. The admission physician orders [REDACTED]. An initial care plan included the resident had a nutritional problem or potential nutritional problem, however, it did not include any specific information or interventions for ensuring the resident received adequate food/fluids. A nurse's note dated (MONTH) 14, (YEAR) revealed the resident was alert and oriented x 1, and was forgetful and confused at times. The note included the resident was able to feed self with set up help, and required extensive assistance with bed mobility and transfers. Another nurse's note dated (MONTH) 14, (YEAR) included the resident had been tugging on his urinary catheter and the physician was notified. Per the note, the catheter was discontinued and Will continue to monitor for voiding. However, there was no clinical record documentation that the resident's urinary output was monitored, after the indwelling catheter was removed. Review of the fluid intake record for resident #120 revealed the resident consumed the following daily fluid amounts: -December 14: 780 cc (cubic centimeters) -December 15: 1860 cc -December 16: 1320 cc A nutrition/hydration risk evaluation dated (MONTH) 16, (YEAR) which was signed by the dietician, revealed the resident fed himself, eats 50-75 % of most meals, consumed between 1000 - 2000 cc of fluids daily, and was on diuretic medication. The evaluation included that the resident was a low risk for dehydration. A nurse's note dated (MONTH) 17, (YEAR) at 2:14 p.m. included the resident had blood coming from his penis and that his urine had a strong odor. A physician's orders [REDACTED]. Review of the fluid intake record revealed the resident consumed the following daily fluid amounts: -December 17: 1200 cc -December 18: 1200 cc -December 19: 1320 cc The results of the urinalysis were reported to the facility on (MONTH) 19, (YEAR) at 2:51 a.m. Per the report, the resident had a large amount of blood and leukocyte esterase in the urine and a blood urine quantitative value of 300 (normal range is negative). However, there was no clinical record documentation that the physician was notified of the urinalysis results on (MONTH) 19. A physician's orders [REDACTED]. A dietary admission evaluation dated (MONTH) 20, (YEAR), included the resident received a regular diet with thin liquids, and fed himself with limited to extensive set up assistance. The evaluation included that the resident required fluid intake amounts of 1584-1650 ml per day. This was the first documentation of the amount of fluids the resident required to maintain adequate hydration. The documentation further included that the resident should consume a minimum average of 72% of meals to meet minimum energy requirements, and that the resident was not meeting his needs. Per the documentation, the resident had a low oral intake, was consuming 1380 ml of fluids daily, (which was less than the required amount) and was receiving a diuretic. Will implement fortified foods and will continue to monitor oral intakes. Further review of the fluid intake record revealed the resident consumed the following daily fluid amounts: -December 20: 1200 cc -December 21: 1880 cc The laboratory results were reported to the facility on (MONTH) 22, (YEAR) at 8:03 a.m., which included that the resident had Proteus Mirabilis (bacteria) in his urine greater than 100,000 per ml. A physician's orders [REDACTED]. Review of the (MONTH) (YEAR) MAR (Medication Administration Record [REDACTED]. A medication administration note dated (MONTH) 22, (YEAR) at 10:03 a.m. included the resident was unable to be awakened. A daily skilled note dated (MONTH) 22, (YEAR) at 6:29 p.m., included that the resident's blood pressure was 102/54, the resident was alert and oriented and had no sensory changes. Continued review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the resident's fluid intake and meal records dated (MONTH) 22, (YEAR), revealed the resident had refused to eat, and received only 180 ml of fluids for the day as follows: 60 ml at 1:13 a.m., no fluids at 1:43 p.m., and 120 ml of fluids at 9:11 p.m. Further review of the clinical record revealed no evidence that the physician was notified on (MONTH) 22, of the resident's drop in blood pressure and that medications were held, that staff were unable to awaken the resident, and that the resident had refused to eat and had only received 180 ml of fluids for the day. According to the SBAR Communication Form dated (MONTH) 23, (YEAR) at 2:45 a.m., the resident was unresponsive, his blood pressure was 70/40 and that the unresponsiveness had started on (MONTH) 23. The documentation included that 911 was called and the resident was transferred to the hospital. A change in condition note dated (MONTH) 23, (YEAR) included the resident was unresponsive, his blood pressure was 70/40, and the primary care clinician had been notified. Review of a hospital admission record dated (MONTH) 23, (YEAR) at 3:06 a.m., revealed the resident was admitted to the critical care unit with the following Diagnoses: [REDACTED]. Review of the hospital laboratory results dated (MONTH) 23, (YEAR) at 3:08 a.m. revealed the following: BUN 204 (normal range 8-23), Creatinine 6.3 (normal range 0.67-1.17) Sodium 149 (normal range 136-145), Potassium 6.5 (normal range 3.4-5.1) and Chloride 119 (normal range 98-107). A hospital history and physical dated (MONTH) 23, 107 at 5:29 a.m. included the resident had severe acute kidney injury and [MEDICAL CONDITION] most likely from severe dehydration. The documentation included patient does appear very dehydrated. A hospital discharge note dated (MONTH) 30, (YEAR) included the resident had been admitted to in-patient hospice care for a [DIAGNOSES REDACTED]. An interview was conducted on (MONTH) 21, (YEAR) at 2:41 p.m., with a CNA (Certified Nursing Assistant/staff #86). Staff #86 stated that she would immediately notify the nurse if a resident has not taken any fluids or has not urinated, and would report symptoms of dehydration immediately to the nurse. An interview was conducted on (MONTH) 22, (YEAR) at 9:37 a.m., with the dietitian (staff #105). After reviewing the dietary evaluation, staff #105 stated that the recommended fluid intake for resident #120 was 1584 ml-1650 ml daily, and the recommendation took into account that the resident received a diuretic medication. An interview was conducted on (MONTH) 22, (YEAR) at 10:00 a.m. with a LPN (Licensed Practical Nurse/staff #9). Staff #9 stated that upon notification by a CNA that a resident has not received any fluids or food, he would immediately assess the resident and notify the physician. An interview was conducted on (MONTH) 22, (YEAR) at 11:12 p.m., with the Director of Nursing (DON/staff #104). During the interview, staff #104 stated that if a resident refused to eat or has not taken any fluids, the nurse should notify the physician immediately. After reviewing the resident's fluid intake amounts for December, staff #104 stated that the amount of fluids which were recorded on the fluid intake record did not take into account the extra fluids that were provided by the nurses with medications. She also stated that the fluid amounts documented by the CNA's were in error for (MONTH) 22, as the resident must have taken in more fluids than the amounts which were documented. She further stated that when abnormal laboratory results are received, the nurse notifies the physician immediately and then writes a notation that the laboratory results were reported to the physician. Another interview was conducted with staff #104 on (MONTH) 22, (YEAR) at 2:31 p.m. Staff #104 stated that she was unable to provide any additional documentation that the nurse had notified the physician on (MONTH) 22, nor any documentation that the resident was provided additional fluids or received the recommended fluid amounts each day. A policy titled, Hydration included the purpose of the policy was to ensure that the resident receives sufficient amount of fluids, based on individual needs to prevent dehydration. The facility will provide each resident with sufficient fluid intake to maintain proper hydration and health. Per the policy, sufficient fluid means the amount of fluid needed to prevent dehydration and maintain health. Risk factors included increased fluid loss and fluid needs, functional impairment that make it difficult to drink or communicate fluid needs and dementia, in which a resident forgets to drink. The policy also included The physician will be notified of any signs of dehydration, for further orders. Review of a Change of Condition Reporting policy revealed that all changes in condition will be reported to the physician, and that unusual signs and symptoms will be communicated to the physician promptly.",2020-09-01
138,PUEBLO SPRINGS REHABILITATION CENTER,35068,5545 EAST LEE STREET,TUCSON,AZ,85712,2019-10-24,578,D,0,1,N8KS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of facility policies and procedures, the facility failed to ensure advance directives were accurately documented for one of two sampled residents (#16). Failing to have accurate documentation for advanced directives could result in performing emergency treatment against residents' wishes. Findings include: Resident #16 was readmitted to the facility on (MONTH) 18, 2019, with [DIAGNOSES REDACTED]. A review of an Intensity of Care - Code Status form dated (MONTH) 18, 2019, signed by the resident's power of attorney, revealed FULL CODE: Receive CPR (cardiopulmonary resuscitation) and all life sustaining measures available at the facility - 911 will be called for emergency transport to area hospital. Review of the face sheet in the electronic medical record dated (MONTH) 22, 2019 revealed Code Status: Full Code. Further review of the clinical record revealed a Pre Hospital Medical Care Directive (Do Not Resuscitate) dated (MONTH) 24, 2019 signed by the resident. The significant change Minimum Data Set assessment dated (MONTH) 25, 2019 revealed a BIMS (Brief Interview for Mental Status) score of 5 which indicated the resident had severely impaired cognition. Review of a physician's orders [REDACTED].>An interview was conducted with a Licensed Practical Nurse (LPN/staff #96) on (MONTH) 23, 2019 at 2:35 p.m. The LPN stated that she should be aware of the resident's advance directive status. The LPN stated that she would refer to the resident's electronic clinical record, paper clinical record, and the physician orders. An interview was conducted with another LPN (staff #69) on (MONTH) 23, 2019 at 2:53 p.m. Staff #69 stated that she would refer to the resident's electronic clinical record, paper clinical record, and physician orders [REDACTED]. The LPN further stated that all three documents should be the same. An interview was conducted with the DON (director of nursing/staff #82) on (MONTH) 23, 2019 at 3:04 p.m. The DON stated that the resident's advance directive status should be documented in the electronic clinical record and the paper clinical record. The DON further stated that she did not know who would have had resident #16 sign the Do Not Resuscitate form on (MONTH) 24, 2019 as the resident's family member is the power of attorney. Review of the facility's policy, Advance Directive Documentation dated (MONTH) (YEAR) revealed .The resident or the surrogate decision maker can modify or cancel the Advance Directive at any time. Facility staff must report promptly to the licensed nurses any evidence of the resident's or surrogate decision maker's desire to change their decision. In turn, immediate action must be taken to implement the desired changes. The attending physician will promptly be notified. These events are to be recorded in the resident's health record.",2020-09-01
139,PUEBLO SPRINGS REHABILITATION CENTER,35068,5545 EAST LEE STREET,TUCSON,AZ,85712,2019-10-24,623,D,0,1,N8KS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and policy, the facility failed to notify one resident (#31) in writing of a transfer and the reasons for the transfer and failed to send a copy of the notice to the Office of the State Long-Term Care Ombudsman. Findings include: Resident #31 was admitted to the facility on (MONTH) 10, 2019, with [DIAGNOSES REDACTED]. Review of a progress note dated (MONTH) 3, 2019, revealed the physician gave an order for [REDACTED]. The Transfer Form dated (MONTH) 3, 2019, revealed the resident was transferred to the hospital on (MONTH) 3, 2019. Further review of the clinical record revealed no evidence the resident and the Ombudsman were provided written notice about the transfer. An interview was conducted on (MONTH) 24, 2019 at 8:45 a.m. with the Director of Social Services (staff #81), who stated that she does not notify the Ombudsman in writing when a resident is transferred to the hospital. She said that the nurses notify the Ombudsman when a resident is transferred to the hospital. An interview was conducted on (MONTH) 24, 2019 at 9:03 a.m. with a Licensed Practical Nurse (LPN/staff #60), who stated that she verbally explains to the resident why he or she is going to the hospital, but does not give the resident or representative an explanation in writing. She stated the Ombudsman is notified by phone that the resident is being transferred to the hospital and that the phone notification is documented in a progress note. The LPN said that she does not give the Ombudsman a written explanation for the transfer to the hospital. During an interview conducted on (MONTH) 24, 2019 at 9:18 a.m. with a LPN (staff # 106), the LPN said the Ombudsman is notified by phone when a resident is transferred to the hospital and that it is documented in the transfer summary that goes with the resident to the hospital. She said she is not aware of a written explanation being sent to the Ombudsman. Review of the facility transfer policy revised (MONTH) (YEAR), did not include written notification of the transfer and the reasons for the transfer to the resident and the resident's representative and the Ombudsman.",2020-09-01
140,PUEBLO SPRINGS REHABILITATION CENTER,35068,5545 EAST LEE STREET,TUCSON,AZ,85712,2019-10-24,625,D,0,1,N8KS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to provide written notice which contained specified information about their bed hold policy to one resident (#31) upon transfer to the hospital. Findings include: Resident #31 was admitted to the facility on (MONTH) 10, 2019, with [DIAGNOSES REDACTED]. Review of a progress note dated (MONTH) 3, 2019, revealed the physician gave an order for [REDACTED]. The Transfer Form dated (MONTH) 3, 2019, revealed the resident was transferred to the hospital on (MONTH) 3, 2019, but did not include the resident was notified about the facility's bed hold policy. Review of a Bed Hold Policy form signed and dated (MONTH) 3, 2019 by a Licensed Practical Nurse (LPN/staff #73), revealed the resident's family member had been notified about the bed hold policy. However, the policy form did not include the number of days for the duration, the reserve bed hold payment, and permitting the return of the resident to the next available bed if the leave exceeds the bed hold period. An interview was conducted on (MONTH) 24, 2019 at 8:45 a.m. with the Director Social Services (staff #81), who said that nursing informs the resident of the bed hold policy when the resident is transferred to the hospital. She said that she does not do anything when a resident is transferred to the hospital. On (MONTH) 24, 2019 at 9:00 a.m., an interview was conducted with the Admissions Director (staff #118), who said she does not inform a resident of the bed hold policy when the resident is transferred to the hospital. An interview was conducted on (MONTH) 24, 2019 at 9:03 a.m. with a Licensed Practical Nurse (LPN/staff #60), who stated that every resident has a bed hold policy in his or her clinical record. The LPN stated it is the Admissions Nurse who informs the resident about the bed-hold policy when the resident is admitted . Review of the facility's bed hold policy revised (MONTH) (YEAR), revealed the resident, or resident's representative, shall be informed in writing, of their right to exercise the bed hold provision in the event of a transfer from the facility to a general acute care hospital. Each notice shall include: the duration of the state bed hold policy (if any) and/or of the facility policy that the resident's bed will be held for the duration of the bed hold period; the amount required to be paid by the resident or by the resident's payor source to hold the bed for the duration of the bed hold period; that insurance may or may not cover such costs and , accordingly, the resident may have some liability for payment uncovered costs; and the facility's policy regarding bed-hold periods permitting the resident to return. This information shall be provided to the resident and/or his/her representative in a language they can understand at the time of transfer to the general acute hospital.",2020-09-01
141,PUEBLO SPRINGS REHABILITATION CENTER,35068,5545 EAST LEE STREET,TUCSON,AZ,85712,2019-10-24,641,D,0,1,N8KS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, clinical record review, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 2 of 20 sampled residents (#31 and #54) regarding dental status. The deficient practice could result in inaccurate factors for care planning decisions. Findings include: -Resident #54 was admitted [DATE], with [DIAGNOSES REDACTED]. Review of the significant change MDS assessment dated [DATE], revealed resident #54 was not edentulous (without teeth). During an interview conducted with the resident on 10/21/19 at 12:58 PM, the resident was observed to have no teeth. An interview was conducted with the Director of Nursing (DON/staff #82) on 10/24/19 at 10:26 AM. The DON confirmed resident #54 has no natural teeth. After reviewing the significant change MDS assessment, she stated that the dental section was incorrect. During an interview conducted with the MDS Coordinator (staff #20) on 10/24/19 at 10:36 AM, she stated that the dental section of the significant change MDS assessment was incorrect. The RAI manual instructs Conduct exam of the resident's lips and oral cavity, Check L0200B, no natural teeth if resident is edentulous. -Resident #31 was readmitted on (MONTH) 6, 2019, with [DIAGNOSES REDACTED]. Review of the initial nursing assessment dated (MONTH) 6, 2019, revealed the resident had cavities and missing teeth. Review of the significant change MDS assessment dated (MONTH) 13, 2019, revealed the resident had none of the dental issues listed which included no cavity or broken tooth. During an observation conducted on (MONTH) 24, 2019 at 10:55 a.m. with a Licensed Practical Nurse (LPN/staff # 106), the resident was observed to have brown spots on teeth and broken teeth. An interview was conducted on (MONTH) 24, 2019 at 11:12 a.m. with the MDS Coordinator (staff #20), who stated that she completes and updates the MDS assessments for the residents. She stated that she gathers information for the MDS assessments by interviewing the residents, talking to the nurses, and gathering information from the physician, nurses, and Certified Nursing Assistants notes. Staff #20 stated that she codes the MDS assessment dental section from the dental information on the initial nursing assessment. After reviewing the initial nursing assessment and the significant change MDS assessment, she stated that she missed the documentation on the initial nursing assessment and that she did not code the dental section correctly for resident #31. The RAI manual instructs Conduct exam of the resident's lips and oral cavity, Check L0200D, obvious or likely cavity or broken natural teeth if any cavity or broken tooth is seen. The RAI manual also included that it is required the assessment accurately reflects the resident's status and that the importance of accurately completing and submitting the MDS assessment cannot be over emphasized.",2020-09-01
142,PUEBLO SPRINGS REHABILITATION CENTER,35068,5545 EAST LEE STREET,TUCSON,AZ,85712,2019-10-24,658,E,0,1,N8KS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, and policy review, the facility failed to ensure services provided met professional standards of quality regarding medications for 2 of 6 sampled residents (#235 and #31). The deficient practice could result in residents not receiving optimal outcomes. Findings include: -Resident #235 was readmitted on (MONTH) 2, 2019, with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. However, review of the clinical record revealed no evidence the physician was notified the medication was unavailable or that the medication was reordered from the pharmacy. An interview was conducted on 10/24/19 at 9:52 AM with the Licensed Practical Nurse (LPN/staff #40) caring for the resident. The LPN stated that the resident did have an itching problem and was constantly being reminded not to scratch. She said that the medication was available most of the time and she did administer the medication when it was available. The LPN also stated that she believes when a medication is unavailable, the policy is to call the pharmacy and reorder the medication and notify the physician. She further stated that she has called the pharmacy, but is not sure if she called the physician and that there is no documentation that either action was done. An interview was conducted with the Director of Nursing (DON/Staff #91) on 10/24/19 at 10:17 AM. The DON stated that if a medication is unavailable, the nurse is expected to document why the medication is not available and when the medication is expected to be available. She also stated that the nurse should notify the physician or the Medical Director regarding the medication not being available. The DON stated that she was not certain that the pharmacy or the physician was notified about the unavailability of resident #235's medication. Review of the facility's policy for medication administration revised on 8/2016, revealed medications are to be administered in accordance with the written physician's orders [REDACTED]. -Resident #31 was readmitted to the facility on (MONTH) 12, 2019, with a [DIAGNOSES REDACTED]. Review of the clinical record revealed a physician order [REDACTED]. The orders also included accucheck (blood sugar) at bedtime for DM. The resident was discharged to another nursing home return not anticipated on (MONTH) 10, 2019. Resident #31 was readmitted to the facility from another nursing home on (MONTH) 10, 2019, with a [DIAGNOSES REDACTED]. Review of the clinical record revealed a physician's orders [REDACTED]. Hold for systolic blood pressure (SBP) less than 130. Review of the Medication Administration Record [REDACTED]. The MARs included a space for blood sugar recordings with the insulin and blood sugars were recorded. Additional review of the physician orders [REDACTED]. However, further review of the clinical record revealed no order for blood sugars or that the physician was notified for clarification of the insulin order to hold for SPB less than 130. An interview was conducted on (MONTH) 22, 2019 at 2:50 p.m. with a Registered Nurse (RN/staff #110), who stated that when a resident is admitted to the facility, the Assistant Director of Nursing (ADON/staff #111) transcribes the orders into the system and the charge nurse verifies the orders with the physician. The RN stated that she has never seen an order for [REDACTED]. An interview was conducted on (MONTH) 23, 2019 at 12:29 p.m. with the ADON (staff #111). She reviewed the MAR for (MONTH) 2019 and stated that the insulin ([MEDICATION NAME]) order was incorrect. Review of the facility's policy regarding physician orders [REDACTED].",2020-09-01
143,PUEBLO SPRINGS REHABILITATION CENTER,35068,5545 EAST LEE STREET,TUCSON,AZ,85712,2019-10-24,756,D,0,1,N8KS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and review of policy and procedures, the facility failed to ensure that a pharmacy recommendation was implemented timely for one out of five residents (#42). The deficient practice could result in adverse effects from antipsychotic medication not being identified timely. Findings include: Resident #42 was readmitted to the facility on (MONTH) 4, 2019, with [DIAGNOSES REDACTED]. Review of the admission orders [REDACTED]. A Consultant Pharmacist's Medication Regimen Review dated (MONTH) 6, 2019 included that resident #42 had recently been admitted and that a new admission medication review was performed and the following irregularities were noted: in regard to the [MEDICATION NAME], an Abnormal Involuntary Movement Scale (AIMS) assessment was not located in the resident's record. The recommendation was for an AIMS assessment to be done upon initiation/admission and every 3 months. The Medication Review also included initials under the recommendation, however, there was no documentation as to who had initialed the form. Also on this form was a Registered Nurse's (RN) initials in the margin. Review of the clinical record revealed an AIMS assessment was completed on (MONTH) 7, 2019. The assessment included the resident did not display any abnormal movements related to antipsychotic use. The next AIMS assessment was due in three months (in (MONTH) 2019). A care plan for the use of [MEDICAL CONDITION] medication as evidenced by auditory hallucinations dated (MONTH) 12, 2019 included the following goals: Resident to be free from drug related complications, including movement disorder, discomfort, [MEDICAL CONDITION], gait disturbance, constipation/impaction or cognitive/behavioral impairment through the review date; and have fewer episodes of auditory hallucinations. Interventions included to administer medications as ordered, monitor/document for side effects and effectiveness, monitor/record occurrence of target behavior symptoms (auditory hallucinations) and document, monitor/record/report to Medical Doctor as needed of side effects and adverse reactions related to psychoactive medications. A physician's orders [REDACTED]. A significant change Minimum Data Set (MDS) assessment dated (MONTH) 9, 2019 revealed the resident scored a 10 on the Brief Interview for Mental Status (BIMS), indicating she had moderate cognitive impairment. The behavior assessment revealed the resident had no hallucinations, no delusions and no behaviors during the 7-day look back period. The MDS indicated the resident required extensive/total assistance with most Activities of Daily Living (ADLs) and setup/supervision for meals. The MDS also included that a Gradual Dose Reduction (GDR) had not been completed and that the physician had documented that a GDR was clinically contraindicated. According to the Medication Administration Records, the resident continued to receive [MEDICATION NAME] daily from (MONTH) 2019 through (MONTH) 2019. Further review of the clinical record revealed there was no documentation that an AIMS assessment had been completed from (MONTH) 2019 through (MONTH) 2019, per the pharmacist recommendation of one being completed every three months. Review of a pharmacy recommendation for (MONTH) 23, 2019-September 25, 2019 revealed a recommendation for AIMS testing to be done (related to [MEDICATION NAME]). Continued review of the clinical record revealed there was no evidence that an AIMS assessment had been completed from (MONTH) 23 through (MONTH) 22, 2019. During the survey, an AIMS assessment was completed on (MONTH) 23, 2019. On (MONTH) 24, 2019 at 10:47 a.m., an interview was conducted with the Director of Nursing (DON/staff #82). She stated it is her responsibility to receive/review the pharmacist recommendations. She stated that when she receives a recommendation from the pharmacist, she makes copies of it and keeps one for herself and gives the other one to the provider. She stated that if the provider doesn't respond to the recommendation, she calls him and obtains a verbal consent to make changes. She stated that she thought that AIMS assessments were only required once every six months or so. She said that she was not aware of the missed AIMS assessments. Review of a policy titled, Medication Regimen Review stated that it is the policy of this facility that the drug regimen of each resident, which includes a review of the resident's medical chart, will be reviewed at least once a month by a licensed pharmacist. Additionally, the policy stated that irregularities will be documented on a separate written report that is sent to the attending physician, the facility's Medical Director and the Director of Nursing Services, and the list includes the resident's name, the relevant drug and the irregularity the pharmacist identified. The policy included that these reports will be acted upon and that the attending physician will document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. The policy stated that in performing the drug regimen review, the pharmacist utilizes federally mandated standards of care, in addition to other applicable standards.",2020-09-01
144,PUEBLO SPRINGS REHABILITATION CENTER,35068,5545 EAST LEE STREET,TUCSON,AZ,85712,2019-10-24,791,D,0,1,N8KS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, an observation, interviews, and facility policy, the facility failed to ensure one of two sampled residents (#54) received required dental services. The facility census was 89 residents. This deficient practice could result in the residents having unmet dental needs. Findings include: Resident #54 was admitted to the facility 12/8/13, with [DIAGNOSES REDACTED]. Review of the significant change MDS assessment dated [DATE], revealed resident #54 was not edentulous (without teeth). During an interview conducted with the resident on 10/21/19 at 12:58 PM, the resident was observed to have no teeth. A review of dental appointment dated 5/16/19 revealed resident has no natural teeth and is need of dentures top and bottom. Also, indicated resident was to return 5/23/19 for impressions to be made for these. Financial papers for dental expenses dated 5/16/19 indicated the resident needs to pay $241.63 for his dentures. Interview with resident #54 on 9/21/19 at 12:58 PM he stated he would like dentures and has and asked multiple times. During an interview with Social Services Director (SSD/staff #81) on 10/24/19 at 10:19 AM, regarding resident #54's dentures. She stated that Administrative Assistant (AA/staff #32) does all the transportation and appointments. SSD texted AA and the text stated resident #54 has been to dentist but his insurance won't pay for upper and lower plates he has to wait. During an interview with the Director of Nursing (DON/staff #82) on 10/24/19 at 10:26 AM she stated she was unaware resident #53 needed funds for his teeth the facility would have helped. During an interview with resident #54 on 10/24/19 at 10:55 AM, he stated he was never informed he needed to pay any money for his dentures. He wants to eat regular food and has not been able to. Review of the facility's dental policy revised (MONTH) 28, (YEAR), revealed that the policy of the facility is to ensure that all of its residents who require dental services on a routine or emergency basis have access to such services without barrier. The policy's emergency services definition includes broken or damaged teeth and routine dental services includes fillings and smoothing of broken teeth. For Medicare and private pay residents, the facility will ensure that the needed dental services are available, but may bill an additional charge for services. If a resident is unable to pay for dental services, the facility will attempt to find alternative funding sources or delivery systems, so the resident may receive the services needed to meet his/her dental needs and maintain his/her highest practicable level of well-being. The facility guidelines include providing and obtaining from an outside resource, routine and emergency dental services for each resident Based on clinical record reviews, observations, interviews, and facility policy, the facility failed to ensure two of two sampled residents (#31 and #54) received required dental services. The facility census was 89 residents. This deficient practice could result in the residents having unmet dental needs. Findings include: Resident #31 was admitted to the facility on (MONTH) 10, 2019 and was readmitted on (MONTH) 6, 2019 with [DIAGNOSES REDACTED]. Review of the admission record dated (MONTH) 6, 2019, revealed that the resident had Medicaid insurance coverage. The initial nursing assessment dated (MONTH) 6, 2019, revealed that the resident had cavities and missing teeth. Review of a significant change Minimum Data Set (MDS) dated (MONTH) 13, 2019, included a Brief Interview for Mental Status (BIMS) with a score of 15 indicating that the resident was cognitively intact. The MDS was coded to show that the resident did not have any cavities or broken teeth. The clinical record did not contain any evidence that the resident's dental concerns had been addressed or that the resident had been scheduled to see a dentist. An interview was conducted on (MONTH) 21, 2019 at 10:13 a.m. with resident #31, who stated that she asked to see a dentist about two months ago and no one has made her an appointment. It was observed that she had missing teeth, some broken teeth, and several teeth with dark brown spots. An interview was conducted on (MONTH) 24, 2019 at 10:32 a.m. with an administrative assistant (staff #42), who stated that she schedules dental appointments for the residents when she is notified by a nurse that the resident needs to see a dentist. She reviewed her records and stated that the resident had not seen a dentist since being admitted to the facility in (MONTH) 2019 and she did not have an order for [REDACTED]. An interview was conducted on (MONTH) 24, 2019 at 10:55 a.m. with a Licensed Practical Nurse (LPN/staff #113), who observed that the resident had brown spots on her teeth, which she described as tooth decay and broken teeth. She stated that she would report the dental concerns to the charge nurse or the Director of Nursing (DON) because the resident may need to see a dentist. She also said that not receiving dental care can lead to health problems down the line and affect nutrition. -Resident #54 was admitted to the facility on (MONTH) 8, 2013, with [DIAGNOSES REDACTED]. The resident's clinical record indicated that he was receiving Medicaid health insurance. Review of the significant change MDS assessment dated (MONTH) 8, 2019 revealed that the resident scored a 15 on the BIMS indicating that he was cognitively intact. The resident was not coded as being edentulous (without teeth). A dental appointment referral form dated (MONTH) 16, 2019 revealed that the resident had no natural teeth and was in need of full dentures. Also, the referral indicated that the resident was to return on (MONTH) 23, 2019 to make impressions for the dentures. Financial papers for dental expenses dated (MONTH) 16, 2019 indicated that the resident needed to pay $241.63 for his dentures. In an interview with resident #54 on (MONTH) 21, 2019 at 12:58 p.m., he stated he would like dentures and has and asked staff to assist him in getting dentures multiple times. During an observation conducted with the resident on (MONTH) 21, 2019 at 12:58 p.m., the resident was observed to have no teeth. During an interview with the Social Services Director (SSD/staff #81) on (MONTH) 24, 2019 at 10:19 a.m., she stated that the administrative assistant (Staff #42) establishes all the resident appointments and transpiration to the appointments. The SSD checked with staff #42 who told her that the resident had been to the dentist, but his insurance will not pay for the dentures and he has to wait. An interview was conducted with the Director of Nursing (DON/staff #107) on (MONTH) 24, 2019 at 10:26 a.m. She stated she was unaware resident #54 needed money to get his dentures and had she known, the facility would have assisted him in paying the bill. During an interview with resident #54 on (MONTH) 24, 2019 at 10:55 a.m., he stated he was never informed he needed to pay any money for his dentures. Review of the facility's dental policy, revised (MONTH) 28, (YEAR), revealed that the policy of the facility is to ensure that all of its residents who require dental services on a routine or emergency basis have access to such services without barrier. The policy defined emergency services as broken or damaged teeth and defined routine dental services as including fillings and smoothing of broken teeth. The policy included that for Medicaid residents, the facility will provide all emergency dental services and those routine dental services to the extent covered under the Medicaid state plan. The policy noted that the facility will inform the resident of the deduction for the incurred medical expense available under the Medicaid state plan and assist the resident in applying for the deduction. The facility policy provided guidelines which included providing and obtaining from an outside resource, routine and emergency dental services for each resident.",2020-09-01
145,PUEBLO SPRINGS REHABILITATION CENTER,35068,5545 EAST LEE STREET,TUCSON,AZ,85712,2019-10-24,812,E,0,1,N8KS11,"Based on observations, staff interviews, and review of policy and procedures, the facility failed to ensure desserts and produce were covered when stored in the refrigerator. The facility census was 89 residents. The deficient practice could result in food contamination placing residents at risk for foodborne illnesses. Findings include: On (MONTH) 21, 2019 at 2:11 p.m., a kitchen tour was conducted with the dietary supervisor (Staff# 112). In the walk-in refrigerator, a large plastic container of iceberg lettuce was not covered. There were lettuce heads on the top and some wilted brown lettuce leaves next to the lettuce heads. The dietary supervisor picked up one of the lettuce heads and multiple brown and wilted lettuce leaves were observed to be underneath. She moved another lettuce head to the side and more brown and wilted lettuce leaves were observed. There was also one large portable multilevel rack of individual desserts in the middle of the refrigerator. Each individual dessert was partially covered with a plastic lid. It was observed that the lids were too small, so the food items were exposed to the open air. There was also one large tray of desserts on another rack with flat plastic lids lying on top of each dessert. These lids were observed to be too small, so the desserts were also exposed to the air. Also, there was a plastic covering over the entire rack of desserts but there was a large hole in the plastic. An interview was conducted with the dietary supervisor (Staff #112) at the time of the observation. She stated that there is no schedule to rotate the older produce to the front and she said that it was her responsibility to ensure that the produce was checked and that the old produce was removed from the refrigerator. She stated that the wilted lettuce would be removed from the refrigerator. She stated that in regards to the desserts, that the entire dessert rack was covered with plastic, but that there was a large hole in the plastic, about 3 feet by 3 feet, so the desserts were exposed to air. She stated that the desserts were prepared for the dinner meal and should have been covered. A second observation of the kitchen was conducted on (MONTH) 22, 2019 at 11:30 p.m. with the dietary supervisor (Staff #112). Two large trays of chocolate cream pies were observed to be uncovered in the walk-in refrigerator. A second interview was conducted with the dietary supervisor (Staff #112) at the time of the observation. She said that the facility policy requires that all food be covered when stored. An interview was conducted on (MONTH) 23, 2019 at 11:15 a.m. with a cook (staff #49), who stated that she prepares salad the night before it is to be served so that it has time to chill. She said that once the lettuce heads are pulled apart and washed, she stores the lettuce in a plastic container and covers the container with a plastic lid to prevent anything from dripping into the lettuce. She stated that the container of lettuce is stored in the walk-in refrigerator. She stated that she has seen the lettuce in the refrigerator uncovered before and she has found brown lettuce in the plastic bin at times. She said that desserts are prepared by the night cooks the night before they are served and that all the desserts should be covered with a large piece of plastic. She stated that she has seen the plastic with holes in it before and said that this would be considered an inadequate covering. She said the facility doesn't have lids to fit the dessert bowls, so they use a soup bowl lid instead. She said that these lids do not fit because they are not large enough, so the lid only covers part of the dessert, leaving the rest exposed to the air. Review of the facility refrigerated food policy, dated 2013, revealed that all foods should be stored in covered containers or wrapped carefully and securely. The policy noted that refrigerated foods should be stored upon delivery and careful rotation procedures should be followed.",2020-09-01
146,PUEBLO SPRINGS REHABILITATION CENTER,35068,5545 EAST LEE STREET,TUCSON,AZ,85712,2017-12-20,608,D,1,0,B32N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interview, review of facility documentation, and review of facility policies and procedures, the facility failed to report a reasonable suspicion of a crime, misappropriation of $400 from resident #3, to the law enforcement agency. The sample size was one. Findings include: Resident #3 was admitted to the facility on (MONTH) 7, (YEAR) with a [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed a Nursing Note dated (MONTH) 29, (YEAR) documented .Daughter X 2 (two daughters) arrived and stated resident going LOA (leave of absence) for 'important business' and transferred resident to wheelchair and left. Review of facility documentation dated (MONTH) 12, (YEAR) documented (Family member's name) stated that (family members names) had taken resident out of the facility to the bank, changed her account, tried getting another POA (power of attorney) and withdrew $400 from resident's account. (Family member's name) also stated that (family member's name) had called social security to change representative payee to (family member's name). (Family member's name) stated that he was able to change everything back but no longer wanted resident to leave facility without getting verbal approval .Writer explained that APS (Adult Protective Services) should be contacted regarding this situation and (family member's name) stated that he did not want to file a report because 'there is already enough strive between us.' . (MONTH) 18, (YEAR)-APS investigator interviewed resident . An interview was conducted with the social worker, staff #50 on (MONTH) 19, (YEAR) at 11:45 a.m. The social worker stated that he did not report the incident to law enforcement agency because he reported the incident to APS. Review of the facility's policy Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment documented .To assist the Facility's staff members in recognizing incidents of abuse, the following definitions are provided: .Misappropriation of resident property-means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent .Ensure that all allegation of misappropriation of resident property, are reported immediately but: Not later that two hours after the allegation is made if the events that cause the allegation involves abuse or results in serious bodily injury. Not later than twenty four hours if the events that cause the allegation does not involve abuse and does not result in serious bodily injury .",2020-09-01
147,PUEBLO SPRINGS REHABILITATION CENTER,35068,5545 EAST LEE STREET,TUCSON,AZ,85712,2017-12-20,609,D,1,0,B32N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interview, review of facility documentation, and review of facility policies and procedures, the facility failed to report an allegation of misappropriation of resident property, $400 from resident #3, to the State Survey Agency. The sample size was one. Findings include: Resident #3 was admitted to the facility on (MONTH) 7, (YEAR) with a [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed a Nursing Note dated (MONTH) 29, (YEAR) documented .Daughter X 2 (two daughters) arrived and stated resident going LOA (leave of absence) for 'important business' and transferred resident to wheelchair and left. Review of facility documentation dated (MONTH) 12, (YEAR) documented (Family member's name) stated that (family members names) had taken resident out of the facility to the bank, changed her account, tried getting another POA (power of attorney) and withdrew $400 from resident's account. (Family member's name) also stated that (family member's name) had called social security to change representative payee to (family member's name). (Family member's name) stated that he was able to change everything back but no longer wanted resident to leave facility without getting verbal approval .Writer explained that APS (Adult Protective Services) should be contacted regarding this situation and (family member's name) stated that he did not want to file a report because 'there is already enough strive between us.' . (MONTH) 18, (YEAR)-APS investigator interviewed resident . An interview was conducted with the social worker, staff #50 on (MONTH) 19, (YEAR) at 9:30 a.m. The social worker stated that he called APS but did not notify the State Survey Agency because the incident was a family domestic issue and did not involve staff. Review of the facility's policy Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment documented .To assist the Facility's staff members in recognizing incidents of abuse, the following definitions are provided: .Misappropriation of resident property-means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent .Ensure that all allegation of misappropriation of resident property, are reported immediately but: Not later that two hours after the allegation is made if the events that cause the allegation involves abuse or results in serious bodily injury. Not later than twenty four hours if the events that cause the allegation does not involve abuse and does not result in serious bodily injury. Ensure that all alleged violations involving abuse, neglect, mistreatment, exploitation, or misappropriation of resident property are reported to: .The State Survey Agency .",2020-09-01
148,PUEBLO SPRINGS REHABILITATION CENTER,35068,5545 EAST LEE STREET,TUCSON,AZ,85712,2019-12-31,602,D,1,0,SUL711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, and review of facility policies and procedures, the facility failed to ensure that one resident (#2) was free from misappropriation of her bank cards. The deficient practice could result in further misappropriation of property from other residents. Findings include: Resident #2 was admitted to the facility on (MONTH) 13, 2019 with [DIAGNOSES REDACTED]. A review of the admission MDS (Minimum Data Set) assessment dated (MONTH) 20, 2019 revealed the resident's BIMS (Brief Interview for Mental Status) score was a 15 or cognitively intact. Review of a Social Services Note dated (MONTH) 5, 2019 documented Late entry for last Monday (MONTH) 3, 2019. Patient reported her ATM (automated teller machine) and credit card disappeared from wallet. Room was searched by staff. Staff did not find them. Laundry was in the lookup (lookout) for the possibility they were sent out. Patient called bank to cancel cards and to make sure no charges were accrued. Bank informed her a ATM $20.00 transaction was declined at a QT (Quik Trip store). A $400.00 were declined on the credit card. Social service director called Tucson police department .Adult Protective Services was called .Department of Health Services self report was done on line and ombudsman was also informed. Social service director completed investigation today . Review of a Case Summary Report from the Tucson Police Department dated (MONTH) 5, 2019 documented I responded to .on 12/4/19 in reference to a theft call. Staff were calling to report that one of their residents named (resident #2) had her credit card stolen and someone attempted to use it. I was escorted to (resident #2's) room upon my arrival. (Resident #2) told me that she had last used her credit and debit cards about 2 weeks ago when she paid her bills. (Resident #2) said that she placed the cards back into her purse, which she kept at the foot of her bed. (Resident #2) said that she had not used her cards since then. She tried to use it yesterday to purchase a bag of pretzels from the vending machine and she could not locate them. She reported it to staff and they helped her contact the bank to cancel the cards. (Resident #2) stated that she was advised that someone attempted to use her credit card for a $400 transaction but it was declined. (Resident #2) said she was not told where or when it was used. She did not have any suspect information. (Resident #2) daughter, was present and remained with (resident #2). She did not have any information about the incident. I provided (resident #2) with a VINE (victim notification system) form and the case report number. The Director of Social Services requested to speak with me. She told me that she suspected an employee had taken the card and said that she would be willing to help identify the suspect if video/photos were obtained of the suspect. I contacted the bank and he stated that he could provide me with information about (resident #2) account as long as she gave them consent. I returned to (resident #2) room and contacted her. I placed (bank employee) on speaker phone and he spoke with (resident #2). (Resident #2) gave them consent to speak with me about the activity on her account. (Bank employee's name) told me that someone attempted to use the Debit card at a Quik Trip store on 12/2/19 at 2150 hours for $120 and it was declined. Someone tried using her credit card at the same store at 2345 hours for $62.50 and again at 2352 hours for 402.50 but both transactions were declined. I responded to the Quik Trip and I spoke with the manager. He provided me with the phone number for their corporate office and he told me that they would be able to assist me. I called their corporate office and I spoke with their security officer. I relayed the information I had along with my work phone number and (security officer) indicated that he would call back if he were to find any useful footage. Supplement Notes documented (security officer) called me later into my shift and he told me that he located a possible suspect on their surveillance cameras. He told me to respond back to the store so a manager could give me access to their video system. (Security officer's name) said that the times on his system were between 2244-2256 hours. He stated that it was a one-hour difference due to the time zones. I responded to the store and contacted manager. She contacted the store's security office and they were able to remotely access the video footage so I could view it at the store. Security Officer assisted me with the video. The video showed a heavyset [NAME] female wearing grey sweat pants and sweater arrive in a light green SUV. She approached the ATM upon entering the store and it appeared that she did not obtain any money. The female then walked over to the Lottery Ticket machine and she attempted to obtain tickets. It did not appear that she was successful. The female returned to the ATM and used it again. The female then walked out of the store and left westbound on (name of street) in the same vehicle she arrived in. I took photos of images off the monitor and I recorded the video footage. A review of the facility's 5 day investigation report dated (MONTH) 9, 2019 documented On Wednesday (MONTH) 4, 2019 social service director completed an online self-report. The incident involved (resident #2). (Resident #2) reported her debit card missing. (Resident #2) room and laundry was checked. (Resident #2) stated she did see the card the day before. (Resident #2) called and canceled the card, as it appeared someone had it in their possession and was trying to use it according to the bank. (Social services director) then called the cops and Adult Protective Services .has completed their investigation related to the care and services provided for (resident #2). Pueblo Springs couldn't substantiate whether her missing items were stolen or just misplaced; however, the investigation is in process and the Tucson Police Department are taking the necessary steps to follow-up . An interview was conducted with the social services director (staff #37) on (MONTH) 30, 2019 at 11:10 a.m. Staff #37 stated that she talked to the police station yesterday and they have a picture of the person who attempted to use the resident's bank cards. Staff #37 stated the police described the person as a heavy set Caucasian woman who was driving a light green SUV (sport utility vehicle). Staff #37 stated that she was told that this person attempted to use the bank cards twice but was denied. Staff #37 stated that she knew the resident had the bank cards on her possession because she had assisted the resident with paying her bills in the past. Staff #37 stated that she was going to the police station to attempt to get a copy of the picture. An interview was conducted with the administrator (staff #15) on (MONTH) 30, 2019 at 2:40 p.m. Staff #15 stated that staff #37 was on her way back from the police department. Staff #15 stated that the police would not let staff #37 view the photo of the person who attempted to use the bank cards. Staff #15 stated that the police gave staff #37 a description of the person who attempted to use the bank cards and the location. Staff #15 stated that the police will not release a copy of the photo to the facility for three weeks. Staff #15 stated that he was going to go to the location where the bank cards were attempted to be used to see if he could view the surveillance cameras. Another interview was conducted with the administrator (staff #15) on (MONTH) 31, 2019 at 8:40 a.m. Staff #15 stated that he went to the store last night and was told that he had to speak with the manager this morning to obtain permission to view the surveillance camera pictures. An interview was conducted with the social service director (staff #37) on (MONTH) 31, 2019 at 9:10 a.m. Staff #37 stated that she just spoke with the police station and explained that the State Survey agency was at the facility conducting an investigation and it would be helpful to have a copy of the photographs. Staff #37 further stated that the police station stated that she could come to pick up a copy of the photographs. The social services director (staff #37) returned to the facility on (MONTH) 31, 2019 at 10:00 a.m. with a copy of the photographs which were on CD (compact disc). Staff #37 then reviewed the photographs with the administrator (staff #15). An interview was conducted with the administrator (staff #15) on (MONTH) 31, 2019 at 10:15 a.m. Staff #15 stated that he viewed the photographs on the CD and it was, without a doubt, a CNA (certified nursing assistant/staff #112). Staff #15 stated that staff #37 would be notifying the police department immediately to give them the CNA's contact information. Staff #15 further stated that he would immediately contact staff #112 to notify her that she is suspended pending the facility's investigation. Staff #15 stated that staff #112 would be terminated. An interview was not attempted with staff #112 so as to not interfere with the police investigation. Review of the facility's policy Abuse: Prevention of and Prohibition Against, dated (MONTH) 14, 2019 documented .Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent ,.",2020-09-01
149,CASAS ADOBES POST ACUTE REHAB CENTER,35070,1919 WEST MEDICAL STREET,TUCSON,AZ,85704,2018-04-12,637,D,0,1,LBWQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that a significant change Minimum Data Set (MDS) assessment was completed for one resident (#91). Findings include: Resident #91 was admitted on (MONTH) 23, (YEAR), with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A nursing progress note dated (MONTH) 30, (YEAR) included that hospice was notified of the order to evaluate the resident. Nursing progress notes reflected that hospice was contacted on (MONTH) 9, (YEAR) and that the hospice nurse was in to visit the resident on (MONTH) 12. A significant change MDS assessment was initiated on (MONTH) 14, (YEAR), however, the MDS was not completed. A care plan dated (MONTH) 17, (YEAR) included for hospice care, with [DIAGNOSES REDACTED]. A physician's progress note dated (MONTH) 6, (YEAR) included worsening [MEDICAL CONDITION] prompted the hospice enrollment. Review of the nursing progress notes for (MONTH) 3, and (MONTH) 6, (YEAR), revealed the resident was on hospice care. During an interview conducted on (MONTH) 12, (YEAR) at 1:47 p.m. with the MDS coordinator (Licensed Practical Nurse/staff #59), she stated that it was the policy of the facility to use the RAI manual regarding MDS assessments. She stated that when a resident has a significant change, a significant change MDS assessment must be completed. She stated that an example of a significant change would include a resident being accepted on hospice services. She stated that a significant change assessment was initiated on (MONTH) 14, (YEAR), but was not completed. According to the RAI manual, a Significant Change in Status Assessment (SCSA) is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains at the nursing home. The Assessment Reference Date must be within 14 days from the effective date of the hospice election. A SCSA must be performed regardless of whether an assessment was recently conducted for the resident. This is to ensure a coordinated plan of care between hospice and the nursing home is in place. The RAI manual further included that since the nursing care facility remains responsible for care of the resident, the MDS information should reflect the most current condition of the resident and assist the resident in achieving their highest practicable well-being at whatever stage of the disease process the resident is experiencing.",2020-09-01
150,CASAS ADOBES POST ACUTE REHAB CENTER,35070,1919 WEST MEDICAL STREET,TUCSON,AZ,85704,2018-04-12,657,D,0,1,LBWQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy review, the facility failed to ensure one resident's ( #20) care plan was revised to reflect the use of a walking boot. Findings include: Resident #20 had an original admitted (MONTH) 28, (YEAR), with a readmitted (MONTH) 31, (YEAR). [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed the resident sustained [REDACTED]. On (MONTH) 13, x-rays were taken and the resident's hip, knee and right ankle were negative for fractures. Review of a nursing note dated (MONTH) 27, (YEAR) revealed the resident was complaining of right lower leg pain and requested to be sent to the hospital. A review of the hospital documentation revealed the resident did not have any fractures and was discharged back to the facility on (MONTH) 30, (YEAR), with a CAM (walking boot) to the right foot for an infection in the right ankle. Review of the physician's orders for (MONTH) (YEAR) revealed there was no order for the CAM boot. Review of the resident's care plans dated (MONTH) 1, (YEAR) revealed they were not revised to reflect the use of a CAM boot to the right foot, nor when to apply or remove the boot. An interview was conducted with a CNA (Certified Nursing Assistant/staff #106) on (MONTH) 11, (YEAR) at 12:30 p.m. Staff #106 stated that resident #20 wears a CAM boot, when out of bed. During an interview with a LPN (Licensed Practical Nurse/staff #154) on (MONTH) 12, (YEAR) at 10:41 a.m., staff #154 stated the resident wears a boot while in bed, and that the CNA's apply it and remove it. Staff #154 reviewed the resident's clinical record and stated there was no order for the CAM boot or when to apply it. Staff #154 also stated that the care plans were not updated regarding the CAM boot. Staff #154 stated that there should be a physician's order for the boot and that all of the nurses were responsible for updating and revising care plans. A follow-up interview was conducted with staff #106 on (MONTH) 12, (YEAR) at 11:00 a.m. Staff #106 stated she does not document the application or removal of the resident's boot. Staff #106 further stated that there was no care plan documentation for the CNA's as to when to apply or remove the resident's boot. Staff #106 stated that care plan information comes from nursing staff. An interview was conducted with the DON (Director of Nursing/staff #156) on (MONTH) 12, (YEAR) at 11:05 a.m. Staff #156 stated that the resident was readmitted to the facility with the CAM boot. Staff #156 stated that there should have been an order for [REDACTED].#156 stated that the care plans should be revised for the use of the CAM boot. Staff #156 stated that nursing staff were responsible for revisions of resident care plans. A review of the facility policy regarding care plans revealed documentation that the resident's plan of care is reviewed and revised on an on-going basis, quarterly at a minimum and/or as needed with changes in condition.",2020-09-01
151,CASAS ADOBES POST ACUTE REHAB CENTER,35070,1919 WEST MEDICAL STREET,TUCSON,AZ,85704,2018-04-12,684,D,1,1,LBWQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review and staff interviews, the facility failed to ensure there was nursing documentation as to why one resident's (#142) physician ordered insulin was withheld. Findings include: Resident #142 was admitted on (MONTH) 5, (YEAR), with a [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Review of the MAR (Medication Administration Record) for (MONTH) (YEAR) revealed the insulin was to be administered at 7 a.m. and at 4:30 p.m. There was also a space to document the resident's blood sugar level for both times. Further review revealed that on (MONTH) 7 at 4:30 p.m., no insulin was documented as being administered and there was no blood sugar level which was documented. Per the code on the MAR, no insulin was required. However, there was no explanation as to why the insulin was not administered. Review of the clinical record revealed there was no documentation as to why the insulin was held on (MONTH) 7, (YEAR) at 4:30 p.m. An interview was conducted on (MONTH) 11, (YEAR) at 9:03 a.m., with a LPN (Licensed Practical Nurse/staff #100). Staff #100 stated that the resident's blood sugar level should be tested prior to administering insulin, and it should be documented on the MAR. Staff #100 also stated that if insulin is withheld, there should be documentation of why the insulin was not given. Staff #100 stated that it would be a nursing judgement to not administer insulin if the resident's blood sugar level was too low, but the nurse should call the physician and make a note of the physician's response and why the insulin was not given. An interview was conducted with the DON (Director of Nursing/staff #156) and a RN (Registered Nurse consultant/staff #158) on (MONTH) 11, (YEAR) at 9:21 a.m. Upon review of the resident's clinical record, staff #158 stated that the nurse should have documented the resident's blood sugar level on (MONTH) 7 at 4:30 p.m., and called the physician. Staff #158 stated that nurses can use professional judgement to determine if a resident's blood sugar level is too low to administer insulin, but the nurse must document the blood sugar level, notify the physician, and document the notification and the physician's response.",2020-09-01
152,CASAS ADOBES POST ACUTE REHAB CENTER,35070,1919 WEST MEDICAL STREET,TUCSON,AZ,85704,2019-06-27,561,E,0,1,RFYH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, clinical record review, and review of policy, the facility failed to ensure one sampled resident (#3) had the right to make a choice related to the placement of a video camera in her room. The deficient practice could result in residents not having the choice about aspects of their life in the facility that are significant to them. Findings include: Resident #3 was readmitted to the facility on (MONTH) 22, (YEAR), with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set assessments dated (MONTH) 20, 2019 and (MONTH) 17, 2019 revealed the Brief Interview for Mental Status score was 15, which indicated no cognitive impairment. Review of the current care plan revealed the resident was at risk for activities of daily living self-care performance deficit related to immobility and impaired balance. Interventions included for staff to assist with all activities of daily living as needed and to encourage the resident to use the bell to call for assistance. A review of the clinical record revealed a care plan review form dated (MONTH) 19, 2019. Signatures on the form included the resident, social services, a Registered Nurse, dietary and activities staff, and a Certified Nursing Assistant (CNA).The form included the medication list and the care plan summary was reviewed and discussed among the interdisciplinary members and the resident and included additional notes that a room change was discussed which the resident declined. A review of the clinical record from (MONTH) 19 through (MONTH) 16, 2019 revealed no evidence of communication between the resident and staff regarding concerns related to the placement of a video camera in her room. An interview was conducted with resident #3 on (MONTH) 27, 2019 at 11:50 a.m. She stated there is a video camera in her room and she does not like it. The resident stated a family member of her roommate requested a video camera and that a camera was placed in an area near the roommate's bed. The resident stated she could not remember how long the camera had been in the room. She stated that it was an invasion of her privacy. The resident also stated she is not sure if there is both video and audio on the camera. The resident further stated the staff never asked her about placing the camera in the room and that if they had, she would have said she does not like the camera and would have said no. She stated she has told the social worker, the Administrator, and an Assistant Director of Nursing (ADON) that she does not like or want the video camera in her room. She further stated she was told by all of the staff there was nothing they could do other than move her. She stated she repeatedly told the staff she does not want to move and thinks it would be wrong to make her move just because she does not like or want the video camera. During the resident interview the resident invited the ADON (staff #52) to join the interview. Staff #52 stated he was aware of the resident's concerns regarding the video camera. Staff #52 stated there are signs posted at the entry of the room to indicate a video camera is in use. He stated he told resident #3 the camera was only used for the roommate. The resident then asked staff #52 why she could be forced to move and not the roommate. Staff #52 stated the staff are working on moving her to a different room. The resident told him she wanted to stay in her room and have the roommate move. An interview was conducted with the Director of Social Services (DSS/staff #137) on (MONTH) 27, 2019 at 12:04 p.m. She stated that she thought the camera was installed in the room of resident #3 in (MONTH) 2019. She stated the camera is in the area of the roommate. The DSS stated resident #3 was offered a room change but that she does not want to move as she is very comfortable in her current room. Staff #137 stated there is a posting by the doorway of the room and also a posting by the front door of the facility. She stated everyone entering the facility or the resident's room, needs to know about the video camera due to HIPPA (Health Insurance Portability and Accountability Act), privacy, and dignity issues. The DSS stated the Director of Nursing and Administrator is aware of the resident's concerns regarding the camera and have talked with her about it. Staff #137 stated to her knowledge, there is no documentation in the clinical record regarding the ongoing communication camera concerns with resident #3 and the staff. Staff #137 stated she does not know for sure when the camera was actually placed in the resident's room as nothing is documented, including any concerns voiced from resident #3. An interview was conducted with the Director of Nursing (staff #151) and the Administrator (staff #152) on (MONTH) 27, 2019 at 12:15 p.m. Staff #151 stated several months ago she was told resident #3 stated there was no problem with the video camera in her room. Staff #151 stated even though it was not a problem, resident #3 was offered a new room and declined. Staff #151 stated the facility legal team was contacted and stated the camera placement could not be forbidden and that it would not affect HIPPA or privacy. Staff #151 stated she was aware resident #3 changed her mind about wanting and then not wanting to change rooms. Staff #151 stated residents have the right to make choices about their rights and room changes. Staff #152 stated that they do not have a policy regarding the use of video cameras because their legal team told him it was not necessary. Staff #152 stated it is very important to honor resident rights and their ability to make their own choices in their day to day life. The facility's policy regarding resident rights revealed a resident has the right to receive treatment that supports and respects the resident's individuality, choices, strengths, and abilities and to participate in the development or decisions concerning treatment.",2020-09-01
153,CASAS ADOBES POST ACUTE REHAB CENTER,35070,1919 WEST MEDICAL STREET,TUCSON,AZ,85704,2019-06-27,658,E,1,1,RFYH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, observations, staff interviews, and review of policy, the facility failed to ensure prescribed medications were not outdated for one of four sampled residents (#35) and failed to ensure medications ordered for infection were administered as ordered for one of two sampled residents (#2). The deficient practice could result in residents receiving expired medications and delays in treatment for [REDACTED]. Findings include: -Resident #35 was readmitted to the facility on (MONTH) 30, 2019 with a [DIAGNOSES REDACTED]. A review of the physician orders [REDACTED]. During a medication administration observation conducted on (MONTH) 25, 2019 at 8:25 a.m., a Licensed Practical Nurse (LPN/staff #99) was observed to remove two [MEDICATION NAME] 10 mg from a box that was stored in the medication cart and placed the two capsules in a medication cup to be administered to resident #35. However, upon further inspection of the box of [MEDICATION NAME], it was observed to have an expiration date of (MONTH) 2019. As staff #99 was entering the room of resident #35, the LPN stated that he was going to administer the [MEDICATION NAME] to the resident. When asked to look at the expiration date, he stated the expiration date was (MONTH) 2019 and that since the medication was expired, he could not administer it to the resident. The LPN stated that it is the responsibility of the nurses to check the medication carts to ensure there are no expired medications. An interview was conducted with the Director of Nursing (DON/staff #151) on (MONTH) 27, 2019 at 10:42 a.m. The DON stated that all nurses are to check the medication carts and remove any medications that have expired. Staff #151 also stated that it was standard nursing practice to not administer expired medications. The facility's policy regarding Medication Storage revealed outdated medications are removed from stock, disposed of, and reordered from the pharmacy if a current order exists. -Resident #2 was admitted on (MONTH) 25, (YEAR) with [DIAGNOSES REDACTED]. A nurse note dated (MONTH) 10, 2019 at 3:30 p.m. included that resident #2 had an inflamed follicle on the buttock and the health provider had been notified. The note included medication as ordered. A physician's orders [REDACTED]. A written care plan initiated (MONTH) 10, 2019 for follicle included administering antibiotic(s) as per physician orders [REDACTED]. The care plan also included to monitor for effectiveness and adverse reaction to antibiotic therapy. A skin ulcer non-pressure weekly assessment dated (MONTH) 11, 2019 included that resident #2 had an inflamed hair follicle to the left buttock that measured 2.0 cm (centimeters) by 2.0 cm and was indurate (raised) greater than 2.0 cm. The assessment included that the nurse had spoken with the healthcare provider and IV antibiotics had been ordered. Review of the MAR (Medication Administration Record) for resident #2 revealed spaces to document the administration of [MEDICATION NAME] 750 mg IV. However, further review of the MAR indicated [REDACTED]. Review of the clinical record did not reveal any additional information regarding whether or not resident #2 had received [MEDICATION NAME] IV while at [MEDICAL TREATMENT] on (MONTH) 12 and (MONTH) 14, 2019. A nurse note dated (MONTH) 14, 2019 at 3:30 p.m. included that resident #2 had an open area on the left buttock that measured approximately 1/4 inches in size and was found to have purulent drainage. An annual MDS (Minimum Data Set) assessment dated (MONTH) 16, 2019 included that resident #2 had a BIMS (Brief Interview for Mental Status) score of 15, which indicated that the resident was cognitively intact. The assessment included that resident #2 was provided with application of non-surgical dressings and applications of ointments. Review of the MAR indicated [REDACTED]. An E-MAR Medication Administration Note dated (MONTH) 17, 2019 included that the resident had refused to go to [MEDICAL TREATMENT] and the physician had been notified. A nurse note dated (MONTH) 17, 2019 included that the infected follicle on the left buttock had opened and measured 0.5 cm. by 0.5 cm. The note included that the nurse had spoken to a staff at the [MEDICAL TREATMENT] center regarding whether or not resident #2 had been started on IV antibiotics and had been provided a phone number to speak with the physician at the center. However, there was no additional information included in the nurses note, or anywhere in the clinical record that the nurse had contacted the physician at the [MEDICAL TREATMENT] center, or if the antibiotic medications had been provided at the [MEDICAL TREATMENT] center. Review of the MAR indicated [REDACTED]. Review of E-MAR Medication Administration Notes dated (MONTH) 19, 2019 at 6:37 a.m. included that resident #2 had refused to go to [MEDICAL TREATMENT], and an E-MAR note at 2:43 p.m. included that the [MEDICAL TREATMENT] center had contacted the facility and that the resident had not received the antibiotic medication because the medication needed to be verified by the resident's nephrologist. Continued review of the clinical record did not reveal any additional documented information the resident's attending physician had been notified that the resident had missed multiple doses of [MEDICATION NAME]. A nurse note dated (MONTH) 21, 2019 at 11:25 included that the nurse had phoned the [MEDICAL TREATMENT] center and confirmed that resident #2 had been provided with the first dose of [MEDICATION NAME]. During an interview conducted on (MONTH) 26, 2109 at 10:45 a.m. with the ADON (Assistant Director of Nursing/staff #21), the ADON stated that when a physician's orders [REDACTED]. Staff #21 stated the medication can only be given during the [MEDICAL TREATMENT] treatment because of the potential for toxicity. The ADON stated that upon return of the resident to the facility, the [MEDICAL TREATMENT] center is supposed to provide a note that would include whether or not the resident had been provided with [MEDICATION NAME] during the [MEDICAL TREATMENT] treatment. The ADON stated that if the center failed to provide a note, the nurse should call the center to verify of the resident had received [MEDICATION NAME]. During an interview conducted on (MONTH) 26, 2019 at 11:10 a.m. with the Director of Nursing (DON/staff #151), the DON stated that the [MEDICAL TREATMENT] center is supposed to send a paper with the resident that would include if the resident had received [MEDICATION NAME] IV. The DON stated that on (MONTH) 12 and 14, 2019, the nurse should have verified whether or not the resident had received [MEDICATION NAME] and noted it on the MAR. Staff #151 stated that if the resident did not receive the [MEDICATION NAME], the nurse should have notified the physician and documented the notification when the resident missed the first dose. The facility's policy and procedure titled Administration of Drugs included a statement that it is the policy of the facility that medications shall be administered as prescribed by the attending physician. The policy included that if a medication is withheld, refused, or given other than at the scheduled time, the documentation will be reflected in the clinical record.",2020-09-01
154,CASAS ADOBES POST ACUTE REHAB CENTER,35070,1919 WEST MEDICAL STREET,TUCSON,AZ,85704,2019-06-27,686,G,0,1,RFYH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, staff interviews, and review of policy and procedures, the facility failed to ensure one out of three sampled residents (#51) with a pressure ulcer received care consistent with professional standards of practice to prevent the development of an unstageable pressure ulcer and consistently received necessary treatment and services consistent with professional standards of practice. The deficient practice could result in the development and worsening of pressure ulcers. Findings include: Resident #51 was admitted to the facility on (MONTH) 8, 2014, with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment dated (MONTH) 10, 2019 revealed the Brief Interview for Mental Status (BIMS) assessment could not be completed, as the resident was rarely/never understood and the resident was severely impaired with cognitive skills for daily decision making. The assessment included the resident required extensive assistance with bed mobility and was totally dependent on staff for transfer, toilet use, and personal hygiene. The MDS assessment also included the resident was at risk for the development of pressure ulcers but did not have any pressure ulcers, had a pressure reducing device for the bed but not for the chair, and was not on a turning/repositioning program. A physician's orders [REDACTED]. Additional review of the clinical record revealed the resident had previously received treatment for [REDACTED]. Review of the current care plan initiated (MONTH) 6, (YEAR), revealed the resident was actual for pressure ulcer development related to immobility. The goal was for the resident to have intact skin, free of redness, blisters or discoloration by/through review target date of (MONTH) 31, 2019. Interventions included to administer treatments as ordered and monitor for effectiveness, to encourage fluid intake and assist to keep skin hydrated, Low Air Loss (LAL) mattress, and a weekly head to toe skin at risk assessment. Continued review of the current care plan revealed the resident was at risk for skin breakdown related to impaired mobility, 2/2 right-sided paralysis, and bowel and bladder incontinence. The goal was the resident will not have any skin breakdown through the next review target date of (MONTH) 31, 2019. Interventions included weekly skin assessments, reporting any red and/or open areas, pressure relieving mattress on the bed and pressure relieving device in wheelchair, and providing incontinence care following each incontinent episode. The Braden Scale for Predicting Pressure Sore Risk forms dated (MONTH) 23 and 30, 2019 revealed a score of 9.0, indicating the resident was at very high risk. Some of the factors that contributed to the score included the resident's ability to respond meaningfully to pressure related discomfort was very limited; was only able to respond to painful stimuli and could not communicate discomfort, except by moaning or restlessness. Also included was that the resident was chairfast, completely immobile, and that friction and shear were considered a problem as the resident required moderate to maximum assistance moving and complete lifting without sliding against the sheets was deemed impossible. Review of the Treatment Administration Record (TAR) for (MONTH) 2019 revealed the weekly skin assessments were done. Review of the physician's orders [REDACTED]. A Weekly Skin Evaluation dated (MONTH) 3, 2019 revealed no documentation of ulcers, wounds, or other skin problems. The evaluation included that there were no new skin issues noted at that time. A nursing progress note dated (MONTH) 4, 2019 revealed a Certified Nursing Assistant (CNA) reported to the nurse resident #51's back was bleeding. The note included there was redness noted to the back, mostly the mid-back, with a wound noted to the site. The note also included the wound was cleaned and covered with a foam dressing and that an order for [REDACTED]. A physician's orders [REDACTED]. Review of the Weekly Skin Evaluation dated (MONTH) 4, 2019 revealed redness was noted to the back and a wound to the mid back and that wound care was to evaluate and treat. Another physician's orders [REDACTED]. Review of the TAR for (MONTH) 2019 revealed monitoring for the LALM began on (MONTH) 7. A physician's orders [REDACTED]. A Skin Pressure Ulcer Weekly form dated (MONTH) 8, 2019 revealed for an initial evaluation of the unstageable upper mid back wound. The wound measured 3.6 centimeters (cm) x 4.2 cm, had scant amount of serous drainage, and no odor. The wound bed was described as black/brown (eschar), edges of the wound were defined, and there was peripheral tissue [MEDICAL CONDITION]. The wound was cleansed with normal saline, pat dry, covered with therahoney, and covered with a foam dressing. Also documented was that the resident experienced non-verbal signs of pain that included grimacing, moaning/crying, guarding, irritability, anger, and being tense. Additional comments included orders would be changed to a LALM, staff would use wedges to rotate the resident every 2 hours, physical therapy and occupational therapy would be informed to take a look at the wheelchair, the registered dietician would be informed if any changes of nutrients were needed, and the resident's family would be informed. A nursing progress note dated (MONTH) 8, 2019, revealed the resident's family was notified of the wound. A Dietary Quarterly Evaluation dated (MONTH) 10, 2019, revealed the registered dietician had been informed of the pressure ulcer. However, review of the clinical record revealed no documentation that care was provided for the pressure ulcer between (MONTH) 4 and 8, 2019 and no documentation that the resident was administered pain medication prior to the wound treatment on (MONTH) 8, 2019. The quarterly MDS assessment dated (MONTH) 10, 2019 revealed the resident could not be assessed for the BIMS due to the resident rarely/never being understood. The assessment included the resident had one unstageable pressure ulcer, was receiving pressure ulcer care, had moisture associated skin damage, was not on a turning/repositioning program, had a pressure-reducing device for the bed, but no pressure reducing device for the chair. The assessment also included the resident required extensive assistance for activities of daily living. A physician's orders [REDACTED]. A Skin Pressure Ulcer Weekly form dated (MONTH) 16, 2019 revealed the wound was unstageable and measured 3.6 cm x 4.2 cm x UTD (unable to determine depth), had scant amount of serous exudate, and no odor. The wound bed had black/brown eschar, defined wound edges, and peripheral tissue [MEDICAL CONDITION]. The treatment was provided and the resident showed signs of pain when turning and cleaning the wound of grimacing, moaning/crying, guarding, anger, and hitting. A nursing progress note dated (MONTH) 27, 2019 revealed the unstageable pressure ulcer treatment had been provided by the wound nurse. The Skin Pressure Ulcer Weekly form dated (MONTH) 31, 2019 revealed the unstageable pressure ulcer measured 3.6 cm x 4.2 cm, had scant amount of serous exudate, and no odor. The form included slough to the wound bed, defined wound edges, and normal surrounding tissue. The form included the treatment was provided and that the resident continued to show signs of pain when turning and cleaning the wound of grimacing, moaning/crying, and guarding. Review of the clinical record did not reveal documentation the resident was administered pain medication prior to the wound treatments on (MONTH) 16 and 31, 2019. Further review of the clinical record did not reveal a Skin Pressure Ulcer Weekly form or documentation that the wound was assessed for the week between (MONTH) 16 and (MONTH) 31, 2019. A Skin Pressure Ulcer Weekly form dated (MONTH) 7, 2019 revealed the unstageable pressure ulcer measured 3.6 cm x 4.2 cm, had scant amount of serous exudate, and no odor. The documentation included the wound bed had black/brown eschar, defined wound edges, and normal surrounding tissue. Additional comments included the resident showed signs of pain when turning and cleaning the wound. Also included was that if there are no changes to the wound bed, the family will be asked if another product can be used. A Skin Pressure Ulcer Weekly form dated (MONTH) 14, 2019 revealed the unstageable pressure ulcer measured 3.4 cm x 4.0 cm, had scant amount of serous exudate, and no odor. The wound bed had black/brown eschar, defined wound edges, and normal surrounding tissue. Additional comments included slough was beginning to separate and that the resident showed signs of pain when turning and cleaning the wound. A Skin Pressure Ulcer Weekly form dated (MONTH) 21, 2019 revealed the unstageable pressure ulcer measured 3.6 cm x 4.2 cm, had scant amount of serous exudate, and no odor. The wound bed had slough, defined wound edges, and the surrounding tissue was normal. Comments included slough is continuing to separate, the periwound area has signs of [DIAGNOSES REDACTED], and there is no signs or symptoms of infection. The documentation also included the resident continued to show signs of pain when turning and cleaning the wound of grimacing, moaning/crying, and guarding. Additional review of the clinical record revealed no documentation the resident was provided with pain medication prior to the wound treatments for (MONTH) 7, 14, and 21, 2019. Further review of the clinical record revealed no evidence that the pressure ulcer treatment was consistently provided as ordered every Monday, Wednesday, and Friday on the day shifts for (MONTH) and (MONTH) 2019. An observation was conducted of the pressure ulcer treatment on (MONTH) 26, 2019 at 7:37 AM with a Licensed Practical Nurse (LPN/staff #149) who stated she was a certified wound nurse. A CNA (staff #145) assisted the LPN by turning and holding the resident. As they rolled the resident onto her side, the resident began crying out and was slapping at staff #145. The wound nurse washed her hands, donned clean gloves, and began to remove the old dressing. As the wound nurse was removing the old dressing, she identified the black/brown substance, which was partially attached to the old dressing as eschar. As the old dressing was being removed, the eschar began tearing away from the wound bed, without fully detaching. During this time, the resident squirmed and cried out during the treatment, as staff #145 continued to hold her at the hip and hands. The nurse changed gloves and cleansed the area with normal saline. Resident #51 cried out again and squirmed against the hold of staff #145. The nurse measured the wound and stated it measured 2.6 cm x 1.6 cm. The nurse then changed gloves and applied therahoney and a foam dressing to the wound. The resident moaned and slapped at the CN[NAME] During the observation, staff #149 stated that the pressure ulcer developed in the facility. She said the resident had been sleeping on a regular mattress, which contributed to the development of the pressure ulcer. The LPN also stated the wheelchair the resident was using contributed to the skin breakdown. She stated that the wound has decreased in size because it is healing. The wound nurse also stated that the resident was not administered pain medication prior to the treatment. An interview was conducted on (MONTH) 26, 2019 at 7:42 AM with the CNA (staff #145). The CNA stated that she is very familiar with resident #51. She stated that part of the resident's daily care is to ensure the resident is clean and dry, and repositioned at least every 2 hours. An interview was conducted on (MONTH) 26, 2019 at 12:36 PM with a LPN (staff #17). She stated that if she were providing treatment care to a resident who was experiencing pain, she would stop the treatment and administer pain medication. She said that it is never ok for the resident to be in pain during the treatment process. During an interview conducted on (MONTH) 26, 2019 at 12:56 PM with the Director of Nursing (DON/staff #151), the DON agreed that if the resident was crying out in pain during treatment, it would be acceptable to stop the treatment, administer [MEDICATION NAME], and resume the treatment in a 1/2 hour. On (MONTH) 27, 2019 at 10:15 AM, an interview was conducted with a CNA (staff #145). Staff #145 stated that she works with resident #51 on a regular basis, and has become very familiar with the resident's responses. She stated that she definitely believed the resident was in pain during her treatment. She said that resident #51 reacted per her norm at first, but during the removal of the dressing, cleaning of the wound, and application of therahoney, the resident reacted as if she were in pain. Another interview was conducted on (MONTH) 27, 2019 at 12:14 PM with the certified wound nurse, staff #149. She stated the criteria for obtaining a physician's orders [REDACTED]. The wound nurse stated that resident #51 had a regular mattress when she started working at the facility approximately 3 months ago. She said she was informed of the redness on the resident's back on (MONTH) 4, 2019 and thought it might be from shearing. The LPN stated that she was not sure it was a pressure ulcer because the wound had not opened. She stated that on (MONTH) 4, 2019 she texted the provider, as that was a customary method of communication between them. She said she wanted to talk with the provider before putting a LALM on the resident's bed as the LALM could put the resident at risk for falling. She stated that the provider did not get back to her until (MONTH) 7, 2019. The wound nurse stated that at that time she obtained an order for [REDACTED].>On (MONTH) 27, 2019 at 1:18 PM, an interview was conducted with the Assistant Director of Nursing (ADON/ staff #52). He stated that if he was unable to contact the attending physician, his process for obtaining an order would include calling the Nurse Practitioner, Team Health (an on-call service), or the Medical Director. The ADON stated that if he needed a physician's orders [REDACTED]. On (MONTH) 27, 2019 at 1:46 PM, another interview was conducted with the DON (staff #151). The DON stated that if an unstageable pressure ulcer was found on a resident, she would expect nursing to contact the physician and notify the wound nurse to do an evaluation. She stated that a LALM is not always necessary, that it depends on the location of the injury and the mobility of the resident. In regard to resident #51, she stated that the wound nurse received a telephone call at home on a Saturday regarding the injury. She stated that after the floor nurse described the injury to the wound nurse, they thought it might be a friction injury. The DON stated that the wound nurse directed the floor nurse to apply a foam dressing to the site, and that it would be good for 5 days. The DON stated that when the wound nurse reported to work on (MONTH) 7th, she assessed the injury to be a pressure ulcer and put the appropriate treatment into place, including the LALM. The facility's policy titled Wound Management stated it is the policy of the facility that a resident who enters the facility without pressure ulcers does not develop pressure ulcers unless clinically unavoidable. The policy included care and services are provided to promote the prevention of pressure ulcer development, promote the healing of pressure ulcers that are present, and to prevent the development of additional, avoidable pressure ulcers. The policy also revealed the nurse is responsible for assessing and evaluating the resident's condition and is expected to take actions which include completing a weekly head to toe skin assessment with follow up as applicable. The policy included that once a wound has been identified, assessed, and documented, the nurses shall administer treatment to each affected area per the physician's orders [REDACTED]. The policy stated that in order to prevent the development of skin breakdown, the following approaches shall be implemented as appropriate: Reposition the resident. Use pressure relieving/reducing and redistributing devices (including but not limited to low air mattresses, wedges, pillows, etc.). Use transfer techniques which minimize friction and skin tears/shears as applicable (mechanical lift). If the resident is incontinent, make sure his/her skin remains clean and dry with regular pericare and toileting when appropriate. The facility's policy regarding Pain Management revealed residents will be assessed for pain and that residents who are cognitively impaired may exhibit pain through changed behaviors. The policy stated the facility assists each resident with pain to maintain or achieve the highest practicable level of well-being and functioning by identifying circumstances when pain can be anticipated.",2020-09-01
155,CASAS ADOBES POST ACUTE REHAB CENTER,35070,1919 WEST MEDICAL STREET,TUCSON,AZ,85704,2019-06-27,697,G,0,1,RFYH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure that 1 of 21 sampled residents (#51) received adequate pain management. The deficient practice could result in residents having pain that may diminish their quality of life. Findings include: Resident #51 was admitted to the facility on (MONTH) 8, 2014 with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment dated (MONTH) 10, 2019 revealed the Brief Interview for Mental Status (BIMS) assessment could not be completed, as the resident was rarely/never understood and the resident was severely impaired with cognitive skills for daily decision making. In Section J, the documentation included the resident was on a scheduled pain medication regimen, was not on PRN pain meds and non-medication interventions for pain were not in place. Under staff assessment for pain, the documentation included the resident exhibited nonverbal sounds (crying, whining, gasping, moaning or groaning) and indicators of pain were present on 3-4 days during the last 5 days of the look back period. A Braden Scale for Predicting Pressure Sore Risk dated (MONTH) 30, 2019 revealed a score of 9.0, indicating the resident was at very high risk. Some of the factors that contributed to the score included the resident's ability to respond meaningfully to pressure related discomfort was very limited; was only able to respond to painful stimuli and could not communicate discomfort, except by moaning or restlessness. Review of the physician orders [REDACTED]. The order had an original order date of (MONTH) 12, (YEAR). The orders also included to monitor the resident's pain level every shift using the following pain scale: 0=no pain; 1-3=mild pain; 4-6=moderate pain and 7-10=severe pain. Another physician's orders [REDACTED]. Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. In addition, the documentation showed the resident's pain level was assessed every shift and was generally at 0-1. At times, the resident's pain level was assessed as follows: on (MONTH) 13, the resident's pain level was documented as a 6 on two separate shifts; on (MONTH) 14, the resident's pain level was documented as a 6 on two separate shifts; and on (MONTH) 29, the resident's pain level was a 6. Further review of the (MONTH) 2019 MAR indicated [REDACTED]. A pain care plan dated (MONTH) 2, 2019 included a goal for the resident to verbalize adequate pain relief or ability to cope with incompletely relieved pain through the review date. Interventions included to administer [MEDICATION NAME] medication as ordered, anticipate need for pain relief and respond immediately to any complaint of pain, follow pain scale to medicate as ordered and notify the physician if interventions were unsuccessful or if the current complaint was a significant change from the resident's past experience of pain. A physician's orders [REDACTED]. Cleanse with normal saline, pat dry, apply therahoney and cover with a foam dressing every Monday, Wednesday, and Friday and PRN for an unstageable pressure injury. A Skin Pressure Ulcer Weekly summary completed by the wound nurse dated (MONTH) 8, 2019 revealed the resident had an unstageable pressure injury to the vertebral, [MEDICATION NAME] area of the back which measured 3.6 cm x 4.2 cm x UTD (unable to determined depth), and the periwound area had signs of [DIAGNOSES REDACTED], but no symptoms of infection. The summary included that wound care was provided and that the resident showed signs of pain, when turning and cleansing the wound. The documentation also included the resident experienced pain related to the wound, as evidenced by grimacing, moaning/crying, guarding, irritability, anger and by being tense. Although there was documentation by the wound nurse that the resident was experiencing pain during the wound treatment, there was no clinical record documentation that the resident was administered PRN [MEDICATION NAME], prior to the wound treatment on (MONTH) 8. A quarterly MDS assessment dated (MONTH) 10, 2019 included the resident was rarely/never understood. Section J revealed the resident had pain indicated by non-verbal sounds such as; crying, whining, gasping, moaning or groaning. The MDS included that non-verbal indicators of pain were observed on 3-4 days out of 5 during the look back period. A Skin Pressure Ulcer Weekly summary dated (MONTH) 16, 2019 revealed that wound care was provided and that the resident showed signs of pain when turning and cleansing the wound; as evidenced by grimacing, moaning/crying, guarding, anger and hitting. A Skin Pressure Ulcer Weekly summary dated (MONTH) 31, 2019 revealed that wound care was provided and that the resident showed signs of pain when turning and cleansing the wound. The summary included the resident was unable to communicate pain related to the wound, however, non-verbal demonstrations of pain were documented as; grimacing, moaning/crying and guarding. Despite documentation by the wound nurse that the resident was experiencing pain during the wound treatments, there was no clinical record documentation that the resident was administered PRN [MEDICATION NAME], prior to the wound treatments on (MONTH) 16 and 31. Further review of the (MONTH) 2019 MAR indicated [REDACTED]. The documentation also showed that the resident's pain was being assessed every shift and was generally rated at 0-1 on a 1-10 pain scale. However, on the following dates the resident's pain level was assessed as follows: on (MONTH) 13 for a pain level of 6; on (MONTH) 15 for a pain level of 7; and on (MONTH) 25 for a pain level of 5. However, further review revealed no documentation that PRN [MEDICATION NAME] was administered at any time during the month. A Skin Pressure Ulcer Weekly summary dated (MONTH) 7, 2019 revealed that wound care was provided and that the resident showed signs of pain when turning and cleansing the wound. A Pressure Ulcer Weekly summary dated (MONTH) 14, 2019 revealed wound care was provided as ordered and that the resident showed signs of pain when turning and cleansing the wound. A Pressure Ulcer Weekly summary dated (MONTH) 21, 2019 revealed that wound care was provided as ordered by the physician. The documentation included the resident was noted with an unstageable pressure injury to the [MEDICATION NAME] area of the back, which measured 3.6 cm x 4.2 cm x UTD and that slough was continuing to separate, the periwound area had signs of [DIAGNOSES REDACTED], and there were no signs or symptoms of infection. Per the summary, the resident showed signs of pain when turning and cleansing the wound, as evidenced by grimacing, moaning/crying and guarding. Again, there was no clinical record documentation that the resident was administered PRN [MEDICATION NAME], prior to the wound treatments on (MONTH) 7, 14, and 21, despite documentation that the resident was in pain. An observation of a pressure ulcer treatment for [REDACTED].#149), who stated that she was a certified wound nurse. The resident was observed in bed and as she was approached by a CNA (staff #145), she grimaced and held tightly to the blanket on her bed. When staff #145 touched the resident, she began guarding and hitting at staff #145. At this time, staff #145 assisted the wound nurse in rolling the resident onto her side. As this was being done, the resident began crying out and was slapping at staff #145. Staff #145 held the resident's hip with one hand, and restrained the resident's hands with the other. Staff #149 then donned clean gloves and began to remove the old dressing. Resident #51 cried out loudly as the old dressing was removed. As the wound nurse was removing the old dressing, she identified the black/brown substance, which was partially attached to the old dressing as eschar. As the old dressing was being removed, the eschar began tearing away from the wound bed, without fully detaching. During this time, the resident squirmed and cried out during the treatment, as staff #145 continued to hold her at the hip and hands. However, the nurse did not stop the treatment to assess the resident's pain. The nurse then changed her gloves and cleansed the area. Resident #51 cried out again and squirmed against the hold of staff #145. The wound nurse measured the wound and stated it measured 2.6 cm x 1.6 cm. The nurse then changed gloves and applied therahoney to the wound. The resident moaned and slapped at the CN[NAME] During the above observation, staff #149 stated the resident was not provided with adjuvant pain medication prior to wound care today. She stated that she usually provides wound care to the resident during the early mornings at approximately 7:00 AM. She said she changes the dressing before the CNAs get the resident up for breakfast and before medications have been administered. Staff #149 stated the resident does not receive pain medication prior to wound care because the resident's family does not want her to have it, due to their concerns about the resident becoming over-sedated. Staff #149 stated the resident cries out whenever care is provided and that it was customary behavior for her. Review of the clinical record including the (MONTH) 2019 MAR, revealed the resident did not receive any pain medication prior to the wound treatment which was done on (MONTH) 26, 2019 at 7:37 a.m. The (MONTH) MAR indicated [REDACTED] Continued review of the (MONTH) 2019 MAR indicated [REDACTED]. However, on the following dates the resident was observed to have pain as follows: on (MONTH) 7 a pain level of 7; on (MONTH) 9 a pain level of 2 and 4; on (MONTH) 10 a pain level of 4 on three separate shifts. There was no indication that the resident had been administered PRN [MEDICATION NAME] during the month. On (MONTH) 26, 2019 at 12:27 PM, an interview was conducted with the Assistant Director of Nursing (ADON/staff #52). He stated that non-verbal residents are assessed for pain through demonstrations of behaviors such as grimacing, moaning or crying. He stated that there is a pain scale in the computer that helps the nurses evaluate by grimace (Pain Aid), and that if he noticed grimacing or signs that the resident was in pain, he would consider administering pain medication. He said he would anticipate giving an adjuvant pain medication prior to therapy, wound care, treatments, or appointments. An interview was conducted on (MONTH) 26, 2019 at 12:36 PM with a LPN (staff #17). She stated that if she were providing treatment care to a resident who was experiencing pain, she would stop the treatment and administer pain medication, or call the provider for an order, or ask to have the order changed so that it could be administered as an adjuvant. She said that it would never be ok for the resident to be in pain during the treatment process. An interview was conducted on (MONTH) 26, 2019 at 12:56 PM with the Director of Nursing (DON/staff #151). She stated that the administration of pain medication depends on how the medication is ordered, as some are ordered on a schedule. She said that if a resident was experiencing pain with a treatment or wound care, she would anticipate the nurse would look to see if the resident had an order for [REDACTED].#51, she stated that the resident's family has insisted the resident does not receive too much pain medication, due to the sedating effects. However, she agreed that if the resident were crying out in pain during treatment, it would be acceptable to stop the treatment and administer as needed [MEDICATION NAME], and come back to resume the treatment in a 1/2 hour. A Pain Management Review dated (MONTH) 27, 2019 revealed the resident was not interviewable. The document stated that the resident displayed crying, grimacing, moaning, grunting, and yelling out at baseline. It stated that when the resident is experiencing pain or needed a break in care related to possible discomfort, she tapped her fist or open palm repeatedly on the nearest surface to indicate that there may be an issue or discomfort. The note stated that interventions included, but were not limited to, taking a break from care, repositioning, calming speech, distraction, tv, and offering as needed medication. On (MONTH) 27, 2019 at 10:15 AM, an interview was conducted with a CNA (staff #145). She stated that while she provides care to residents, she definitely monitors for pain or changes in behaviors. She stated that she feels any type of pain is concerning. If a resident was non-verbal, she said she would watch for facial expressions and reactions to care. She said that if the resident always reacts to treatment as if they were in pain, she would pay attention to a more intense reaction. Staff #145 stated that she works with resident #51 on a regular basis, and has become very familiar with the resident's responses. She stated that she definitely believed the resident was in pain during her treatment. She said that resident #51 reacted per her norm at first, but during the removal of the dressing, cleaning of the wound, and application of therahoney, the resident reacted as if she were in pain. The facility's policy titled Pain Management stated it is the policy of the facility to provide an environment and programs that assist each resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Residents are provided and receive the care and services needed according to established practice guidelines. Resident pain is assessed and managed by an interdisciplinary team who work together to achieve the highest practicable outcome. Additionally, the policy stated the facility assists each resident with pain to maintain or achieve the highest practicable level of well-being and functioning by screening to determine if the resident has been or is experiencing pain, comprehensively assessing the pain, and identifying circumstances when pain can be anticipated. The policy also stated that residents will be assessed for pain upon development of new symptoms of acute or chronic pain that have not previously been assessed, and staff should consult the physician for additional interventions if pain is not relieved by the currently ordered treatment modalities and comfort measures.",2020-09-01
156,CASAS ADOBES POST ACUTE REHAB CENTER,35070,1919 WEST MEDICAL STREET,TUCSON,AZ,85704,2019-06-27,732,B,0,1,RFYH11,"Based on observations and staff interviews, the facility failed to ensure the daily posted nurse staffing information was complete. Findings include: An observation was conducted on (MONTH) 24, 2019 at 10:14 a.m. of the posted nurse staffing information dated (MONTH) 24, 2019 located in a bookcase with glass doors at the entrance of the building to the right of the reception desk. On the daily nurse staffing information form three nursing shifts were listed with the following times: 6:00 a.m. - 2:00 p.m., 2:00 p.m. - 10:00 p.m., and 10:00 p.m. - 6:00 a.m. for the Registered Nurses, Licensed Practical Nurses, and the Certified Nursing Assistants. However, no nursing hours were documented for the nursing staff on the 2:00 p.m. - 10:00 p.m. and 10:00 p.m. - 6:00 a.m. shifts. During an observation conducted on (MONTH) 25, 2019 at 11:03 a.m. of the daily posted nurse staffing information dated (MONTH) 25, 2019, again no hours were observed documented for the nursing staff on the 2:00 p.m. - 10:00 p.m. and the 10:00 p.m. - 6:00 a.m. shifts. An interview was conducted with the Staffing Coordinator (staff #118) with the Director of Nursing (staff #151) present on (MONTH) 26, 2019 at 10:02 a.m. Staff #118 stated that she is responsible for ensuring the daily nurse staffing information is accurate and posted. She stated that the hours missing for the two shifts on the nurse staffing information for (MONTH) 24 and 25, 2019 is required to be documented and that she would be including that information going forward. Review of the facility's policy regarding Posted Staffing Numbers revealed the daily posting is to include hours worked by the Registered Nurses, Licensed Practical Nurses, and Nursing Assistants for each shift.",2020-09-01
157,CASAS ADOBES POST ACUTE REHAB CENTER,35070,1919 WEST MEDICAL STREET,TUCSON,AZ,85704,2019-06-27,757,E,0,1,RFYH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure one of five sampled residents (#33) was free from unnecessary drugs, by failing to administer drugs according to the physician ordered parameters. The deficient practice could result in low blood pressures and residents receiving drugs which may not be necessary. Findings include: Resident #33 was admitted on (MONTH) 18, 2019 with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the MAR for (MONTH) 2019 revealed [MEDICATION NAME] was administered on (MONTH) 21 for a blood pressure of 101/65 and (MONTH) 31 for a blood pressure of 80/89. Further review of the MAR for (MONTH) 2019 revealed [MEDICATION NAME] was administered on (MONTH) 6 for a pulse of 58, (MONTH) 10 for a pulse of 58, (MONTH) 13 for a pulse of 58, (MONTH) 14 for a pulse of 53, (MONTH) 15 for a pulse of 51, (MONTH) 17 for a pulse of 50, (MONTH) 18 for a pulse of 58, (MONTH) 19 for a pulse of 55, (MONTH) 20 for a pulse of 59, (MONTH) 25 for a pulse of 55, (MONTH) 26 for a pulse of 55, (MONTH) 28 for a pulse of 54, (MONTH) 29 for a pulse of 58, and (MONTH) 31 for a pulse of 56. Review of the MAR for (MONTH) 2019 revealed [MEDICATION NAME] was administered on (MONTH) 1 for a pulse of 58, (MONTH) 2 for a pulse of 52, and (MONTH) 3 for a pulse of 54. An interview was conducted on (MONTH) 25, 2019 at 2:02 PM with a Licensed Practical Nurse (LPN/staff # 5). The LPN stated that she checks a resident's blood pressure and pulse before administering antihypertensive medications. She also stated that she follows the physician's orders [REDACTED]. During an interview conducted with a LPN (staff #115) on (MONTH) 25, 2019 2:14 PM, the LPN stated that she would not administer an antihypertensive if the blood pressure and pulse were outside of the ordered parameters. She stated that administered the blood pressure medication outside of the ordered parameters could result in the resident having a low blood pressure and/or pulse. Review of the facility's policy for Administration of Drugs revealed medications must be administered in accordance with the written orders of the attending physician. The policy also included medications are checked against the order before they are given.",2020-09-01
158,CASAS ADOBES POST ACUTE REHAB CENTER,35070,1919 WEST MEDICAL STREET,TUCSON,AZ,85704,2019-06-27,761,E,0,1,RFYH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and review of policy and procedures, the facility failed to ensure expired medications and biologicals in one of two medication rooms and one of four medication carts were not available for resident use. The deficient practice could result in expired medications being administered to residents. Findings include: On (MONTH) 25, 2019 at 11:20 a.m., an observation of the 200 hall medication room was conducted with a Licensed Practical Nurse (LPN/staff #51). The following medications and biologicals were observed stored on the shelves: -30 purple topped Vacutainer with an expiration date of (MONTH) 31, (YEAR) -7 bottles of Aspirin (nonsteroidal anti-[MEDICAL CONDITION] drug) with an expiration date of (MONTH) 2019 -2 bottles of[NAME]Vite (supplement) with an expiration date of (MONTH) 2019 -6 bottles of [MEDICATION NAME] (supplement) with an expiration date of (MONTH) 2019 -1 bottle of Folic acid (supplement) with an expiration date of (MONTH) 2019 -3 bottles of Magnesium chloride (supplement) with an expiration date of (MONTH) 2019 -4 18 Gauge shielded catheters with an expiration date of (MONTH) 30, 2019 During an observation of the medication cart on the 500 hall conducted on (MONTH) 26, 2019 at 2:10 p.m. with a Registered Nurse (RN/staff #70), the following were stored in the cart: -2 cards of [MEDICATION NAME] (antipsychotic) 1 mg tablets with an expiration date of (MONTH) 31, 2019 -1 Piston irrigation tray with an expiration date of (MONTH) 31, (YEAR) An interview was conducted with the Director of Nursing (DON/staff #151) on (MONTH) 26, 2019 at 12:56 p.m. The DON stated that her expectation is that the nurses dispose expired medications. During an interview conducted with the RN (staff #70) on (MONTH) 26, 2019 at 2:20 p.m., the RN stated that she had not noticed the expiration dates before the observation but that she would dispose the products. The facility's policy titled Medication Access and Storage revealed outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are removed from stock, disposed of according to procedures for medication destruction, and reordered from the pharmacy, if a current order still exists.",2020-09-01
159,MISSION PALMS POST ACUTE,35071,6461 EAST BAYWOOD AVENUE,MESA,AZ,85206,2020-01-09,609,D,1,0,VTMM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interviews, record reviews and review of policies and procedures and review of the State Agency Data base, the facility failed to ensure that an allegation of abuse for one resident (resident #1) was reported to the Administrator, and to other officials including AZDHS (Arizona Department of Health Services) and APS (Adult Protective Services). The deficient practice may result in additional allegations of abuse not being reported to the Administrator and to other officials. Findings include: Resident #1 was admitted on (MONTH) 21, 2019 with [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set Assessment) dated (MONTH) 26, 2019 included a BIMS (Brief Interview for Mental Status) score of 14, which indicated that resident #1 was cognitively intact. The assessment included that resident #1 had clear comprehension and understands others, and required limited physical assistance from another person for bed mobility, transferring, walking in the room, toilet use and bathing. Review of the clinical record from (MONTH) 21, 2019 through (MONTH) 8, 2020 did not reveal documented evidence of behavioral symptoms, or behavioral care interventions associated with the resident's diagnosed dementia with behavioral disturbance or depression. Review of the State Agency database revealed that on (MONTH) 8, 2020 a report was received by the State Agency that resident #1 had been touched inappropriately by a CNA (Certified Nursing Assistant) on (MONTH) 6, 2020. The reporting source identified the CNA as staff #87, and included that the Social Services Director was informed of the allegation. The reporting source also included that staff #87 was not removed from duty and completed his shift after the allegation was reported to the Social Services Director. An interview was conducted on (MONTH) 8, 2020 at 1:45 p.m. with staff #87 who stated that he had been assigned to care for resident #1 on (MONTH) 6, 2020. Staff #87 stated that resident #1 functioned independently with care and that he did not provide any hands on care to the resident during his shift. Staff #87 stated that nothing unusual had occurred during his care of resident #1. During an interview conducted on (MONTH) 9, 2020 at 9:00 a.m. with resident #1, she stated repeatedly that she had not been touched inappropriately or mistreated by any staff or other person at the facility. An interview was conducted on (MONTH) 9, 2020 at 9:10 a.m. with the Social Services Director (staff #58) who stated that resident #1 has not voiced any allegations or accusations that any staff or other resident had tried to touch her inappropriately, or asked if they could touch her and has not voiced any allegations of abuse or mistreatment. An interview was conducted on (MONTH) 9, 2020 at 9:58 a.m. with an RN (Registered Nurse/staff #106). The RN stated that on (MONTH) 9, 2020 at 11:00 a.m. resident #1 stated to her that she had been touched and had told the person who touched her don't touch me there. The RN stated that when she asked the resident where she had been touched, the resident pointed to her shoulder and upper chest area near her shoulder. The RN stated that at that moment a CNA (staff #87) was walking by and the resident pointed with her lips at the CNA and stated don't tell anyone. When asked to define what she meant when she stated that the resident had pointed with her lips at the CNA, the RN stated we were speaking in Spanish and she pointed with her lips. The RN stated that she took the resident to the DON's Director of Nursing/staff #125) office and told her the the resident had something to tell her and the DON directed the RN to take the resident to the Social Service office. During the interview conducted on (MONTH) 9, 2020 at 9:58 a.m. with RN/staff #106, the RN did not state at any time that she informed the Administrator or the Director of Nursing that resident #1 had voiced a possible allegation of abuse, or that resident #1 had indicated that a CNA (staff #87) had touched her inappropriately or abused her. An interview was conducted on (MONTH) 9, 2020 at 10:25 a.m. with the Social Services Director (staff #58) who stated that on (MONTH) 6, 2020 an RN (staff #106) had brought resident #1 into her office and told her that resident #1 has something to tell you. Staff #58 stated that the resident who was seated in a wheelchair, looked up at the RN and asked her Now what am I supposed to say and the RN told resident #1 just tell her what you told me and then the RN exited staff #58's office. Staff #58 stated it was now just she and resident #1 in the office and the resident stated that someone had asked if they could touch her. However, staff #58 stated that resident #1 was unable to provide additional details regarding who had asked to touch her, or when, or where this had occurred, or if this had even occurred in the facility. The social worker stated that the RN did not tell her that a CNA/staff #87 had been accused of touching resident #1 inappropriately, and if the RN had told her that, she would have immediately notified the Director of Nursing. During interviews conducted on (MONTH) 9, 2020 with the Director of Nursing/staff #125 she stated the following: -At 10:35 a.m. she stated that on (MONTH) 6, 2020 she saw the RN/staff #106 wheeling resident #1 in front of the Social Service office and that the RN told her that resident #1 had a concern but did not say what the concern was, and the Director told the RN to take resident to see the social worker. The Director stated that RN did not tell her that resident #1 had voiced a possible allegation of abuse, and that later that morning when the social worker told her what resident #1 had said about someone asking to touch her she immediately interviewed resident #1, and that the resident had stated that nobody had touched her inappropriately or had asked to touch her in an inappropriate manner. The Director also stated that she had a private meeting with the RN on (MONTH) 6, 2020 at 4:30 p.m. and that the RN did not tell inform her during the private meeting that resident #1 had voiced an allegation of abuse. -At 1:10 p.m. the Director stated that when a resident voices an allegation of abuse to staff, the staff is to immediately report the allegation to the Administrator, whose phone number is available at the nurses station. The Director stated that if a staff is accused of abuse, the staff is to report to her office immediately, she obtains a statement from the staff, and the staff is removed from duty. The Director stated that the RN did not notify her, or any other staff, including the Administrator, about an allegation of abuse for resident #1, and that because the RN did not follow the protocol for reporting abuse, the allegation was not reported and the accused CNA was not removed from duty that day. Review of a personnel record for the RN/staff #106 revealed a notice dated (MONTH) 1, 2019 and signed by the RN regarding the Elder Justice Act. Further review of the notice revealed a statement that ALL EMPLOYEES have the following responsibilities and rights under Federal Law: If you reasonably suspect that a crime has been committed against a resident or person receiving care in the facility, you MUST report that suspicion to the police AND State Survey Agency within 2 hours after you first suspect that a crime has occurred if the suspected crime involves serious bodily injury to the individual, or within 24 hours if there is no serious injury involved. A policy and procedure titled Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment included a statement that it is the policy of the facility that each resident has the right to be free from abuse, neglect, exploitation and mistreatment. The policy included that the facility will ensure that all alleged violations of abuse, neglect, exploitation and mistreatment are reported within two hours, and that all alleged violations are reported to the Administrator of the facility, the State Survey Agency and Adult Protective Services.",2020-09-01
160,MISSION PALMS POST ACUTE,35071,6461 EAST BAYWOOD AVENUE,MESA,AZ,85206,2020-01-09,610,D,1,0,VTMM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interviews, record reviews and review of policies and procedures and review of the State Agency Data base, the facility failed to investigate an allegation of abuse for one resident (#1) and failed to prevent further potential abuse during the investigation, by failing to remove from duty a staff member (#87) who the resident accused of abusing her. The deficient practice may result in additional allegations of abuse not being investigated and residents not being protected from further abuse while an investigation is ongoing Findings include: Resident #1 was admitted on (MONTH) 21, 2019 with [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set Assessment) dated (MONTH) 26, 2019 included a BIMS (Brief Interview for Mental Status) score of 14, which indicated that resident #1 was cognitively intact. The assessment included that resident #1 had clear comprehension and understands others, and required limited physical assistance from another person for bed mobility, transferring, walking in the room, toilet use and bathing. Review of the State Agency database revealed that on (MONTH) 8, 2020 a report was received by the State Agency that resident #1 had been touched inappropriately by a CNA (Certified Nursing Assistant) on (MONTH) 6, 2020. The reporting source identified the CNA as staff #87, and included that the Social Services Director was informed of the allegation. The reporting source also included that staff #87 was not removed from duty and completed his shift after the allegation was reported to the Social Services Director. An interview was conducted on (MONTH) 8, 2020 at 1:45 p.m. with staff #87 who stated that he had been assigned to care for resident #1 on (MONTH) 6, 2020. Staff #87 stated that resident #1 that he did not provide any hands on care to the resident during his shift, and that he did complete his shift, and has not worked since that day. An interview was conducted on (MONTH) 9, 2020 at 9:10 a.m. with the Social Services Director (staff #58) who stated that resident #1 has not voiced any allegations or accusations that any staff or other resident had tried to touch her inappropriately, or asked if they could touch her and has not voiced any allegations of abuse or mistreatment. An interview was conducted on (MONTH) 9, 2020 at 9:58 a.m. with an RN (Registered Nurse/staff #106). The RN stated that on (MONTH) 9, 2020 at 11:00 a.m. resident #1 stated to her that she had been touched and had told the person who touched her don't touch me there. The RN stated that when she asked the resident where she had been touched, the resident pointed to her shoulder and upper chest area near her shoulder. The RN stated that at that moment a CNA (staff #87) was walking by and the resident pointed with her lips at the CNA and stated don't tell anyone. The RN stated that she took the resident to the DON's Director of Nursing/staff #125) office and told her the the resident had something to tell her and the DON directed the RN to take the resident to the Social Service office. During the interview conducted on (MONTH) 9, 2020 at 9:58 a.m. with RN/staff #106, the RN did not state at any time that she informed the Administrator or the Director of Nursing that resident #1 had voiced a possible allegation of abuse, or that resident #1 had indicated that a CNA (staff #87) had touched her inappropriately or abused her, or that she had removed staff #87 from duty when the resident accused him of touching her inappropriately. An interview was conducted on (MONTH) 9, 2020 at 10:25 a.m. with the Social Services Director (staff #58) who stated that on (MONTH) 6, 2020 an RN (staff #106) had brought resident #1 into her office and told her that resident #1 has something to tell you. However, the social worker stated that the RN did not tell her that a CNA/staff #87 had been accused of touching resident #1 inappropriately, and if the RN had told her that, she would have immediately notified the Director of Nursing. During interviews conducted on (MONTH) 9, 2020 with the Director of Nursing/staff #125 she stated the following: -At 10:35 a.m. she stated that on (MONTH) 6, 2020 that RN/staff #106 did not tell her that resident #1 had voiced a possible allegation of abuse, and that during a private meeting with the RN on (MONTH) 6, 2020 at 4:30 p.m. and the RN did not tell inform her during the private meeting that resident #1 had voiced an allegation of abuse. -At 1:10 p.m. the Director stated that when a resident voices an allegation of abuse to staff, the staff is to immediately report the allegation to the Administrator, whose phone number is available at the nurses station. The Director stated that if and a staff is accused of abuse, the staff is to report to her office immediately, she obtains a statement from the staff, and the staff is removed from duty and they start an investigation. The Director stated that because the RN did not notify her, or any other staff, including the Administrator, about an allegation of abuse for resident #1, and did not follow the protocol for reporting abuse, the allegation was not reported and the accused CNA was not removed from duty that day. A policy and procedure titled Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment included a statement that it is the policy of the facility that each resident has the right to be free from abuse, neglect, exploitation and mistreatment. The policy included that in order to comply with the Facility's obligations as set forth in 42 CFR Section 483.12, it will conduct a prompt, thorough and complete investigation in response to reportable allegations of abuse, neglect, mistreatment, exploitation, or misappropriation of resident property. A policy and procedure titled Abuse: prevention of and Prohibition Against included a statement that if an allegation of abuse, neglect, misappropriation of resident property, or exploitation is reported, discovered or suspected, the facility will take steps to protect all residents from physical and psychological harm during and after the investigation. If the allegation of abuse, neglect, misappropriation of resident property, or exploitation involves and employee, the facility will immediately remove he employee from the care of any resident, and suspend the employee during the pendancy of the investigation.",2020-09-01
161,MISSION PALMS POST ACUTE,35071,6461 EAST BAYWOOD AVENUE,MESA,AZ,85206,2019-03-07,677,D,0,1,D8F311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, facility documentation, and resident and staff interviews, the facility failed to ensure 1 of 3 sampled residents (#295) received an adequate number of showers. The deficient practice could result in hygiene needs not being met. Findings include: Resident #295 was admitted to the facility on (MONTH) 26, 2019 with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set assessment dated (MONTH) 5, 2019, revealed a Brief Interview for Mental Status score of 13 which indicated the resident was cognitively intact. The assessment included the resident was totally dependent for bathing and required extensive assistance for personal hygiene and dressing. An interview was conducted with resident #295 on Tuesday, (MONTH) 5, 2019 at 8:25 AM. The resident stated that she had not had a shower since admission. She stated she was supposed to receive a shower twice a week. She said that on her last scheduled shower day, the Certified Nursing Assistant (CNA) informed her there was no time to give her a shower on the day shift and that the next shift would assist her with a shower. The resident stated when she asked the CNA on the next shift for a shower, the CNA did not respond. Review of the facility's shower schedule revealed the resident was scheduled for showers on Wednesday/day shift and Saturday/night shift. A second interview was conducted with resident #295 on Thursday, (MONTH) 7, 2019 at 1:16 PM. The resident stated that she still had not received a shower despite several requests. She stated the CNA currently on shift told her that she could not give her a shower because she had three other showers scheduled for that day. She stated the CNA also told her that her shower day was on Wednesday. The resident stated she did not receive a shower yesterday. During the interview, the resident was observed sitting in her wheelchair in her room. The resident was dressed in pajamas and her hair did not appear to be combed. Review of the shower book containing shower sheets for (MONTH) 2019 revealed one shower sheet for resident #295. The shower sheet was dated (MONTH) 2, 2019 and contained documentation that a shower was not provided due to only one CNA being on shift. The sheet was signed by the CNA and the charge nurse. An interview was conducted with the resident's CNA (staff #71) on (MONTH) 7, 2019 at 1:25 PM. The CNA stated residents receive showers twice a week and upon request. She stated the CNAs document the shower on a shower sheet and have the nurse sign it. The CNA said if a resident refuses a shower, the refusal and the reason for the refusal will be documented on the shower sheet and the resident will be asked to sign the sheet. The CNA also stated that showers are sometimes missed due to short staffing. She stated that she knows if a resident had a shower by looking in the shower book. She said if there is no shower sheet she would assume the shower was not provided. The Administrator (staff #65) was asked if there were any additional shower sheets as there was only one in the shower book. Approximately 2 hours later the Director of Nursing (staff #84) provided two more shower sheets. One was dated (MONTH) 3, 2019 which included the resident received a shower. The second sheet was dated (MONTH) 7, 2019 which included the resident received a shower. A follow up interview was conducted with staff #71 on (MONTH) 7, 2019 at 3:03 PM. Staff #71 stated she was working on (MONTH) 3, 2019 but she did not give resident #295 a shower that day. The CNA stated she just cleaned her up a little bit but it was not even a bed bath. She also stated the sheet was not in the shower book earlier today because she had just filled it out. She stated one of the supervisors asked her to sign it. The CNA also stated that resident #295 was provided a shower today, (MONTH) 7, 2019.",2020-09-01
162,MISSION PALMS POST ACUTE,35071,6461 EAST BAYWOOD AVENUE,MESA,AZ,85206,2019-03-07,687,G,0,1,D8F311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, and family and staff interviews, the facility failed to provide care and treatment for one (#2) of two sampled residents with routine foot care, which resulted in an infection to the resident's toe. The facility census was 99. Findings include: Resident #2 was admitted to the facility on (MONTH) 15, (YEAR), with [DIAGNOSES REDACTED]. A care plan for alteration in skin due to mobility limitations dated (MONTH) 2, (YEAR) included a goal that the resident would be free from additional skin breakdown/irritation. An approach included .Podiatry consult and treatment as indicated . A significant change MDS (Minimum Data Set) assessment dated (MONTH) 8, (YEAR) revealed the resident's BIMS (Brief Interview for Mental Status) score was 13, indicating intact cognition. The MDS further revealed the resident required extensive assistance of one person with personal hygiene. Review of the Comprehensive CNA (certified nursing assistant) Shower Reviews dated (MONTH) 3, 22 and 26, (YEAR), (MONTH) 12 and 19, 2019, and (MONTH) 6, 13, 26 and 20, 2019 revealed the following: .Does the resident need his toenails cut? Yes . The Shower Reviews were signed by a licensed nurse. However, there was no clinical record documentation that the resident's toenails were cut from (MONTH) (YEAR) through (MONTH) 2019. Review of a Comprehensive CNA Shower Review dated (MONTH) 2, 2019 revealed .Does the resident need his toenails cut? Yes. Right big toenail is coming off. The Shower Review sheet was signed by a licensed nurse. There was no clinical record documentation that the resident's right toenail had been addressed on (MONTH) 2 or 3 or on (MONTH) 4, 2019, prior to 2:07 p.m. An interview was conducted on (MONTH) 4, 2019 at 2:07 p.m., with the resident and a family member. The family member stated that podiatry care had been requested, but they were informed that the podiatrist was just at the facility or the resident was not on the podiatry list. The resident's family member stated that the resident's toenails are long and needed to be cut. The resident's family member then proceeded to take the resident's socks off. The resident's toenails were observed to be approximately 1/4 inch past the tips of his toes and the right great toe was red and swollen. The family member immediately notified a RN (registered nurse/staff #107). An assessment of the resident's right great toe was conducted on (MONTH) 4, 2019 at 3:08 p.m., by the wound nurse. Per the Wound Assessment Note the following was documented: Resident seen today as report of right great toe possibly infected. Resident's nail on right great toe lifted, area below nail red and warm, blanchable at this time. Reported to primary doctor. New orders received for daily dressing change using [MEDICATION NAME] and Kerlix. Also orders for antibiotic therapy for five days. Podiatrist contacted with permission from family and primary doctor. Toenails were trimmed during this visit but needs a podiatry visit. A Physician's Note dated (MONTH) 4, 2019 included .Right great toe redness with discharge .Right great toe infection concerning for underlying infection, placed on [MEDICATION NAME] (antibiotic) 100 milligrams twice a day for five days . A physician's orders [REDACTED]. A Podiatry Note dated (MONTH) 5, 2019 documented .Patient seen for examination and care of feet and nails. Seen for follow-up care of feet and nails .Nails painful and uncomfortable. Patient unable to cut own toenails .Nurses state patient jammed right foot and great toenail is loose .Nails elongated 1 - 5 bilaterally. Thickened, yellow, dystrophic painful nails 1-5 left and 1-5 right. Lytic (infection) right first toenail. Localized [DIAGNOSES REDACTED] and serosanguinous drainage. Subungual hematoma. Tender to palpation .Pitting [MEDICAL CONDITION] bilaterally 2/4 or greater .Reduced nails 1-5 bilaterally, manual and mechanical debridement .Elevate legs throughout the day as much as possible to reduce swelling. Nail removed following cleansing area with alcohol pad .[MEDICATION NAME] and Band-Aid applied to be changed every day for 5 days. Notify if any increased signs of infection occur, including but not limited to purulence, swelling, redness and streaking . Another physician's orders [REDACTED]. Pat dry. Apply [MEDICATION NAME] (antibiotic ointment) and Band-Aid daily times seven days. Monitor for signs of infection. A Nurse's Note dated (MONTH) 5, 2019 documented Patient on oral [MEDICATION NAME] for right great (toe) infection. First dose started today. Podiatrist in facility today to treat patient's toes. Dressing change daily with [MEDICATION NAME] . An interview was conducted with a CNA (staff #66) on (MONTH) 6, 2019 at 1:51 p.m. Staff #66 stated that if she noticed that a resident's toenails were long she would document it on the Shower Review sheet, and then the licensed nurses are supposed to cut the resident's toenails. The CNA stated that she had noticed that the resident's toenails were long. An interview was conducted with a LPN (licensed practical nurse/staff #118) on (MONTH) 7, 2019 at 9:31 a.m. Staff #118 stated that if a CNA documented on the Shower Review sheet that a resident needed their toenails cut, she would assess the resident and cut the toenails if needed. An interview was conducted with a RN (staff #107) on (MONTH) 7, 2019 at 10:19 a.m. Staff #107 stated that when she signs the Shower Review sheets, she is just acknowledging that the resident received a shower. Staff #107 stated that the resident's toenails were very hard and he needed a podiatrist to trim his nails. Staff #107 stated the resident has been at the facility for almost two years, but she did not know if the resident had ever been seen by the podiatrist. Staff #107 further stated that she had asked the resident why he didn't tell her that he needed his toe nails cut. An interview was conducted with the DON (Director of Nursing/staff #84) on (MONTH) 7, 2019 at 10:34 a.m. Staff #84 stated that if anything new is documented on the Shower Review sheets, the licensed nurses should assess the resident. Staff #84 stated that if the resident is diabetic or the licensed nurse was unable to cut the resident's toenails, the licensed nurse should write a consult for podiatry care. Another interview was conducted with staff #84 on (MONTH) 7, 2019 at 11:40 a.m. Staff #84 stated that the facility did not have a policy regarding foot care, but it was a standard of practice.",2020-09-01
163,MISSION PALMS POST ACUTE,35071,6461 EAST BAYWOOD AVENUE,MESA,AZ,85206,2019-03-07,689,G,1,1,D8F311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews and facility and hospital documentation, the facility failed to ensure that adequate supervision was provided to one (#193) of two sampled residents during care, resulting in a fall with a fracture. The resident census was 99. Findings include: Resident #193 was admitted to the facility on (MONTH) 11, 2014, with [DIAGNOSES REDACTED]. Review of a quarterly MDS (Minimum Data Set) assessment dated (MONTH) 1, (YEAR), revealed the resident had a BIMS (Brief Interview for Mental Status) score of 6, which indicated severe cognitive impairment. In Section G, Functional Status, the resident was assessed to require the assistance of two or more with bed mobility. A care plan included the resident had a self care deficit, as evidenced by maximum assist for most ADL's (activities of daily living) related to muscle weakness with additional risk related to orthostatic [MEDICAL CONDITION] . The goals were Will participate to ability .Will be washed, dressed . Approaches included Setup, cue and assist as needed for ADLs. Encourage participation to ability. Task segmentation as needed .Provide assist as needed for completion of ADL cares . The care plan did not include that the resident required the assistance of two or more with bed mobility. A Nurse's Note dated (MONTH) 18, (YEAR) documented .total care with ADLs, bed mobility and transfers. Another Nurse's Note dated (MONTH) 29, (YEAR) documented the resident was total care with ADLs, bed mobility and Hoyer lift for transfers. A Medicare Note dated (MONTH) 28, (YEAR) included .was changing the patient in bed. Patient fell out of bed and onto the floor .Patient was still in pain at time of transfer but was alert again and able to answer some questions appropriately but still had a noticeable change in mentation. A written statement by a RN (registered nurse/staff #110) dated (MONTH) 28, (YEAR) documented the supervisor (staff #110) was notified that the resident was involved in a fall. The CNA (certified nursing assistant/staff #136) reported that he was cleaning the patient in bed without the assistance of another CN[NAME] Per the statement, he had the resident roll on his side with the resident's body facing toward him. The CNA reported that the resident began to roll into his body and off the bed and that he attempted to break the patient's fall with his body, but the resident ultimately fell to the ground. The CNA was asked how hard the resident had hit the floor and the CNA responded with some force. The CNA was asked if the resident hit his head and he responded no. The floor nurse reported that he entered the room to find the resident on the floor face down. When supervisor entered the room, the resident was already placed back in bed. Supervisor assessed the resident. His face was pale and he had a dazed look in his eyes. Pupils were sluggish to react. Resident was asked if he was feeling any pain and stated that he had a headache which he rated at a 7 out of 10, with 10 being the worst pain he ever felt. Also noted a 12 centimeter circular skin tear to the right arm. When asking the resident if he was experiencing any pain in his arm, he stopped responding to questions. His head fell back onto the pillow and he seemed to lose consciousness. MD was notified. He advised to send the resident to the emergency department for assessment. Hospital documentation dated (MONTH) 28, (YEAR) included the following: .A CNA was attempting to wash the patient while on his bed. The bed was raised at the time with no safety rails as the CNA rolled the patient to wash his back. The patient fell off his bed and on to the ground. The patient hit his head resulting in loss of consciousness .Stable small presumed left frontal subdural hygroma without mass effect .Stable low-density 8 millimeter left frontal potential subdural hygroma without significant interval change .There is a mildly impacted [MEDICAL CONDITION] humeral neck . A Nurse's Note dated (MONTH) 29, (YEAR) revealed Late entry (MONTH) 28, (YEAR). Patient fell out of bed during patient care by CN[NAME] Assessment done and charge nurse during shift notified .Patient sent out to .hospital. Review of the facility's Reportable Event Record Report dated (MONTH) 2, (YEAR) revealed .At approximately 6:00 a.m. on (MONTH) 28, (YEAR), the CNA was performing bed bath/linen change on resident .when resident appeared to no longer participate and subsequently rolled out of the bed. Immediate assessment following the fall concluded significant symptomatic [MEDICAL CONDITION]. Resident .was transported to (name of hospital) and admitted for symptomatic [MEDICAL CONDITION]. On (MONTH) 29, (YEAR), per hospital records, x-rays of bilateral shoulder and bilateral hand/wrists were obtained and conclusive for positive [MEDICAL CONDITION] shoulder . Further review of the clinical record revealed the resident was readmitted to the facility on (MONTH) 3, (YEAR) and was enrolled in hospice services. A Change in Condition Note dated (MONTH) 9, (YEAR) documented Late entry (MONTH) 8, (YEAR) .Time of death called .at 7:07 p.m . An interview was conducted with a RN (staff #110) on (MONTH) 6, 2019 at 9:13 a.m. Staff #110 stated that a CNA (staff #136) was caring for the resident at the time of the fall. Staff #110 said the CNA rolled the resident toward himself to provide care and the resident stiffened and fell out of bed. Staff #110 stated the resident's bed was at the normal height and that the resident only required one person for cares while in bed. Multiple attempts were made to contact staff #136 by telephone on (MONTH) 6 and 7, 2019, however were unsuccessful. An interview was conducted with the Therapy Director (staff #11) on (MONTH) 7, 2019 at 9:54 a.m. Staff #11 stated that if a resident required maximum assistance for bed mobility it would mean that one or two staff were required to assist the resident. An interview was conducted with the MDS coordinator (staff #64) on (MONTH) 7, 2019 at 10:45 a.m. Staff #64 stated that the resident was a big guy and should of had two staff for bed mobility. An interview was conducted with a CNA (staff #58) on (MONTH) 7, 2019 at 11:15 a.m. Staff #58 stated that if he was unsure if a resident required one or two staff for bed mobility and cares, he would check with a nurse. An interview was conducted with the DON (Director of Nursing/staff #84) on (MONTH) 7, 2019 at 11:21 a.m. Staff #84 stated that the facility only initiated a two person assist for bed mobility after a fall, or if a resident had a large abdominal girth, which would put the resident at risk with turning in a bed. Staff #84 stated the facility's Smart Charting (CNA charting tool) is updated by the MDS. Staff #84 stated that she was unable to review how much assistance the resident required at the time of this fall, as the resident was readmitted to the facility and she was only able to review the most recent admission. Staff #84 stated that if the MDS included that the resident required a two person physical assist for bed mobility, this information should have auto-populated to the Smart Charting.",2020-09-01
164,MISSION PALMS POST ACUTE,35071,6461 EAST BAYWOOD AVENUE,MESA,AZ,85206,2019-03-07,725,E,0,1,D8F311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, resident and staff interviews, and the facility's assessment, the facility failed to ensure there were sufficient nursing staff to meet the needs of multiple residents (#248, #247, #69, #7, #28, #250, #2, #26, #295 and #46). The deficient practice resulted in residents' needs not being met. The resident census was 99. Findings include: Interviews were conducted with multiple residents regarding staff response time to residents' call lights and nursing services and included the following: -Resident #248 was interviewed on (MONTH) 4, 2019 at 12:27 p.m. He stated that he has waited up to 30 minutes for his call light to be answered. The admission Minimum Data Set (MDS) assessment dated (MONTH) 22, 2019, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident's cognition was intact. -Resident #247 was interviewed on (MONTH) 4, 2019 at 12:57 p.m. He stated he has waited up to 45 minutes for assistance. The admission MDS assessment dated (MONTH) 2, 2019 revealed a BIMS score of 15, which indicated the resident was cognitively intact. -Resident #69 was interviewed on (MONTH) 4, 2019 at 1:12 p.m. She stated it takes about 30 minutes for staff to answer her call light. The resident stated staff will come into her room, turn the call light off and say they will come back, but that they never return. She stated the staffing is low at night and that there is only one Certified Nursing Assistant (CNA) for the entire hall. The quarterly MDS assessment dated (MONTH) 3, 2019 revealed a BIMS score of 12, which indicated the resident had moderate cognition impairment. -During the same interview conducted with resident #69, her roommate resident #7 stated that she has urinated through her clothes onto the wheelchair several times waiting for staff to assist her. The quarterly MDS assessment dated (MONTH) 22, 2019 revealed a BIMS score of 12, which indicated the resident had moderate cognition impairment. -Resident #28 was interviewed on (MONTH) 4, 2019 at 1:13 p.m. She said she is receiving [MEDICATION NAME] (diuretic) and she has waited a long time to have her brief changed especially at night. The admission MDS assessment dated (MONTH) 25, 2019 revealed a BIMS score of 13, indicating the resident was cognitively intact. -Resident #250 was interviewed on (MONTH) 4, 2019 at 1:27 p.m. He said that he has waited for 20 minutes for staff to assist him. The admission MDS assessment dated (MONTH) 6, 2019 revealed a BIMS score of 14, which indicated the resident had intact cognition. -Resident #2 was interviewed on (MONTH) 4, 2019 at 1:50 p.m., with a family member present. The family member stated resident #2 will not ask to be changed. It was observed the resident had a dried wet spot on his shorts. The Significant Change in Status MDS assessment dated (MONTH) 28, (YEAR) for resident #2, included a BIMS score of 13, indicating the resident was cognitively intact. -Resident #26 was interviewed on (MONTH) 4, 2019 at 2:21 p.m. He stated the facility is short staffed on the night shift and the weekends most of the time. He said there was one CNA providing care to 43 residents this past weekend. Review of the quarterly MDS assessment dated (MONTH) 10, (YEAR), revealed a BIMS score of 14, which indicated the resident had intact cognition. -Resident #295 was interviewed on (MONTH) 5, 2019 at 8:25 a.m. The resident stated she had not had a shower since admission (February 26, 2019). She stated she was supposed to receive a shower twice a week. She said that on her last scheduled shower day, the CNA informed her there was no time to give her a shower on the day shift and that the next shift would assist her with a shower. The resident stated when she asked the CNA on the next shift for a shower, the CNA did not respond. Review of the shower book containing shower sheets for (MONTH) 2019 revealed one shower sheet for resident #295. The shower sheet was dated (MONTH) 2, 2019 and contained documentation that a shower was not provided, due to only one CNA being on shift. The sheet was signed by the CNA and the charge nurse. At 8:36 a.m., resident #295 stated it can take up to an hour for staff to answer her call light. She said staff come into the room, turn the call light off, and tell her they will be right back. Resident #295 stated the staff are supposed to assist her to the toilet and that some of the staff have told her to go in her brief. Review of the admission MDS assessment dated (MONTH) 5, 2019 included a BIMS score of 13, which indicated the resident had intact cognition. Resident #295 was interviewed again on (MONTH) 7, 2019 at 1:16 p.m. The resident stated that she still had not received a shower despite several requests. She stated the CNA currently on shift told her that she could not give her a shower, because she had three other showers scheduled for that day. She stated the CNA also told her that her shower day was on Wednesday. The resident stated she did not receive a shower yesterday. During the interview, the resident was observed sitting in her wheelchair in her room. The resident was dressed in pajamas and her hair did not appear to be combed. -Resident #46 was interviewed on (MONTH) 5, 2019 at 9:29 a.m. She stated sometimes there is only one CNA on the night shift and the nurses work double shifts. Review of the quarterly MDS assessment dated (MONTH) 29, 2019 for resident #46 included a BIMS score of 15, indicating the resident was cognitively intact. Multiple residents were interviewed during a Resident Council meeting conducted on (MONTH) 6, 2019 at 2:23 p.m. Several residents stated there were not enough CNAs to provide care for the residents, and that sometimes residents have to wait 1 hour or longer to receive assistance. The residents stated often, only one CNA is working on station 1 during the evening shift. The residents also stated they will not put on their call light unless it is emergent, because one CNA cannot help all the residents on that station. An interview was conducted on (MONTH) 7, 2019 at 11:59 a.m. with the Staffing Coordinator (staff #55). Staff #55 stated staffing is determined by the acuity of care and the census. He stated when they are short staffed, staff will be asked to stay over to help and that he, the Assistant Director of Nursing (ADON), or the Charge Nurse will work a shift if needed. He stated there is never a time when there is only one CNA working on a unit. He then stated there is usually one CNA working once or twice a week on the night shift on Station 1. The Staffing Coordinator stated when this occurs, he will ask 2 CNAs from the day shift to stay and help for 2-3 hours to get residents ready for bed and that sometimes he will ask CNAs to come in early to help get residents up. He stated two CNAs are scheduled for Station 1 on the night shift and the expectation is that 2 CNAs work the entire shift. He said the census for Station 1 is always around 40 and requires two CNAs for the night shift. After reviewing the staff schedule for Friday, (MONTH) 1, 2019 and Saturday, (MONTH) 2, 2019, staff #55 acknowledged 2 CNAs did not work the entire shift on those nights and that the day shift CNAs did not stay to help for 2-3 hours and that no one came in early to assist the night CN[NAME] He further stated he had not heard of residents waiting for assistance for an hour or more. He also stated the nurses pass medications around 7:00 to 8:00 p.m. and the CNAs start assisting residents to bed around 7:00 p.m., so some residents may have to wait for a nurse to help with ADLs when there is only 1 CNA available. The Staffing Coordinator stated that he had not heard any residents complain the facility was short staffed. He stated it is usually the CNAs that complain about needing more help. An interview was conducted on (MONTH) 7, 2019 at 12:44 p.m. with the Administrator (staff #65), who stated the number of residents on Station 1 is usually stable. The administrator stated one CNA would be appropriate for a maximum of 15 residents for the day shift. She stated the night shift on station 1 required 2 CNAs and that a floater CNA and the charge nurse should be available to help. She stated that if a CNA called off, staff #55 would be responsible for working that shift or finding staff to work the shift. The Administrator stated that she has cut back on staff because they were overstaffed and the residents were used to having staff available at all times. During an interview conducted with a CNA (staff #71) on (MONTH) 7, 2019 at 1:25 PM, the CNA stated showers are sometimes missed due to short staffing. Review of the facility assessment revised (MONTH) 25, 2019 included how the facility determines and reviews individual staff assignments for coordination and continuity of care for residents, within and across assignments. The facility determines individual staff assignments based on the residents needs including activities of daily living to be done each shift and assign staff accordingly.",2020-09-01
165,MISSION PALMS POST ACUTE,35071,6461 EAST BAYWOOD AVENUE,MESA,AZ,85206,2019-03-07,761,E,0,1,D8F311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and policies and procedures, the facility failed to ensure that medications available for resident use on 3 of 6 medication carts were not expired, failed to ensure that medications were not pre poured, and failed to ensure that narcotics were properly stored for destruction. The deficient practices could result in expired medications being administered to residents; increased risk for potential medication errors among residents; and allowed easier access to narcotics. Findings include: -An observation was conducted on (MONTH) 7, 2019 at 9:29 AM, with a Registered Nurse (RN/staff #102) of the Oasis back hall medication cart. Inside the cart was one bottle of [MEDICATION NAME], which had an expiration date of (MONTH) 2019. -An observation was conducted on (MONTH) 7, 2019 at 10:26 AM of the Station 1 front hall medication cart, with a Licensed Practical Nurse (LPN/staff #124). One bottle of Vitamin D was observed with an expiration date of (MONTH) 2019. Also, in the top drawer of the cart, there were three medication cups with pills, which were labeled with the residents' name and room number. An interview was immediately conducted with staff #124. She stated the residents were not in their rooms when she went to administer their medications, so she stored their medications in the cart to administer to them later. The LPN stated it is not the facility's policy to pre-pour medications. Regarding the expired medication, staff #124 said when preparing a resident's medication, the expiration date should be checked. -An observation was conducted on (MONTH) 7, 2019 at 10:47 AM, with a LPN (staff #136) of the Station 2 back hall medication cart. Inside the cart was one bottle of normal control solution and one bottle of high control solution, which are used for glucometer calibration. The bottles had an expiration date of (MONTH) (YEAR). An interview was conducted with the Director of Nursing (DON/staff #84) on (MONTH) 7, 2019 at 12:10 PM. She stated supervisors conduct focus rounds on medication carts every day and the night nurse check for expired medications, but that it is ultimately the nurse's responsibility to check the expiration date on a medication when preparing the medication for administration. The DON stated that medications that are prepared in a medicine cup cannot be saved in the cart. She said if the resident is not available, the medications should be destroyed. During this same interview, the DON also stated that narcotics waiting for destruction are stored in a drawer in her office. The DON then proceeded to walk to her office. The door to the DON's office was observed wide open with no one inside. An observation of the desk drawer where the narcotics are stored revealed a single lock and one card of narcotics inside. The DON stated she has the only key to the drawer and the only key to her office. Multiple observations throughout the survey revealed the DON's office door was frequently wide open, with no one inside. With the door to the DON's office often observed being unlocked and open, the narcotics stored in the locked drawer were not stored under a double lock system. The facility's policy regarding medication administration revealed that medications are to be administered at the time they are prepared. The policy included that once removed from the package/container, unused medication doses shall be disposed of according to the nursing care center policy. The policy included the Medication Administration Record [REDACTED]. After completing the medication pass, the nurse returns to the missed resident to administer the medication. The policy further instructs to check expiration dates on the package/container and that no expired medication will be administered to a resident. Review of the facility's policy for controlled medication storage revealed that controlled medications remaining in the nursing care center after the order has been discontinued are retained in the nursing care center in a securely double locked area, with restricted access until destroyed as outlined by state regulation.",2020-09-01
166,MISSION PALMS POST ACUTE,35071,6461 EAST BAYWOOD AVENUE,MESA,AZ,85206,2019-03-07,812,E,0,1,D8F311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, facility documentation and policies and procedures, the facility failed to ensure eating utensils were properly cleaned prior to being stored for use, failed to ensure that quaternary sanitizing solution was maintained at the required level, and failed to ensure that food items stored in 1 of 3 nourishment refrigerators were properly dated, labeled and discarded, prior to their expiration dates. The deficient practices could result in the spread of possible foodborne illnesses. Findings include: -During an observation conducted on [DATE] at 08:56 AM in the dining room with the District Food Service Manager (staff #134), several coffee cups were observed being wiped down with a damp cloth and set up for use by a dietary aid (staff #37). An interview was conducted with staff #37 on [DATE] at 09:02 AM. Staff #37 stated that he uses a cloth damp with sanitizing solution to wipe down the cups and utensils prior to service because they come out of the dishwasher with a thin white calcium film. He stated he was instructed to and has been doing this practice for more than 5 years. Staff #37 stated the sanitizing solution was diluted with water and is also used as the solution to wipe down kitchen surfaces. During an interview conducted with the staff #134 on [DATE] at 11:20 AM, she stated she was unaware that staff #37 was wiping down the utensils with a cloth damped with sanitizing solution. She stated this is an unacceptable procedure and that the utensils should be rinsed with water prior to use. An interview was conducted with the Administrator (Staff #65) on [DATE] at 01:21 PM. The administrator stated it is her expectation that the dietary staff should not apply a cloth with sanitizing solution directly to eating utensils that are being set out for use without first rinsing the utensils with water to prevent possible chemical contamination. Review of the Material Safety Data Sheet for the Oasis 146 Multi-quat Sanitizer revealed the product is not to be ingested as it may cause mouth irritation. The sheet included that after dilution, contacted skin area should be rinsed with water for several minutes. The sheet also included toxicological information that the solution may cause irritation, watering or redness to contacted areas. The facility's Meal Distribution: Infection Control Considerations policy revealed dining service staff will be knowledgeable in proper techniques including chemical sanitizer dispensing. -An observation was conducted in the kitchen with staff #134 on [DATE] at 10:01 AM. Staff #134 used Litmus paper test strips to verify that the strength of the sanitizing solution being used to wipe down counter tops and other food equipment was within the required strength level of 150 ppm (parts per million) to 200 ppm. The strip used in the solution in one of the buckets did not register any strength revealing the sanitization solution was below the required strength. During an interview conducted with staff #134 on [DATE] at 11:20 AM., the manager stated the sanitizer solution should be between 150 ppm and 200 ppm. An interview was conducted with the Administrator (Staff #65) on [DATE] at 01:21 PM. The administrator stated that it is her expectation the sanitizing solution be at the correct strength at all times to properly sanitize the equipment. She stated the deficient strength of the solution is not an acceptable practice. -An observation was conducted on [DATE] at 10:02 AM of the nourishment refrigerators with the manager (staff #134) and the dietary manger (staff #133). The refrigerator for Hall 1 was observed to have one sandwich which was unlabeled and a bottle of mayonnaise with an expiration date of (MONTH) (YEAR). During an interview conducted with staff #134 on [DATE] at 11:20 AM, staff #134 stated the refrigerators are checked weekly and that unlabeled and expired food should not be in the refrigerators. An interview was conducted with the staff #133 on [DATE] at 01:10 PM. Staff #133 stated that he checks the snack refrigerators several times a week to ensure food items are properly labeled and not expired. He stated he missed the expired mayonnaise and that it must have been brought in by an outside source. The facility's Labeling and Dating guidelines revealed items in the refrigerator should be labeled with a use-by date for removal and that the manufacturer's expiration date, when available, is the use by date. The guidelines included items must be in an airtight package or a sealed container with the resident's name, contents, and the date placed in the refrigerator to prevent cross contamination.",2020-09-01
167,MISSION PALMS POST ACUTE,35071,6461 EAST BAYWOOD AVENUE,MESA,AZ,85206,2019-03-07,814,D,0,1,D8F311,"Based on observations, staff interviews, and policy and procedure, the facility failed to ensure garbage was disposed of properly in the dumpster area for 2 of 2 dumpsters. The deficient practice could result in an unsanitary condition and the harborage of pests and insects. Findings include: During an initial kitchen observation conducted on 03/04/19 at 10:37 AM with the Dietary Manager (staff #133), the area behind two dumpsters was observed with several plastic wrappers, dirty tissues, an empty bottle of lotion, and two pair of gloves. An interview was conducted with the Food Service Director (staff #134) on 03/06/19 at 11:20 AM. Staff #134 stated the garbage dumpster area is checked frequently by the maintenance director and each time garbage bags are put into a dumpster. She also stated that garbage outside the dumpster is a health hazard and is not acceptable. An interview was conducted with the Administrator (staff #65) on 03/06/19 at 01:21 PM. The administrator stated that it is her expectation that the dumpster areas be free of trash and checked on a regular basis. She stated garbage behind or around the dumpster is an unacceptable violation. An interview was conducted with the Maintenance Director (staff #137) on 03/07/19 at 10:23 AM. The Maintenance Director stated that the garbage area is checked three times weekly and is cleaned up regularly. He stated that trash outside the dumpster is not acceptable. During an interview conducted with the Dietary Services Director (staff #133) on 03/07/19 at 01:10 PM, staff #133 stated there should be no garbage in the area around the dumpsters. Review of the facility's policy and procedure titled Dispose of Garbage and Refuse dated 8/2017 revealed the Dining Services Director coordinates with the Director of Maintenance to ensure the area surrounding the exterior dumpster area is maintained in a manor free of rubbish or other debris.",2020-09-01
168,MISSION PALMS POST ACUTE,35071,6461 EAST BAYWOOD AVENUE,MESA,AZ,85206,2019-03-07,880,D,0,1,D8F311,"Based on observation, staff interviews, and policy review, the facility failed to ensure infection control practices were followed during medication administration. This deficient practice could result in cross contamination, spreading infections to others. The census was 99. Findings include: A medication administration observation was conducted on (MONTH) 6, 2019 at 7:57 a.m. with a Registered Nurse (RN/staff #75). Staff #75 performed hand hygiene before preparing the medications. Four medications from multi-use bottles were observed being scooped from the bottle with her bare finger into the medication cup. The RN was then observed to pop a medication out of a bubble pack into her bare palm and place it into the medication cup. The medications were administered to the resident at 8:05 a.m. An interview was conducted immediately after the observation with staff #75. The RN stated that she puts the medications into her hand so they do not spill. She also stated this practice is not in compliance with their policy. In an interview conducted with the Director of Nursing (DON/staff #84) on (MONTH) 6, 2019 at 10:05 a.m., she stated her expectation is that medications removed from multi-use bottles be placed into the cap of the bottle and then into the medication cup. She stated if the nurse needs to touch the medication, they should wear gloves. The DON stated that if the medication becomes contaminated in any way, it should be disposed of. Review of the facility's policy titled Medication Administration dated (MONTH) (YEAR) revealed Medications are administered as prescribed in accordance with .good nursing principles and practices . Under Medication Preparation, the policy revealed, Hands are washed with soap and water and gloves applied prior to handling tablets.",2020-09-01
169,MISSION PALMS POST ACUTE,35071,6461 EAST BAYWOOD AVENUE,MESA,AZ,85206,2016-10-28,205,D,0,1,F0G511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident, family, and staff interviews and review of the admission information packet and facility policy and procedure, the facility failed to ensure one resident's (#251) family member was provided written information regarding the facility's bed hold policy prior to a hospitalization . Findings include: Resident #251 was admitted to the facility on (MONTH) 6, (YEAR), with [DIAGNOSES REDACTED]. A review of the Nurses Notes dated (MONTH) 13, (YEAR), revealed the resident was discharged to the hospital with an alteration in consciousness. The resident was readmitted to the facility on (MONTH) 16, (YEAR). During an interview conducted at 10:43 a.m. on (MONTH) 24, (YEAR), the resident's family member stated, when the resident was transferred from the facility to the hospital, the resident or family member was not provided with information regarding the facility's bed hold policy and procedure. During an interview conducted at 9:00 a.m. (MONTH) 26, (YEAR), the Social Service staff member (#66) stated she was not aware of any written information provided to the resident or the resident's representative/family prior to the hospitalization . During an interview conducted at 9:30 a.m. on (MONTH) 26, (YEAR), the Admission Coordinator (staff member #90) stated there was a page in the admission packet about the bed hold policy. After reviewing the admission packet, she stated that the admission packet did not include the information regarding the bed hold policy. During an interview conducted at 10:00 a.m. on (MONTH) 26, (YEAR), the Administrator (staff #38) stated that he had seen a form in the admission packet that indicated the bed hold policy was included in the admission packet. However, after reviewing the admission packet he stated he did not realized that the information regarding the bed hold policy was not included in the packet. A review of the information identified in the Admission Information Packet by the Admission Coordinator as the notification of the bed hold policy revealed Will Medicaid pay to hold my bed until I return if I should leave the Facility? This varies from state to state. The facility Administrator can best answer your questions regarding bed hold policies. Further review of the Admission Information Packet revealed an Acknowledgement form that revealed by signing below, I indicate that I have received a copy of the: .Bed Hold Policy . A review of the Bed-Hold policy and procedure revealed The facility will notify the resident at the time of admission and again prior to a hospital transfer or therapeutic leave of its bed-hold and return policies.",2020-09-01
170,MISSION PALMS POST ACUTE,35071,6461 EAST BAYWOOD AVENUE,MESA,AZ,85206,2016-10-28,278,D,0,1,F0G511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that Minimum Data Set (MDS) assessments were coded correctly for two residents (#19 and #178). Findings include: -Resident #19 was admitted to the facility on (MONTH) 11, (YEAR) with [DIAGNOSES REDACTED]. Review of the nursing notes indicated that the resident sustained [REDACTED]. A resident incident report confirmed that the resident had sustained a fall on (MONTH) 6, (YEAR) and indicated that he had tried to transfer himself from his wheelchair and had slipped, landing on the floor. The nursing notes also indicated that the resident had fallen on (MONTH) 10, (YEAR). Review of a resident incident report confirmed that the resident had fallen on (MONTH) 10, (YEAR) as he was found sitting on the floor. Review of the resident's fall care plan revealed that it had been updated on (MONTH) 6 and (MONTH) 10, (YEAR) and noted that the resident had falls on these dates. However, review of a MDS assessment dated (MONTH) 4, (YEAR) revealed that the resident was coded as having no falls since the previous assessment dated (MONTH) 7, (YEAR). An interview was conducted with the MDS coordinator (staff #74) at 10:15 a.m. on (MONTH) 28, (YEAR). She stated that when she is coding the fall section of the MDS, she will review a resident's medical record for any indication that they have fallen including nursing notes and any incident reports. She stated that she would have coded any falls that occurred between the time of the first MDS assessment done on (MONTH) 7, (YEAR) and the second assessment dated (MONTH) 4, (YEAR). After reviewing the nursing notes for (MONTH) (YEAR), she stated that the (MONTH) 4, (YEAR) Quarterly MDS assessment had been coded incorrectly for falls. -Resident #178 was admitted to the facility on (MONTH) 12, (YEAR) with [DIAGNOSES REDACTED]. Review of a skin assessment dated (MONTH) 12, (YEAR) revealed that the resident did not have a pressure ulcer on admission. On (MONTH) 17, (YEAR), a nursing note revealed that the resident complained of pain in his right heel and there was noted purple discoloration. The physician was made aware and new orders were received. A physician's orders [REDACTED]. A wound assessment dated (MONTH) 17, (YEAR) revealed that the resident had developed an unstageable suspected deep tissue injury on his right heel. This wound was classified as a pressure ulcer. The Treatment Administration Record (TAR) for (MONTH) 17 through 19, (YEAR) was reviewed and the resident received the [MEDICATION NAME] treatment to his right heel as ordered. Review of the admission MDS assessment dated (MONTH) 19, (YEAR) revealed that the resident was coded as having no pressure ulcers. In an interview with the MDS coordinator (staff #74) at 2:00 p.m. on (MONTH) 26, (YEAR), she stated that when she codes the MDS assessment for pressure ulcers, she reviews the nursing notes, the wound assessments, as well as some internal wound tracking. After reviewing this resident's chart, she stated that the MDS assessment was not coded correctly and should have reflected the pressure ulcer's existence. During a second interview with the MDS coordinator (staff #74) at 3:00 p.m. on (MONTH) 31, (YEAR), she stated that she was not aware of a specific facility policy regarding MDS accuracy. She stated that she follows the RAI manual when coding MDS assessments. Review of the RAI manual revealed that the RAI process, which includes the Federally-mandated MDS, is the basis for an accurate assessment of the nursing home resident. The RAI manual also noted that the importance of accurately completing and submitting the MDS cannot be over-emphasized as the MDS is the basis for the development of an individualized care plan. Further noted was that federal regulation require that the assessment accurately reflects the resident's status.",2020-09-01
171,MISSION PALMS POST ACUTE,35071,6461 EAST BAYWOOD AVENUE,MESA,AZ,85206,2016-10-28,279,D,0,1,F0G511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the clinical record, staff interview, and review of a policy and procedure, the facility failed to ensure two resident's (#178 and #22) care plans accurately reflected the resident's care and needs. Findings include: Resident #178 was admitted to the facility on (MONTH) 12, (YEAR), with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 19, (YEAR), revealed the resident was not receiving [MEDICAL TREATMENT]. A review of the Care Plan revealed a problem area of Self Care Deficit . with an approach of Increase levels of assist as needed r/t (related to) fatigue following [MEDICAL TREATMENT] treatments (enter days of week}. The problem area also revealed the goals included Will tolerate [MEDICAL TREATMENT] (_-x/wk} {enter days} {enter [MEDICAL TREATMENT] contact info}. During an interview conducted at 10:05 a.m. on (MONTH) 27, (YEAR), the MDS Coordinator (staff #74) stated she was responsible for initiating the comprehensive care plan. She stated the computerized care plans begin with a template that includes multiple problems, approaches, and goals, and that she is responsible for deleting goals and approaches that are not appropriate and adding goals and approaches that reflect the resident's needs. She further stated the resident comprehensive admission MDS assessment was accurate and the resident was not receiving [MEDICAL TREATMENT]. The MDS Coordinator also stated she failed to deleted the goal and approaches regarding [MEDICAL TREATMENT] from the resident's comprehensive care plan. -Resident #22 was admitted to the facility on (MONTH) 14, (YEAR) with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. The order included to provide catheter care every shift. The admission Minimum Data Set (MDS) assessment dated (MONTH) 21, (YEAR) indicated that the resident had an indwelling urinary catheter. On Section V of the MDS assessment, urinary catheter triggered and was coded as being addressed in the care plan. Review of the resident's comprehensive care plan revealed no evidence that a care plan regarding the resident's catheter had been developed. An interview was conducted with the MDS coordinator (staff #74) at 2:05 p.m. on (MONTH) 26, (YEAR). She stated that she completes the MDS assessments and initiates the comprehensive care plans based on what triggers from the MDS assessment. She stated that urinary catheters should be addressed on the care plan since they are addressed on the MDS and require special care needs. After reviewing the resident's care plan, she stated that the catheter was not addressed in the care plan and that it was either missing or had been deleted. Review of the facility's care planning policy revealed that the facility's care planning team/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. The policy further included that a comprehensive care plan for each resident is developed within seven days of the completion of the resident assessment (MDS). Another policy regarding comprehensive care plans included that the care plan is based on a thorough assessment that includes, but is not limited to, the MDS. The policy included that each care plan is designed to incorporate identified problem areas, reflect treatment goals, timetables, and objectives in measurable outcomes, and identify professional services that are responsible for each element of care.",2020-09-01
172,MISSION PALMS POST ACUTE,35071,6461 EAST BAYWOOD AVENUE,MESA,AZ,85206,2016-10-28,281,D,0,1,F0G511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, staff interviews, and review of a policy and procedure, the facility failed to ensure an interim care plan was developed for one resident (#261) to address the resident's hemo-[MEDICAL TREATMENT]. Findings include: Resident #261 was admitted to the facility on (MONTH) 21, (YEAR), with [DIAGNOSES REDACTED]. A review of the Physician's admission orders [REDACTED]. A review of the interim care plan revealed no problem, approaches or goals related to the need for hemo-[MEDICAL TREATMENT]. During an interview conducted at 1:23 p.m. on (MONTH) 27, (YEAR), a licensed practical nurse (staff #9) stated a resident with orders for [MEDICAL TREATMENT] would require care by the nurses, such as checking for bruit and thrill, checking the [MEDICAL TREATMENT] site and sending the resident to the [MEDICAL TREATMENT] center at appointment times. She also stated the nurse admitting the resident was responsible for completing the initial care plan. During an interview conducted at 1:36 p.m. on (MONTH) 27, (YEAR), a Minimum Data Set staff member (#74) stated the nurse admitting the resident was responsible for the development of the interim care plan. During an interview conducted at 1:55 p.m. on (MONTH) 27, (YEAR), the Director of Nursing (88#) stated that an interim care plan should immediately be developed for a resident on [MEDICAL TREATMENT]. She also stated the care plan should include approaches to address checking the bruit and thrill, assessing the shunt site, and identifying where the [MEDICAL TREATMENT] port site was. A review of the Care Plan policy and procedure provided by the facility revealed no guidelines for the completion of the interim/initial care plan.",2020-09-01
173,MISSION PALMS POST ACUTE,35071,6461 EAST BAYWOOD AVENUE,MESA,AZ,85206,2016-10-28,315,D,0,1,F0G511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to provide and document consistent catheter care for one resident (#22). Findings include: Resident #22 was admitted to the facility on (MONTH) 14, (YEAR) with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. The order included to provide catheter care every shift. The admission Minimum Data Set (MDS) assessment dated (MONTH) 21, (YEAR) indicated that the resident had an indwelling urinary catheter. Review of the Treatment Administration Record (TAR) from (MONTH) 14 through 30, (YEAR), revealed that catheter care was to be documented three times per day (for each shift). However, the documentation was only completed every Friday. There was no documentation to show that the catheter care had been performed for all other days. Review of the TAR for (MONTH) 1 through 26, (YEAR) revealed that the resident's catheter care continued to be documented as being completed every Friday. All other days were left blank. In an interview with a licensed practical nurse (LPN/staff #8) at 11:20 a.m. on (MONTH) 26, (YEAR), she stated that the nurses or the Certified Nursing Assistants (CNA's) provide catheter care and it is documented in either the CNA documentation or the TAR. She stated that she was not sure which part of the chart included this information. During an interview with the Director of Nursing (DON/staff #88) at 9:30 a.m. on (MONTH) 27, (YEAR), she stated that she was unsure where the catheter care was to be documented but thought that it could be under the CNA charting system. After reviewing the chart, she stated that the documentation was not under the CNA charting system, but was instead documented on the TAR. She stated that something had gone wrong with the order as it is written to provide the care each shift, but was only prompting the nurses to document on it every Friday. She stated that it was likely put into the computer system incorrectly and nobody had noticed it. She stated that the resident likely was getting care more often than just every Friday, but there was no documentation to show this. Review of the facility's urinary catheter care policy and procedure revealed that the following information should be recorded in the resident's medical record: the date and time that catheter care was given, the name and title of the individual providing the catheter care, and the signature and title of the person recording the data.",2020-09-01
174,MISSION PALMS POST ACUTE,35071,6461 EAST BAYWOOD AVENUE,MESA,AZ,85206,2016-10-28,323,D,0,1,F0G511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, staff interviews, and review of policy and procedure, the facility failed to provide supervision to ensure one cognitively impaired resident (#70) was not found outside multiple times unsupervised. Findings include: Resident #70 was readmitted to the facility on (MONTH) 25, 2014, with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A review of the quarterly MDS assessment dated (MONTH) 14, (YEAR) revealed a Brief Interview for Mental Status (BIMS) score of 3 which indicates severe cognitive impairment. A review of the Nurses Notes dated (MONTH) 9, (YEAR), revealed the resident was found outside twice today by staff. Resident claimed he was looking for his wife. The physician, DON (Director of Nursing), ADON (Assistant Director of Nursing), and social worker were notified. New orders were received for a bed alarm and wheelchair alarm. A review of the physician's orders [REDACTED]. A review of the Nurses Notes dated (MONTH) 23, (YEAR) revealed patient left facility, seen on sidewalk of the road by staff nurse, immediately brought back to the facility, vitals normal limits no injuries noted, patient was in his wheelchair. Appropriate staff notified. A review of a second Nurses Notes dated (MONTH) 23, (YEAR) revealed . resident wandered off facility grounds by ambulation with wheelchair. Patient has confusion and disorientation (sic). CNA from station three spotted patient called front desk to report. Nurse . was informed of situation. Run outside found patient wondering (sic) in the street. Brought patient back to facility patient has no injuries vitals were within normal limits . A review of a Nurses Note dated (MONTH) 25, (YEAR), written by the ADON (staff #49) revealed clarified with the nurse who was on grounds at the time of the incident that the patient was outside the facility but remained on facility grounds. 10/23/16. During an interview conducted on (MONTH) 28, (YEAR), the administrator stated he was called on (MONTH) 23, (YEAR), and notified that the resident was found on Baywood Avenue. He clarified that the staff member could see the resident on the sidewalk by the offices on the side of the building facing the Baywood Avenue entrance. He stated that the resident was just sitting there. The staff in the Oasis dining room saw the resident through the windows and called the nurse caring for the resident, informing the nurse where the resident was. During an interview conducted at 11:00 a.m. on (MONTH) 28, (YEAR), a Licensed Practical Nurse (staff #58) stated the resident has exhibited behaviors of anxiety and packs his belonging to go home and paces. When the resident exhibits behaviors he is placed by the nurses ' station and provided one to one supervision. She also stated that if the resident exhibits wandering outside of the facility the care plan should be revised to reflect approaches to prevent further wandering outside the facility unsupervised. She further stated that the north and south entrances to the facility did not have alarms to let staff know if a wandering resident attempts to exit the facility. During an interview conducted at 11:32 a.m. on (MONTH) 28, (YEAR), the Director of Nursing (staff #88) stated she did not believe the resident going outside unsupervised was an attempt to elope since he was looking for his wife and she usually visits him daily. She also stated that as long as he remained on the property the resident was allowed to go outside. She further stated that no assessment of the resident's wandering outside the facility was completed. A review of the Elopement Protocol revealed Elopement is the ability of a resident who is not capable of protecting himself or herself from harm to successfully leave the facility unsupervised and unnoticed and who may enter into harm's way.",2020-09-01
175,MISSION PALMS POST ACUTE,35071,6461 EAST BAYWOOD AVENUE,MESA,AZ,85206,2016-10-28,334,D,0,1,F0G511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, staff interviews, and review of policy and procedure, the facility failed to ensure three residents (#s 254, 253, and 46) were offered the flu and/or [MEDICATION NAME] vaccine. The sample size was 5. Findings include: -Resident #254 was readmitted on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A review of the Medication Administration Record [REDACTED]. -Resident #253 was admitted to the facility on (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. The orders also included an order to administer [MEDICATION NAME] 0.5 cc (cubic centimeter) every 5 years. A review of the Medication Administration Record [REDACTED]. Further review of the clinical record revealed no evidence that the resident had already received the flu or Pneumococcal immunizations. -Resident #46 was readmitted to the facility on (MONTH) 17, 2014, with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A review of the clinical record revealed a signed consent for receiving the flu shot annually. Review of the Medication Administration Record [REDACTED]. During an interview conducted on (MONTH) 28, (YEAR), the DON (Director of Nursing, Staff #88) stated that the facility had the flu vaccine available in the facility. She also stated that some of the residents had received the immunizations. A review of the Influenza and Pneumococcal Vaccinations policy and procedure revealed Annual vaccination against seasonal influenza if recommended/offered for all people age 6 months and older that do not have a valid contraindication to the vaccine or have already been vaccinated in this time frame. The policy also included Vaccination will begin in October/November based on availability of the vaccine and will not be offered after March/April. Vaccine immunity has not been shown to diminish significantly during the influenza season, even in those vaccinated early.",2020-09-01
176,MISSION PALMS POST ACUTE,35071,6461 EAST BAYWOOD AVENUE,MESA,AZ,85206,2016-10-28,356,D,0,1,F0G511,"Based on observations, staff interviews, and review of a policy and procedure, the facility failed to post nurse staffing data at the beginning of the day shift and in an area accessible to residents and visitors. Findings include: During the initial tour of the facility conducted at 7:25 a.m. on (MONTH) 24, (YEAR), no nurse staffing data posted in the facility was observed. A notice was observed posted, at the reception desk, stating the receptionist was not on duty and to check in with staff at the nurses' station. During an observation conducted at 8:30 a.m. on (MONTH) 24, (YEAR), the nurse staffing information was observed posted on the front reception desk. The reverse side of the posting, revealed the notice regarding the receptionist not being on duty and the need to check in with staff at the nurses' station. During an interview conducted at 2:10 p.m. on (MONTH) 25, (YEAR), the receptionist stated the nurse staffing information is visible to residents and visitors during the day when the receptionist is working and not visible after the receptionist goes home. She also stated that the staff development nurse provides the receptionist with the information to post and the receptionist posts the information daily. A review of the Nurse Staffing Information policy and procedure revealed Posting requirements. (i) The facility must post the nurse staffing data specified in paragraph (e) (1) of this section on a daily basis at the beginning of each shift. (ii) Data must be posted as follows: (A) Clear and readable format. (B) In a prominent place readily accessible to residents and visitors.",2020-09-01
177,MISSION PALMS POST ACUTE,35071,6461 EAST BAYWOOD AVENUE,MESA,AZ,85206,2016-10-28,371,E,0,1,F0G511,"Based on observations, review of facility documentation, staff interviews, and policy review, the facility failed to ensure the nourishment refrigerator temperature logs were consistently monitored and documented on two units. Findings include: An observation of the nourishment refrigerator located on Station one was conducted with the Assistant Director of Nursing, (ADON) (registered nurse/staff #49) on (MONTH) 25, (YEAR) at 3:11 p.m. Review of the refrigerator temperature log revealed that there were no temperatures recorded for (MONTH) 1-5, 9-12, and 17-19, (YEAR). Another observation was conducted on the Oasis unit with the ADON (MONTH) 25, (YEAR) at 3:21 p.m. The refrigerator temperature log for this unit revealed no temperatures recorded for (MONTH) 1-2, 5-8, 13-14, and 19-22. Following the observations, the ADON stated she was not certain who was responsible for recording the refrigerator temperatures. An interview was conducted on (MONTH) 25, (YEAR) with the DON (staff # 88) who stated it is the management team responsibility to confirm the refrigerator logs are completed. During an interview conducted on (MONTH) 26, (YEAR) 8:27:a.m., a Licensed Practical Nurse (LPN staff #9) stated when she works the night shift she knows it is her responsibility to record the refrigerator temperatures. Review of the facility policy revealed that acceptable temperatures should be 35 degrees Fahrenheit to 40 degrees Fahrenheit for refrigerators and less than 0 degrees Fahrenheit for freezers. In addition, the facility will ensure safe refrigerator and freezer maintenance and temperatures. The policy also included monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures. Food service supervisors or their designated employees will check and record refrigerator and freezer temperatures daily.",2020-09-01
178,MISSION PALMS POST ACUTE,35071,6461 EAST BAYWOOD AVENUE,MESA,AZ,85206,2016-10-28,431,E,0,1,F0G511,"Based on observations, review of facility documentation, staff interviews, and policy review, the facility failed to ensure that the medication refrigerator logs and the glucometer control logs were consistently monitored and documented on two units. Findings include: An observation of the medication refrigerator and glucometer log on nursing Station one was conducted with the Assistant Director of Nursing, (ADON) (registered nurse/staff #49) on (MONTH) 25, (YEAR) at 3:11 p.m. Review of the refrigerator temperature log revealed that there were no temperatures recorded for (MONTH) 1-5, 9-12, and 17-19. The glucometer log revealed missing recorded test results for (MONTH) 1, 2, 6, 7, 13, and 15. Another observation was conducted on the Oasis unit with the ADON on (MONTH) 25, (YEAR) at 3:21 p.m. The medication refrigerator log lack temperature recordings for (MONTH) 1-2, 5-8, 13-14, and 19-22. The glucometer log was missing recorded test results for (MONTH) 6, 7, 8, 13, 15, 16 and 20. Following the observations, the ADON stated she was not certain who was responsible for recording the refrigerator temperatures and the glucometer test results. An interview was conducted on (MONTH) 25, (YEAR) with the DON (staff # 88) who stated it is the management team responsibility to confirm the refrigerator logs are completed. During an interview conducted on (MONTH) 26, (YEAR) 8:27:a.m., a Licensed Practical Nurse (LPN staff #9) stated when she works the night shift she knows it is her responsibility to record the refrigerator temperatures and test and record the glucometer test results. Review of the facility policy revealed that acceptable temperatures should be 35 degrees Fahrenheit to 40 degrees Fahrenheit for refrigerators and less than 0 degrees Fahrenheit for freezers. In addition, the facility will ensure safe refrigerator and freezer maintenance and temperatures. The policy also included monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures. Food service supervisors or their designated employees will check and record refrigerator and freezer temperatures daily. A review of the glucometer policy revealed that quality control tests will be done nightly on the 10-6 shift and the test results logged nightly on the glucometer quality control log. Nursing administration will monitor compliance with the log being completed.",2020-09-01
179,MISSION PALMS POST ACUTE,35071,6461 EAST BAYWOOD AVENUE,MESA,AZ,85206,2017-12-13,550,D,0,1,LQN111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and policy review, the facility failed to ensure one resident (#308) was treated in a respectful and dignified manner. Findings include: Resident #308 was admitted to the facility on (MONTH) 6, (YEAR), with [DIAGNOSES REDACTED]. An observation of the resident was conducted on (MONTH) 7, (YEAR) at 7:56 a.m. The resident was observed in bed and was only wearing a brief. The resident was easily visible from the hallway. At this time, a Certified Nursing Assistant (CNA) entered the resident's room, but then left and did not cover up the resident or get the resident dressed. Observations of the resident continued for approximately 30 minutes. At 8:26 a.m., the resident's legs and feet were observed touching the window blinds next to the bed. Again, the resident only had a brief on and an indwelling urinary catheter tube which was coming from the brief was visible. During the observation, multiple staff passed by the resident's room, without providing assistance. An interview was attempted with resident #308 during the observation, however, the resident was unable to verbalize in a manner that was understandable. At 8:30 a.m., a CNA (staff #32) asked another CNA for assistance with the resident. When the CNA's left the room, the resident had been repositioned and had a gown on. In an interview conducted with staff #32 on (MONTH) 7, (YEAR) at 8:35 a.m., staff #32 stated it was her routine to look at the residents every time she went up and down the hall. Staff #32 stated if she noticed something out of the ordinary in a room, she would fix it or tell the staff who were assigned to the resident. Staff #32 stated that she did see that the resident was unclothed and was going to get someone to help, but she didn't. Staff #32 stated that when she saw the resident with his feet up in the blinds, she then asked someone to help her. An interview with a CNA (staff #85) was conducted on (MONTH) 7, (YEAR) at 8:52 a.m. Staff #85 stated when she came in this morning around 6:30 a.m., she saw that the resident was not dressed. She stated that she and a Registered Nurse (RN/staff #75) went in his room and straightened him up and that staff #75 told her to get him dressed, but she had not done this yet. In an interview with staff #75 on (MONTH) 7, (YEAR) at 9:55 a.m., staff #75 stated when she first comes on duty she makes rounds of the residents and tells the CNA's what the priorities are. She stated she saw that resident #308 was mostly naked and covered him with a sheet. Staff #75 said she told staff #85 to put clothes on him around 6:45 a.m. Staff #75 further stated that around 8:30 a.m., she then told staff #32 to put some clothes on the resident. Review of a policy titled, Resident Rights revealed the resident has a right to be treated with respect and dignity. The policy also included the resident has a right to personal privacy that includes accommodations. A facility policy titled, Quality of Life-Dignity included that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. The policy included that treated with dignity meant the resident will be assisted in maintaining and enhancing his or her self esteem and self worth. The policy further documented that Staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Demeaning practices and standards of care that compromise dignity are prohibited.",2020-09-01
180,MISSION PALMS POST ACUTE,35071,6461 EAST BAYWOOD AVENUE,MESA,AZ,85206,2017-12-13,641,D,0,1,LQN111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, review of the Resident Assessment Instrument (RAI) manual and policy review, the facility failed to ensure the Minimum Data set (MDS) assessment accurately reflected one resident's (#2) status. Findings include: Resident #2 was admitted on (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. physician's orders [REDACTED]. Review of the [MEDICAL TREATMENT] care plan revealed the resident receives [MEDICAL TREATMENT] three times a week. However, review of the quarterly MDS assessment dated (MONTH) 24, (YEAR), revealed in Section O, Special Treatments and Procedures that [MEDICAL TREATMENT] was not checked as receiving these services. An interview was conducted on (MONTH) 11, (YEAR) at 8:56 a.m., with a Registered Nurse (RN/staff #75). She stated the resident is currently receiving [MEDICAL TREATMENT] on Monday, Wednesday and Fridays. An interview was conducted with the MDS nurse (licensed practical nurse/staff #99) on (MONTH) 11, (YEAR) at 2:10 p.m. She stated the resident has been on [MEDICAL TREATMENT] long term, both prior to his admission and since his admission. She said the [MEDICAL TREATMENT] box on the MDS should have been checked and that she missed it. The RAI manual for the MDS stated that the importance of accurately completing and submitting the MDS assessment cannot be over emphasized. The manual also included that the MDS assessment is the basis for the development of an individualized care plan. According to a policy regarding MDS accuracy, all personnel who complete any portion of the MDS assessment must sign a hard copy certifying the accuracy of the assessment.",2020-09-01
181,MISSION PALMS POST ACUTE,35071,6461 EAST BAYWOOD AVENUE,MESA,AZ,85206,2017-12-13,677,D,0,1,LQN111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, facility documentation, resident and staff interviews and policies and procedures, the facility failed to ensure that three residents (#44, #93 and #305) received the necessary services to maintain good grooming and personal hygiene. Findings include: -Resident #93 was admitted on (MONTH) 17, (YEAR), with [DIAGNOSES REDACTED]. Review of the shower schedule revealed the resident was scheduled for showers every Sunday and Thursday. Review of a Comprehensive CNA (Certified Nursing Assistant) Shower Review sheet dated (MONTH) 20, (YEAR), revealed the resident's skin was checked, however, there was no documentation which indicated that the resident had a shower. This sheet was not signed by the CNA, but was signed by a nurse. An admission MDS (Minimum Data Set) assessment dated (MONTH) 24, (YEAR) included a BIMS (Brief Interview for Mental Status) score of 13, which indicated the resident was cognitively intact. The MDS included the resident was totally dependent on staff for bathing. The MDS also included that bathing had not occurred during the 7 day look back period from (MONTH) 17-23. A care plan dated (MONTH) 27, (YEAR) documented the resident had a self-care deficit and would be washed, dressed and out of bed daily. During an interview with resident #93 on (MONTH) 5, (YEAR) at 8:38 a.m., the resident stated that she has had only one shower since she was admitted , and that no one has spoken to her about a shower schedule. Review of the skilled nursing notes from (MONTH) 17 through (MONTH) 6, (YEAR) revealed no documentation that the resident was offered, refused, or was given any showers or bed baths. An interview was conducted with a licensed practical nurse (staff #68) on (MONTH) 7, (YEAR) at 8:30 a.m. Staff #68 stated the resident's shower days, per the shower schedule were Sundays and Thursdays. On (MONTH) 7, (YEAR) at 2:00 p.m., a follow-up interview was conducted with resident #93. The resident stated that she did receive a bath today. She stated when she requested a bath previously, she was told that she had to get her shower request in before her shower day, and that she could only have one shower per week. The resident stated that she was never offered a bed bath. The resident was observed to have a soft splint on her right forearm. An interview was conducted with a CNA (staff #11) on (MONTH) 8, (YEAR) at 8:46 a.m. Staff #11 stated that he had provided cares to the resident a couple of times, but had not given the resident a shower. Staff #11 stated that showers are documented on a shower sheet and the CNAs sign the sheet indicating the resident had a shower, and it is signed off by the nurse. On (MONTH) 8, (YEAR) at 11:29 a.m., an interview was conducted with the DON (Director of Nursing/staff #1). Staff #1 stated that the resident's showers are scheduled by room number and are provided two times per week. Staff #1 stated that residents can request additional showers, which should be provided. Staff #1 provided copies of the computer generated ADL (activities of daily living) Support Flow sheets for (MONTH) and Dec (YEAR). A review of the flow sheets revealed there was no documentation that resident #93 received a bath or shower. Staff #1 stated she could not find any additional documentation regarding showers/bathing for resident #93. An interview was conducted with a CNA (staff #8) on (MONTH) 8, (YEAR) at 11:46 a.m. Staff #8 stated that she and another CNA (staff #32) were designated shower aides from (MONTH) (YEAR) to (MONTH) 4, (YEAR). Staff #8 stated that she was not always able to complete the showers for all of her assigned residents, so the unit CNAs would pick up the residents which were not completed. Staff #8 stated that she had not bathed or showered resident #93. Staff #8 stated that the shower aides should document showers on paper and in the computer. An interview was conducted on (MONTH) 8, (YEAR) at 12:32 p.m. with a CNA (staff #32), who stated that she documents showers on the shower sheet and gives it to the nurse. On (MONTH) 8, (YEAR) at 2:00 p.m., staff #1 provided copies of the Bath Day Roster for resident #93, which was dated (MONTH) 17, (YEAR) through (MONTH) 8, (YEAR). The roster did not include any documentation that the resident was provided showers/baths. Staff #1 stated she found it hard to believe that resident #93 had not received any showers or baths during that period, however, no other shower schedules could be located. Staff #1 stated she discontinued the designated shower aide program on (MONTH) 4, because showers/baths were not being completed. -Resident #305 was admitted to the facility on (MONTH) 22, (YEAR), with [DIAGNOSES REDACTED]. The resident discharged from the facility on (MONTH) 6, (YEAR). Review of the facility's shower schedule revealed the resident was to receive showers on Mondays and Fridays. Review of a Comprehensive CNA Shower Review sheet dated (MONTH) 22, (YEAR), revealed the resident's skin had been checked, however, there was no CNA signature on the form and no other indication that the resident had received a shower on this date. The admission MDS assessment dated (MONTH) 28, (YEAR) revealed the resident had BIMS score of 15, which indicated no cognitive impairment. The MDS identified that the resident required extensive assistance with bed mobility and transfers, and required limited assistance with hygiene. The MDS also indicated that the activity of bathing had not occurred in the 7-day look-back period of the assessment. Review of the Activity of Daily Living (ADL) care plan revealed the resident required extensive assistant with ADL's. The goal was for the resident to be washed, dressed and out of bed daily. An intervention included to encourage the resident to participate as able, with ADLs. Review of the bath day roster documentation from (MONTH) 22 through (MONTH) 30, (YEAR), revealed no evidence that the resident received a shower. According to the corresponding nursing notes from (MONTH) 22 through (MONTH) 30, (YEAR), revealed there was no evidence that the resident was provided a shower during this time. Review of a Comprehensive CNA Shower Review sheet dated (MONTH) 2, (YEAR) revealed it was signed by a CNA, however, there was no indication that a shower had been provided to the resident. Review of the bath day roster documentation from (MONTH) 1 through (MONTH) 6, (YEAR) revealed no evidence that the resident received a shower. Review of the corresponding nursing notes from (MONTH) 1 through (MONTH) 6, (YEAR) revealed no evidence that the resident was provided a shower. An interview with the resident was conducted at 11:15 a.m. on (MONTH) 5, (YEAR). He stated that he did not get a shower for 12-13 days after admission and that staff did not offer him a bed bath. An interview was conducted with a CNA (staff #8) at 11:45 a.m. on (MONTH) 8, (YEAR). She stated that she was a designated shower aide from (MONTH) to (MONTH) 4. She said there were two CNAs designated as shower aides during that time. She said that she was not able to complete all of her assigned residents, so the CNAs working on the floor would help with the showers. She said the showers are to be documented on a paper shower sheet and also can be documented in the electronic charting system on the bath day roster. During an interview with the Director of Nursing (staff #1) at 10:50 a.m. on (MONTH) 12, (YEAR), she stated that she is new to this position. She stated the shower process includes that a CNA fills out a shower sheet when they administer a shower to a resident and the CNA's sign and date it, and then give it to the nurse who will sign the form as well. She said that if the form is not signed by the CNA, the CNA may have forgotten to sign it or the CNA may not have provided the shower. She said that she was aware that there was an issue with showers not being completed and this was because they had two CNAs who were doing all of the showers in the building and they weren't able to get them all done. She stated that on (MONTH) 6, (YEAR) she decided that the CNAs working on the floor would be responsible for their own showers for the residents they are assigned to. She said that the expectation in the building is that residents receive two showers per week, per the shower schedule unless they request more or less. In another interview with staff #1 at 12:00 p.m. on (MONTH) 12, (YEAR), she said that the facility does not have a shower policy and that the only documentation regarding showers is the shower schedule, which indicates that residents are schedule for two showers per week. -Resident #44 was admitted on (MONTH) 6, 2014, with [DIAGNOSES REDACTED]. Review of a MDS assessment dated (MONTH) 20, (YEAR) revealed the resident had a BIMS score of 3, which indicated severe cognitive impairment. The MDS further included that the resident required extensive assistance with dressing and personal hygiene. Review of a care plan revealed the resident had self-care deficits with bathing, toileting and personal hygiene, due to forgetfulness, weakness, pain and dementia. A goal included the resident would be washed, dressed and out of bed. The approaches included for staff to assist with completing activities of daily living and for a carrot appliance to be placed in the resident's left hand, except when bathing. On (MONTH) 12, (YEAR) at 11: 55 a.m., the resident was observed in his wheelchair in the day room. The resident appeared unshaven, and his fingernails were elongated and jagged. The resident's left hand fingernails were contracted and were digging into the palm of the hand, despite having a carrot appliance in place. Also, the resident's shirt was observed to be wet, with a brown matter. Another observation of the resident was conducted at 12:05 p.m. on (MONTH) 12, (YEAR). Resident #44 was in the assisted dining room eating. The resident was still wearing the same soiled shirt. An observation of the resident in bed was conducted on (MONTH) 12, (YEAR) at 2:50 p.m., with the Assistant Director of Nursing (ADON/staff #2). The ADON stated that the resident needed to be shaved. The ADON stated that the resident's fingernails were elongated and were digging into the thumb, and needed to be trimmed. The ADON stated that the carrot appliance to the left hand was incorrectly placed. Staff #2 stated that she expected the resident's nails to be trimmed by nursing staff as needed or during a bath. Staff #2 stated that the resident's shirt was wet and stained and should have been changed. During the observation, the resident agreed that he needed to be shaved. Review of a policy titled, Dressing and Undressing the Resident revealed that the purpose was to assist the resident as necessary with dressing/undressing and to promote cleanliness. The policy included that residents who may need some assistance with dressing and undressing include a confused resident and a resident with limited mobility. A policy titled, Shaving the Resident indicated the purpose was to promote cleanliness and provide skin care.",2020-09-01
182,MISSION PALMS POST ACUTE,35071,6461 EAST BAYWOOD AVENUE,MESA,AZ,85206,2017-12-13,684,D,0,1,LQN111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record reviews, resident and staff interviews, and policy and procedures, the facility failed to ensure one resident (#308) was positioned properly in bed, failed to ensure that a physician's orders [REDACTED].#203) and failed to implement physician orders [REDACTED].#18 and #203). Findings include: -Resident #308 was admitted to the facility on (MONTH) 6, (YEAR), with [DIAGNOSES REDACTED]. Review of the nursing admission data set dated (MONTH) 7, (YEAR) revealed the resident was alert to person only and had poor short and long term memory. The assessment also included the resident required maximum assistance with eating and bed/chair transfers. During a breakfast observation conducted on (MONTH) 7, (YEAR) at 7:56 a.m., resident #308 was in bed and the head of the bed was elevated. The resident was slumped down in bed and his head and shoulders were bent forward toward his chest. The resident was visible from the hallway. At this time, a Certified Nursing Assistant (CNA) entered the room, but then left. The CNA did not reposition the resident. Following this, an interview with resident #308 was attempted. However, the resident was unable to verbally respond in a manner that was understood. Continued observations revealed that the resident remained in bed as described above for 30 minutes. During this time, multiple staff passed by the resident's room and did not reposition the resident. At 8:26 a.m., the resident was observed to have slid further down toward the foot of the bed and the resident's legs and feet were up in the window blinds next to the bed. At 8:30 a.m., a CNA (staff #32) asked another CNA for assistance and they repositioned the resident. In an interview conducted with a CNA (staff #32) on (MONTH) 7, (YEAR) at 8:35 a.m., staff #32 stated it is her routine to look at the residents every time she goes up and down the hall. Staff #32 stated if she noticed something out of the ordinary she would fix it or tell the staff member who was assigned to the resident. Staff #32 stated that she did see that the resident was slumped in bed and was going to get someone to help move him, but didn't. Staff #32 stated when she saw him with his feet up in the blinds, she asked someone to help reposition him. Review of a facility policy titled, Repositioning revealed the purpose was to provide guidelines for the evaluation of resident repositioning needs; to promote comfort for all bed or chair bound residents; to prevent skin breakdown, and to promote circulation and provide pressure relief for residents. The policy further documented that repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. -Resident #203 was admitted to the facility on (MONTH) 28, (YEAR), with [DIAGNOSES REDACTED]. Regarding the positioning bars: A physician's orders [REDACTED]. According to the Position/Reposition Equipment assessment dated (MONTH) 29, (YEAR) completed by therapy, the resident was assessed for safe use of the mobility bars, as an assistive device to be used for turning and positioning. Another physician's orders [REDACTED]. Review of the clinical record revealed there was no documentation that the positioning bars had been applied to the resident's bed on (MONTH) 29 or 30. A third physician's orders [REDACTED]. Review of the Treatment Administration Record (TAR) for (MONTH) (YEAR) revealed documentation that the mobility bars were in place on (MONTH) 31, (YEAR) at 8:00 p.m. An interview was conducted with a Licensed Practical Nurse (LPN/staff #52) on (MONTH) 7, (YEAR) at 11:47 a.m. Staff #52 stated when bed mobility bars are ordered, the request is entered into the electronic order requisition system and the bars are applied by maintenance. In an interview with the Maintenance Manager (staff #105) conducted on (MONTH) 7, (YEAR) at 2:15 p.m., staff #105 stated there was no request in the electronic service system to apply positioning bars for resident #203 in March. In an interview with the Director of Rehabilitation Services (staff #128) conducted on (MONTH) 11, (YEAR) at 1:45 p.m., the Director stated when an order is placed for mobility bars, therapy assesses the resident, and if safe, then maintenance would be notified to apply the bars. Regarding the wound treatment: A physician's orders [REDACTED]. Review of a Minimum Data Set (MDS) assessment dated (MONTH) 3, (YEAR) revealed the resident had a Brief Interview for Mental status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS also included that the resident required extensive assistance of 1-2 persons for all activities of daily living. Review of the TAR for (MONTH) and (MONTH) (YEAR) revealed the [MEDICATION NAME] was applied one time only on (MONTH) 30, (MONTH) 1, (MONTH) 2, (MONTH) 3, instead of twice daily as ordered. There was no documentation that the resident refused the application. In an interview conducted on (MONTH) 7, (YEAR) at 9:55 a.m. with a Registered Nurse (RN/staff #75), staff #75 stated that if it is not charted, it was not done. Staff #75 stated it is important to make sure the cream is applied to protect from further breakdown. Regarding the scheduling of a physician ordered appointment: Review of the clinical record revealed the resident was sent to the emergency department at 10:30 p.m. on (MONTH) 30, (YEAR), for insertion of an indwelling catheter. The resident returned to the facility a couple of hours later. Review of the emergency department discharge instructions dated (MONTH) 31, (YEAR) revealed the resident was to follow up with the urologist in 5-7 days. A physician's orders [REDACTED]. A Medicare note dated (MONTH) 3, (YEAR) included the resident's family member asked about the appointment with the urologist and the order was placed in the appointment book, but was not scheduled yet. Further review of the clinical record revealed there was no documentation that the urology appointment was ever scheduled or that the resident was seen by the urologist. An interview was conducted on (MONTH) 7, (YEAR) at 2:37 p.m., with the facility scheduler (staff #97). She stated that she receives a daily list of new admissions and discharges with orders for appointments. Staff #97 stated that she keeps a log with the resident's name, date, time and location of any appointments, but does not document it in the resident's record. She stated the logs are kept, but the scheduling for the urology appointment for resident #203 was handed off to someone else for a while. She stated that she no longer has the logs for the appointments from (MONTH) or (MONTH) (YEAR). A policy for resident appointments was requested and the Director of Nursing stated they had no policy. -Resident #18 was admitted on (MONTH) 17, (YEAR), with [DIAGNOSES REDACTED]. Review of an admission skin check dated (MONTH) 17, (YEAR) revealed the resident's skin was not intact. Physician orders [REDACTED]. A self-care deficit care plan included an intervention for weekly skin checks to be done. Review of the clinical record revealed the a skin check was completed on (MONTH) 27, (YEAR), which was ten days after the previous assessment (July 17). The next weekly skin check was completed on (MONTH) 4, (YEAR), and identified that the resident had an existing wound present. However, the next weekly skin check was not completed until 21 days later on (MONTH) 25. The resident was discharged to the hospital on (MONTH) 5, (YEAR) and was readmitted on (MONTH) 12, (YEAR). Physician orders [REDACTED]. The re-admission wound assessment report dated (MONTH) 13, (YEAR) documented the resident had excoriation to the sacral area. Further review of the clinical record revealed a weekly skin check was completed on (MONTH) 20, (YEAR), and included the resident's skin was intact. The next weekly skin check was completed 14 days later on (MONTH) 4, and the resident's skin was not intact. The next weekly skin check was completed nine days later on (MONTH) 13, (YEAR) and included the resident's skin was not intact. An interview was conducted on (MONTH) 7, (YEAR) at 1:41 p.m., with a licensed practical nurse (LPN/staff #64). She stated the resident has a chronic wound due to limited mobility and has excoriation to the sacral area. She further stated the nurses are to complete weekly skin checks. An interview was conducted on (MONTH) 8, (YEAR) at 9:42 a.m., with a LPN (staff #100). She stated every resident is to have weekly skin checks done. She stated the nurses on the unit are responsible for completing the weekly skin checks. An interview was conducted on (MONTH) 8, (YEAR) at 10:19 a.m., with a LPN (staff #69). She stated skin checks are to be completed weekly. She stated once a skin check is completed it is signed off by the nurse on the treatment administration record (TAR) on the day it is completed. She stated there were several weekly skin checks which were signed off as completed on the TAR, however, she stated there was no evidence that some of the weekly skin checks were completed. An interview was conducted on (MONTH) 8, (YEAR) at 10:50 a.m. with the Director of Nursing (staff #1), who stated that nurses on the unit are expected to complete the weekly skin checks. She further stated they were missing weekly skin checks for this resident. Review of the facility's Skin System policy and procedure revealed that skin assessments will be completed on admission/readmission and weekly thereafter.",2020-09-01
183,MISSION PALMS POST ACUTE,35071,6461 EAST BAYWOOD AVENUE,MESA,AZ,85206,2017-12-13,686,D,0,1,LQN111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policies and procedures, the facility failed to ensure physician orders [REDACTED].#18), with a pressure ulcer. Findings include: Resident #18 was admitted on (MONTH) 17, (YEAR), with [DIAGNOSES REDACTED]. An admission Braden Scale assessment dated (MONTH) 17, (YEAR) included the resident had very limited mobility, was chair fast and occasionally had moist skin. The assessment identified that the resident was at mild risk for pressure ulcer development. Review of the admission wound assessment report dated (MONTH) 18, (YEAR) revealed the resident had an unstageable sacral pressure ulcer (a suspected deep tissue injury). physician's orders [REDACTED]. According to a pressure ulcer care plan, an intervention was for weekly Braden Scale assessments to be completed. Review of the clinical record revealed the next Braden Scale assessment was completed on (MONTH) 4, (YEAR), which was 17 days after the previous assessment (July 17). The next Braden Scale assessment was completed 7 days later on (MONTH) 11. However, the next Braden Scale assessment was not completed until 14 days later on (MONTH) 25, (YEAR). Resident #18 was discharged to the hospital on (MONTH) 5, (YEAR) and was readmitted on (MONTH) 12, (YEAR). physician's orders [REDACTED]. Review of the re-admission wound assessment report dated (MONTH) 13, (YEAR) revealed the resident had excoriation to the sacral area. A Braden Scale assessment was completed on (MONTH) 13 and 20, (YEAR), which included the resident was at mild risk for pressure ulcer development. Further review of the clinical record revealed the next Braden Scale assessment was not completed until one month later on (MONTH) 20, (YEAR). The assessment included that the resident was at mild risk for pressure ulcer development. An interview was conducted on (MONTH) 8, (YEAR) at 9:42 a.m., with a licensed practical nurse (LPN/staff #100). She stated that every resident is to have weekly Braden scale assessments done. She stated that the nurses on the unit are responsible for completing the weekly Braden Scale assessments. An interview was conducted on (MONTH) 8, (YEAR) at 10: 19 a.m., with a LPN (staff #69). She stated Braden Scale assessments are to be completed weekly. She stated once a Braden Scale assessment is completed, it should be signed off on the treatment administration record (TAR) on the day it is completed by the nurse. She stated there were several weekly Braden Scale assessments which were signed off as completed on the TAR, however, they were not completed. An interview was conducted on (MONTH) 8, (YEAR) at 10:50 a.m. with the Director of Nursing (staff #1), who stated that nurses on the unit are expected to complete weekly Braden Scale assessments. She further stated they were missing weekly Braden Scale assessments for this resident. The facility's Skin System policy and procedure included that residents who have pressure sores receive the necessary treatment and services to promote healing, prevent infection, and prevent new sores form developing. The intent of the policy included to promote the prevention of pressure ulcer development and to promote the healing of pressure ulcers. The policy further included that Braden Scale assessments will be completed on admission, then weekly for four weeks, then quarterly.",2020-09-01
184,MISSION PALMS POST ACUTE,35071,6461 EAST BAYWOOD AVENUE,MESA,AZ,85206,2017-12-13,690,D,0,1,LQN111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interview and policy review, the facility failed to ensure the tubing of an indwelling urinary catheter was secured for one resident (#47). Findings include: Resident #47 was admitted to the facility on (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. An observation of wound care was conducted on (MONTH) 11, (YEAR) at 9:31 a.m. Resident #47 was observed to have an indwelling urinary catheter in place, and the catheter tubing was not secured to the resident's thigh. During the procedure, the catheter tubing was stretched tight from the urethra outward, when the resident was turned and repositioned on three occasions. In an interview with a registered nurse (RN/staff #82) conducted on (MONTH) 11, (YEAR) at 9:50 a.m., staff #82 stated that the catheter should be secured to the resident's thigh to prevent pulling or dislodgement. In an interview with the Director of Nursing (DON/staff #1) conducted on (MONTH) 11, (YEAR) at 10:00 a.m., the DON stated it was not their process to routinely secure the indwelling catheter tubing to the leg. The DON stated the catheter could be secured if the resident requested it. The DON stated she was not familiar with what the facility policy required. Review of the facility policy titled, Catheter Care revealed that the catheter should be secured to the inner thigh of the resident with a strap.",2020-09-01
185,MISSION PALMS POST ACUTE,35071,6461 EAST BAYWOOD AVENUE,MESA,AZ,85206,2017-12-13,692,E,0,1,LQN111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews and policy review, the facility failed to monitor the fluid intake for one resident (#25), who had a physician's orders [REDACTED]. Findings include: Resident #25 was admitted on (MONTH) 28, (YEAR), with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A dietary note dated (MONTH) 3, (YEAR) identified that the resident was on a fluid restriction. The note included that Per nursing staff, resident not likely to be compliant with fluid restriction, family brings in cases of water. Will encourage resident and family compliance and ensure are aware of risks and benefits. The note was signed by a registered dietitian (staff #140). A nutrition care plan was revised on (MONTH) 4, (YEAR) and included fluid restriction as ordered. Review of the clinical record revealed a form titled, Fluid Restriction. This form included that the resident had orders for a 1200 ml fluid restriction. The form also contained a chart with how much fluid residents should consume based on various fluid restriction amounts. For a 1200 ml fluid restriction, the documentation included that a resident should consume 360 ml from nursing across all shifts and 840 ml from meals. Further review of the clinical record revealed there was no documentation that the resident's fluid intake was being monitored in (MONTH) and (MONTH) (YEAR), despite having orders for a 1200 ml fluid restriction. On (MONTH) 12, (YEAR) at 10:45 a.m., an interview was conducted with a RN (registered nurse/staff #75), who stated the resident is non-compliant with the fluid restriction, as the family brings in cases of water, even though the family and resident have been educated regarding the fluid restriction. Staff #75 stated she had spoken to the resident's physician and nurse practitioner regarding the resident's non-compliance. Staff #75 stated that she only documents the percentage of the liquid supplement that the resident consumes and does not document the amount of fluids the resident drinks throughout the day. She stated that the resident drinks the bottled water brought in by the family, but that amount is not documented. An interview was conducted with resident #25 on (MONTH) 12, (YEAR) at 11:40 a.m., with a certified nursing assistant (CNA/staff #85) present as an interpreter. Resident #25 stated she only drinks the bottled water brought in by the family, and that the nurses do not ask her how much she drinks in a day. The resident stated she drinks at least a bottle (12 ounce) and a half per day. An interview was conducted with the dietary manager (staff #117) on (MONTH) 12, (YEAR) at 12:15 p.m. Staff #117 stated that the resident eats in her room, so dietary staff do not document the resident's fluid intakes, as that would be nursing's responsibility. An interview was conducted with the ADON (Assistant Director of Nursing/staff #2) on (MONTH) 12, (YEAR) at 2:00 p.m. Staff #2 stated she was unable to provide any clinical record documentation that the resident's daily fluid intake was being monitored. Review of a policy regarding Encouraging and Restricting Fluids revealed that the purpose of the policy was to provide the resident with the amount of fluids necessary to maintain optimum health, which may include encouraging or restricting fluids. The policy further documented for staff to follow specific instructions regarding fluid restrictions and accurately record fluid intake, and to be sure an intake and output record is maintained.",2020-09-01
186,MISSION PALMS POST ACUTE,35071,6461 EAST BAYWOOD AVENUE,MESA,AZ,85206,2017-12-13,695,D,0,1,LQN111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review and staff and physician interviews, the facility failed to ensure one resident (#308) had an order for [REDACTED].>Findings include: Resident #308 was admitted to the facility on (MONTH) 6, (YEAR), with [DIAGNOSES REDACTED]. Review of the nursing Admission data set dated (MONTH) 7, (YEAR), revealed the resident was alert, with confusion and had short and long term memory problems. Under respiratory status, the documentation included that the resident had oxygen via a nasal cannula. An observation was conducted on (MONTH) 7, (YEAR) at 7:56 a.m., of resident #308 in bed. Next to the resident's bed was an oxygen concentrator. At this time, the resident was not receiving any oxygen. An observation was conducted approximately 30 minutes later at 8:30 a.m. Two CNA's were observed entering the resident's room and assisted the resident, then left the room. The resident was now observed to have oxygen on via nasal cannula at 2 liters per minute. However, review of the clinical record revealed there were no physician orders for the resident to receive oxygen. In an interview conducted on (MONTH) 7, (YEAR) at 9:47 a.m. with the resident's physician (Medical Director/staff #141), the physician stated that when residents are admitted staff are to reconcile the orders from the hospital and if there are questions, they are to call. The physician stated if a resident comes in with oxygen on and there was no order, the nurses should have called for an order. In an interview with a registered nurse (staff #75) on (MONTH) 7, (YEAR) at 9:55 a.m., staff #75 stated if the resident comes in with oxygen and there is no order, the Dr. needs to be called. In an interview conducted with the Assistant Director of Nursing (ADON/staff #2) on (MONTH) 8, (YEAR) at 12:13 p.m., the ADON stated that the nurse should have obtained an order for [REDACTED].>",2020-09-01
187,MISSION PALMS POST ACUTE,35071,6461 EAST BAYWOOD AVENUE,MESA,AZ,85206,2017-12-13,697,E,1,1,LQN111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews and policy and procedures, the facility failed to ensure two resident's (#19 and #66) received pain medications per the physician's orders [REDACTED]. Findings include; -Resident #19 was admitted to the facility on (MONTH) 13, (YEAR), with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 20, (YEAR), revealed a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS also included the resident was receiving scheduled pain medication and the care area for pain triggered, with a decision to proceed to care planning. Review of a care plan titled Risk for alterations in comfort dated (MONTH) 13, (YEAR) revealed the following approaches: medications as ordered; pain assessment per protocol; and attempt and document effectiveness of non pharmacological interventions as appropriate (breathing, imagery, reposition, heat, ice). The recapitulation of physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. However, the documentation on the MAR indicated [REDACTED]. The MAR indicated [REDACTED] Review of the corresponding nursing notes for (MONTH) 2 and 3, (YEAR) on the evening shift revealed no documentation of any non pharmacological interventions which were attempted, to address the resident's pain level of a 6. Further review of the (MONTH) (YEAR) MAR indicated [REDACTED]. In addition, there was no documentation the physician had been notified that the [MEDICATION NAME] was unavailable on (MONTH) 2, 3 and 4. During an interview conducted with a licensed practical nurse (LPN/staff #72) at 11:20 a.m. on (MONTH) 8, (YEAR), staff #72 stated he worked on (MONTH) 2, and 3, on the evening shift. He stated during his shift he realized the scheduled [MEDICATION NAME] was not available in the medication cart, so he was unable to administer it. Staff #72 stated he thought the pharmacy would be delivering the medication later so he took no other steps. He stated the next day (December 3), he noticed that the pain medication was still not available so he called the pharmacy, but took no steps to ensure the resident received any other pain medication, nor did he inform the physician that the [MEDICATION NAME] was unavailable. During an interview with a registered nurse (RN/staff #75) at 10:54 a.m. on (MONTH) 12, (YEAR), staff #75 stated if a nurse tries to administer a narcotic medication and the medication is not in the medication cart, the nurse should call the pharmacy and arrange to take the medication from the E-Kit (emergency medication kit). During an interview conducted at 11:15 a.m. on (MONTH) 12, (YEAR), the Director of Nursing (staff #1) stated when the [MEDICATION NAME] 5 mg was not available, the evening nurse should have contacted the physician and pharmacy to get orders and obtain a code, in order to access the [MEDICATION NAME] from the 'RX Now' system. She also stated that the system did contain [MEDICATION NAME] 5 mg on (MONTH) 2, 3 and 4. -Resident #66 was admitted to the facility on (MONTH) 3, (YEAR), with [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment dated (MONTH) 10, (YEAR) included the resident had a BIMS score of 15, which indicated the resident was cognitively intact. The MDS also included the resident experienced frequent pain; was not on scheduled pain medication, but was receiving as needed pain medication; and was not receiving any non-medication interventions for pain. A review of the comprehensive care plan dated (MONTH) 17, (YEAR), revealed a problem area of increased risk for pain. The approaches included pain assessment per protocol; identify location and rate of pain prior to and after any interventions and medications as ordered. A physician's orders [REDACTED]. A review of the MAR for (MONTH) (YEAR) revealed the resident was assessed to have a pain level of 5 at 8 a.m. on (MONTH) 2, a pain level of 7 at 8 a.m. on (MONTH) 4, a pain level of 9 at 8 p.m. on (MONTH) 6, a pain level of 4 at 8 a.m. on (MONTH) 26, and a pain level of 7 at 8:00 a.m. on (MONTH) 28. However, further review of the MAR indicated [REDACTED]. According to the corresponding Nurses Notes, there was no documentation regarding what actions were taken to address the resident's pain or why the [MEDICATION NAME] was not administered on (MONTH) 2, 4, 6, 26 and 28. During an interview conducted at 1:50 p.m. on (MONTH) 8, (YEAR), a LPN (staff #69) stated that she could not say why the pain medication was not administered when the resident reported pain between 4-9. She stated the medication should have been administered per the physician's orders [REDACTED]. A review of the Pain Management Process policy revealed The facility recognizes that each resident has the right to treatment and services to maintain their quality of life .The facility will react to the residents pain control needs based on the resident's goals for pain relief and the resident's goals for functional ability. The resident's goals for pain control will be met by the use of medications and alternative methods to reduce pain as outlined in the Federal Regulatory Requirements for LTC (Long Term Care.) This system will suggest necessary evaluation, intervention, and re-evaluation as standard care practice for licensed nurses.",2020-09-01
188,MISSION PALMS POST ACUTE,35071,6461 EAST BAYWOOD AVENUE,MESA,AZ,85206,2017-12-13,700,D,0,1,LQN111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, and policy review, the facility failed to ensure two residents (#305 and #20) were assessed for the safe use of grab bars prior to installation and informed of the risks and benefits of their use. Findings include: -Resident #305 was admitted to the facility on (MONTH) 22, (YEAR), with [DIAGNOSES REDACTED]. The resident discharged from the facility on (MONTH) 6, (YEAR). A physician's orders [REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 28, (YEAR), revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated that the resident was cognitively intact. The MDS also included the resident required extensive assistance with bed mobility and transfers. Review of the Activity of Daily Living (ADL) care plan revealed the resident had a self care deficit, as evidenced by the need for extensive assistance with bed mobility and transfers. The goal was that the resident will participate to his ability, and would return to his prior level of functioning. Interventions included for Occupational and Physical Therapy; encourage the resident to participate to his ability; and for a grab bar to the left side of the resident's bed. During an observation of the resident's room conducted at 1:00 p.m. on (MONTH) 5, (YEAR), a grab bar was observed on the left side of the resident's bed. Further review of the clinical record revealed no evidence that the facility conducted an assessment for the safe use of the grab bar, nor provided the resident with the risks and benefits of utilizing a grab bar on the bed. An interview was conducted with the Director of Nursing (DON/staff #1) at 10:50 a.m. on (MONTH) 12, (YEAR). She stated that she was new to the facility, but it was her understanding that there was a change in how the grab bars/side rails were assessed. She said it used to be that when an order for [REDACTED].#1 stated the residents are assessed to determine if the rail is needed and if it is safe for their use. She said that this recently changed and now it is the floor nurses responsibility to complete the assessment. She said the assessment also includes the risks and benefits and the informed consent, which the resident signs. During an interview with the Director of Rehabilitation services (staff #128) at 11:05 a.m. on (MONTH) 12, (YEAR), she stated that there was a change a few months ago regarding who does the assessments for the bed rails and grab bars. She stated that prior to the change, the therapy department did the assessments after an order was obtained. She said they would assess the resident to determine if use of the rail was appropriate and safe. She said when this changed, therapy was no longer involved and the nurses became responsible for assessing the residents for the safe use of the grab bars. Staff #128 stated this process includes obtaining informed consent and providing the resident with the risks and benefits of the use of the grab bars. She further stated that she realizes this is not happening. In an interview with a Registered Nurse (RN/staff #75) at 12:40 p.m. on (MONTH) 12, (YEAR), she stated that when there is a physician's orders [REDACTED]. She stated the assessment also includes providing the resident or the resident's family with the risks and benefits of the side rail or grab bar and obtaining informed consent. She said this assessment is in the electronic computer system. An interview was conducted with the Administrator (staff #88) at 1:00 p.m. on (MONTH) 12, (YEAR). She stated that she was aware that there was an issue with the side rail/grab bar assessments and that they had switched the process this year. She said this resident got his rail installed quickly, but the nurses were not aware of the need to conduct an assessment of the rail. -Resident #20 was admitted to the facility on (MONTH) 26, (YEAR), with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. An admission Minimum Data Set assessment dated (MONTH) 3, (YEAR) revealed a BIMS score of 14, which indicated the resident had no cognitive impairment. A care plan dated (MONTH) 13, (YEAR) documented the resident required moderate assistance with bed mobility. A goal included that the resident will return to his prior level of function. An intervention included for bilateral grab bars for mobility. An observation was conducted of the resident's room on (MONTH) 11, (YEAR) at 9:38 a.m. The resident's bed had a grab bar on both sides of the bed. At this time, the resident stated that he uses the bars for positioning. Review of the clinical record revealed there was no documentation that the resident had been assessed for the safe use of the grab bars, nor any documentation that the risks and benefits of their use were explained to the resident, prior to their use. An interview was conducted on (MONTH) 11, (YEAR) at 10:48 a.m. with the Director of Rehabilitation (staff #128). She stated that prior to September, therapy staff assessed the residents for the safe use of grab bars/siderails, but the new process is that the nursing staff are now responsible to provide the assessment and document it. An interview was conducted on (MONTH) 17, (YEAR) at 11:01 a.m., with a Registered Nurse (staff #75). She stated that she could not find documentation in the clinical record that the resident had been assessed for the safe use of the grab bars. She stated the current procedure is if a resident makes a request for an assistive bar, the physician is notified and an order is obtained. She stated the resident is then assessed for safety which is documented on the safety device form in the medical record, and then they can be installed. Review of the facility's Restraint policy revealed that residents with safety devices will be reviewed upon admission, quarterly, and with a change of condition, to determine if the device is a restraint or enabler and if the device is needed. If an enabler is used, a Safety Device Assessment must be completed and the responsible party must be notified. A consent must be completed, signed and dated by all appropriate parties for any device.",2020-09-01
189,MISSION PALMS POST ACUTE,35071,6461 EAST BAYWOOD AVENUE,MESA,AZ,85206,2017-12-13,755,D,0,1,LQN111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, staff interviews and policy and procedures, the facility failed to maintain a system of receipt and disposition of controlled drugs in sufficient detail to enable an accurate reconciliation of one resident's (#19) narcotic medication. Findings include: Resident #19 was admitted to the facility on (MONTH) 13, (YEAR), with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set assessment dated (MONTH) 20, (YEAR), revealed a Brief Interview for Mental Status score of 9, indicating the resident had moderate cognitive impairment. Review of the recapitulation of physician's orders [REDACTED]. A review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. According to the facility's investigation, a card of [MEDICATION NAME] for resident #19 was delivered on (MONTH) 1, (YEAR). When the narcotic count was done on the evening shift on (MONTH) 1, and on the morning shift on (MONTH) 2, there were a total of 10 narcotic cards. However, when the evening nurse went to administer resident #19 his 8 p.m. dose of [MEDICATION NAME] on (MONTH) 2, there was no [MEDICATION NAME] for the resident in the medication cart and the narcotic sheet for the [MEDICATION NAME] was also missing. Per the report, the facility determined that a LPN who had worked the day shift on (MONTH) 2 and 3, had taken the card of [MEDICATION NAME] belonging to resident #19. Review of the Controlled Drugs Count Record which was located in the narcotic book on medication cart #2 was reviewed. This form was undated, however, per the Director of Nursing (staff #1), this form was for the month of (MONTH) (YEAR). Regarding their process for reconciliation of controlled substances, the DON stated that they use a controlled drug sheet for each resident's medication, which includes the number of pills left on the card. She stated that they also use the Controlled Drugs Count Record to keep track of the number of narcotic cards that are in the medication cart. Further review of the Controlled Drugs Count Record revealed there were areas to document the number of narcotic cards which were in the medication cart and a place for the nurses to sign who performed the count. The form also included a comment section. The documentation on the Controlled Drugs Count Record included the following: on the day shift on (MONTH) 1 there were 10 cards; for the 6p-6a shift there were 9 cards; and on the day shift and on the 6p-6a shift on (MONTH) 2, there were 8 cards. In the comment section, there were plus or minus symbols written in, with no explanation. There was no documentation as to when narcotic cards were added to the count or when they had been used up and removed. As a result, the controlled drug card counts varied from shift to shift with no clear explanation as to what occurred. Based on the documentation on the Controlled Drugs Count Record, it was difficult to identify if any narcotic cards were missing. During an interview conducted with a licensed practical nurse (LPN/staff #72) at 11:20 a.m. on (MONTH) 8, (YEAR), the nurse stated he worked the evening/night shift on (MONTH) 2, and 3, (YEAR). He stated that at the beginning of his shift on (MONTH) 2, he completed the narcotic count with another LPN, but had not identified any discrepancy on the Controlled Drugs Count Record. He stated that later in his shift, he realized that the scheduled 8 p.m. dose of the [MEDICATION NAME] was not available for the resident in the medication cart. He further stated that on (MONTH) 3, the medication was still not available, so he called the pharmacy and they informed him that a card of 59 doses of [MEDICATION NAME] 5 mg tablets was delivered to the facility on (MONTH) 1, (YEAR). During an interview conducted at 10:54 a.m. on (MONTH) 12, (YEAR), a registered nurse (staff # 75) stated that when a nurse begins a shift, the nurses must reconcile the narcotic count in the medication cart, prior to taking responsibility for that cart. She stated the nurse whose shift is ending and the oncoming nurse count the number of narcotics that are on each medication card, and count the number of narcotic cards that are in the cart. She said when a new card of narcotics is received from the pharmacy or if they use the last tablet of a narcotic medication and remove the card, the nurse is to document the information in the comments section on the Controlled Drugs Count Record. During an interview conducted at 11:15 a.m. on (MONTH) 12, (YEAR), staff #1 stated the documentation on the Controlled Drugs Count Record for (MONTH) was unclear and that the information in the comment section did not make sense. A review of the Storage of Medications policy revealed to store all drugs and biologicals in a safe, secure, and orderly manner. The policy also included The nursing staff shall be responsible for maintaining medication storage in a safe manner.",2020-09-01
190,MISSION PALMS POST ACUTE,35071,6461 EAST BAYWOOD AVENUE,MESA,AZ,85206,2017-12-13,757,E,0,1,LQN111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, and staff and nurse practitioner (NP) interviews, the facility failed to ensure one resident (#66) was free of unnecessary drugs, by failing to ensure physician orders were in place for a narcotic pain medication. Findings include: Resident #66 was admitted to the facility on (MONTH) 3, (YEAR), with [DIAGNOSES REDACTED]. A physician's order dated (MONTH) 4, (YEAR) included for [MEDICATION NAME] (narcotic pain medication) 20 mg PO (by mouth) every 12 hours as needed. An admission Minimum Data Set (MDS) assessment dated (MONTH) 10, (YEAR) included the resident had a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. The MDS also included the resident experienced frequent pain and was receiving as needed pain medication. A review of the comprehensive care plan dated (MONTH) 17, (YEAR) revealed a problem area of increased risk for pain. One of the approaches included Medications as ordered. Review of the Medication Administration Record [REDACTED]. The documentation showed that [MEDICATION NAME] ER was administered over 15 times from (MONTH) 1 through 28. However, review of the clinical record revealed there was no order for [MEDICATION NAME] ER 20 mg twice a day as needed. The only pain medication order was from (MONTH) 4, for [MEDICATION NAME] 20 mg every 12 hours as needed for pain. A handwritten physician's order dated (MONTH) 29, (YEAR) included to Reduce [MEDICATION NAME] to 10 mg every 12 hours as needed for pain. Again, there was no previous order for [MEDICATION NAME], only an order for [REDACTED].>Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. The medication was given on (MONTH) 3. However, there was no physician's order to administer [MEDICATION NAME] ER. A physician's order dated (MONTH) 7, (YEAR) included Give 20 mg ER [MEDICATION NAME] PO (by mouth) x 1 now. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. This medication was administered on (MONTH) 7. The MAR indicated [REDACTED]. Further review of the (MONTH) (YEAR) MAR indicated [REDACTED]. According to the (MONTH) (YEAR) MAR, [MEDICATION NAME] 10 mg ER continued to be administered between (MONTH) 1 and 15. The [MEDICATION NAME] ER was administered more than 9 times. Continued review of the clinical record revealed there was no order to administer [MEDICATION NAME] 10 mg ER from (MONTH) 1-15, A physician's order dated (MONTH) 16, (YEAR) included to discontinue [MEDICATION NAME] ER and give [MEDICATION NAME] 10 mg ER daily at 6:00 p.m. During an interview conducted at 1:50 p.m. on (MONTH) 8, (YEAR), a LPN (staff #69) stated that she could not say why the orders had not been accurately transcribed into the electronic MAR. An interview was conducted at 1:55 p.m. on (MONTH) 8, (YEAR), with the NP. After reviewing the clinical record, the NP stated the nurse must have entered the order into the MAR indicated [REDACTED].",2020-09-01
191,MISSION PALMS POST ACUTE,35071,6461 EAST BAYWOOD AVENUE,MESA,AZ,85206,2017-12-13,761,D,0,1,LQN111,"Based on observation, staff interview and policy review, the facility failed to ensure one medication cart was locked, when left unattended. Findings include: An observation of the medication cart on Station 3 was conducted on (MONTH) 8, (YEAR) at 3:14 p.m. The medication cart was located at the far end of the hall. At this time, the medication cart was left unattended and was unlocked for approximately five minutes. Multiple staff were observed walking by the medication cart. In an interview conducted on (MONTH) 8, (YEAR) at 3:20 p.m. with a Registered Nurse (RN/staff #77), staff #77 stated she had gotten a suppository from the cart. Staff #77 stated that residents or others could obtain medications if the cart was left unlocked. In an interview conducted with the Director of Nursing (DON/staff #1) on (MONTH) 8, (YEAR) at 3:27 p.m., the DON stated the cart is supposed to be locked any time the nurse leaves the cart and the nurses know better than to leave it unlocked. Review of a facility policy titled Storage of Medications revealed to store all drugs and biologicals in a safe, secure, and orderly manner. The policy further documented that compartments (including, but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.",2020-09-01
192,MISSION PALMS POST ACUTE,35071,6461 EAST BAYWOOD AVENUE,MESA,AZ,85206,2017-12-13,803,D,0,1,LQN111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, resident and staff interviews and facility documentation, the facility failed to ensure one resident's (#307) request for no meat was honored. Findings include: Resident #307 was admitted to the facility on (MONTH) 6, (YEAR), with [DIAGNOSES REDACTED]. Review of a nursing Admission data set dated (MONTH) 6, (YEAR) revealed the resident was alert, oriented to person, time, place and purpose and had no memory problems. A physician's orders [REDACTED]. According to the Diet Order and Communication sheet in the clinical record dated (MONTH) 6, (YEAR), the resident was on a regular diet with thin liquids. A handwritten note on the form included No Meat. Review of the interim care plan initiated on (MONTH) 6, (YEAR) revealed the resident was on a regular diet and included a dietary preference of No meat. A breakfast meal observation was conducted on (MONTH) 7, (YEAR) at 7:56 a.m. Resident #307 was eating a pancake with syrup and on the resident's plate was a sausage patty. An interview with resident #307 was conducted on (MONTH) 7, (YEAR) at 8:08 a.m. Resident #307 stated that she was not supposed to have sausage on her plate. She stated that she has told them she does not want any meat at all. The resident then held up the menu sheet that accompanied her meal. The menu sheet contained the resident's name, room number and identified her diet as Regular, No Meat. In an interview conducted with a Registered Nurse (RN/staff #75) on (MONTH) 7, (YEAR) at 9:55 a.m., the RN stated that the resident told her she got sausage on her tray and that she wasn't supposed to get meat. The RN stated the CNA who served the meal should have seen that and not served it to the resident. In an interview conducted on (MONTH) 7, (YEAR) at 10:34 a.m. with dietary staff (cook/staff #107), the cook stated when a resident is admitted they receive a copy of the diet order and the diet order slips are printed for each resident. Staff #107 stated that he had plated the breakfast that morning and either didn't see the diet sheet or no one communicated to him what the diet order was when he was filling the plate. Staff #107 stated it got missed in the kitchen and again on the unit when it was delivered.",2020-09-01
193,MISSION PALMS POST ACUTE,35071,6461 EAST BAYWOOD AVENUE,MESA,AZ,85206,2017-12-13,808,D,0,1,LQN111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review and staff interview, the facility failed to ensure one resident (#66) who was served a mechanical soft diet, had physician orders in place for the therapeutic diet. Findings include: Resident #66 was readmitted to the facility on (MONTH) 3, (YEAR), with [DIAGNOSES REDACTED]. A review of the (MONTH) (YEAR) recapitulation of physician's orders revealed for the resident to receive a regular diet, with thin liquids. During a dining observation conducted at 12:00 p.m. on (MONTH) 5, (YEAR), the meal tray for resident #66 was delivered to the resident's room. The meal on the tray was a mechanical soft diet of ground chicken mixed with gravy, rice and squash. According to the meal ticket on the tray, the resident was to receive a regular diet. At this time, additional observations were conducted of other resident's trays which were being served. Observations revealed that the regular diet consisted of a boneless piece of chicken with gravy, rice and squash. Review of the clinical record revealed there was no physician's order for the resident to receive a therapeutic diet (mechanical soft). An interview was conducted at 10:45 a.m. on (MONTH) 11, (YEAR), with the Dietary Manager (staff #141). He stated a mechanical soft diet was a therapeutic diet. He also stated that a resident was not allowed to receive a therapeutic diet, without a physician's order.",2020-09-01
194,MISSION PALMS POST ACUTE,35071,6461 EAST BAYWOOD AVENUE,MESA,AZ,85206,2017-12-13,812,E,0,1,LQN111,"Based on observations, staff interviews and policies and procedures, the facility failed to ensure food stored in 2 of 3 nourishment refrigerators were dated and labeled with a resident name, and failed to ensure 3 of 3 nourishment refrigerators were clean. Findings include: On (MONTH) 7, (YEAR) at 10:07 a.m., an observation was conducted of the nutrition refrigerator on Unit 1. The refrigerator contained an uncovered plate of salad which was not labeled with a resident's name. Also, the inside of the refrigerator had food debris and stains throughout. At this time, an interview was conducted with a licensed practical nurse (staff #69) on Unit 1. Staff #69 stated that all staff should be making sure food in the nourishment refrigerator was dated and has a resident's name on the container/package. Staff #69 also stated that normally the night shift was responsible for cleaning the refrigerator, but all staff should make sure the refrigerator was kept clean. Staff #69 acknowledged that the refrigerator was not clean. An observation was conducted of the nourishment refrigerator on Unit 2 on (MONTH) 7, (YEAR) at 10:19 a.m. On the outside of the refrigerator door was a sign which read: Attention all staff. This refrigerator is only to be used for resident foods/nursing items and must be labeled and dated for three days from which the food was brought in. Any food that is found not labeled or dated will be thrown out. No exceptions. This fridge is not for staff use. Thank you for you assistance in keeping our nourishment room fridges clean/organize/dated and in compliance. If you have any questions/concerns please let me know. Dietary Manager. Further observations revealed that this refrigerator contained a half loaf of banana bread which was partially wrapped, but was not dated, nor was it labeled with a resident's name. In addition, the inside of the refrigerator had food debris and stains throughout. On (MONTH) 7, (YEAR) at 10:31 a.m., an observation was conducted of the nourishment refrigerator on the Oasis unit. The inside of the refrigerator had food debris and multiple stains throughout. On (MONTH) 7, (YEAR) at 10:40 a.m., additional observations were conducted of the nourishment refrigerators on Unit 1 and 2 and on the Oasis Unit, with the dietary manager (staff #117). Staff #117 stated the refrigerators were not clean and that dietary staff should be wiping the refrigerators when they place snacks in them, but nursing staff should also be monitoring. A facility policy regarding the safe storage of food documented that when resident food items were intended for later consumption, the responsible staff member will label foods with the resident's name and current date. The policy further included that refrigerator/freezers for the storage of resident food should be properly maintained and cleaned weekly.",2020-09-01
195,MISSION PALMS POST ACUTE,35071,6461 EAST BAYWOOD AVENUE,MESA,AZ,85206,2017-12-13,842,D,0,1,LQN111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility failed to ensure that a medication consent was complete for one resident (#54). Findings include: Resident #54 was admitted on (MONTH) 25, (YEAR), with a [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the clinical record revealed a medication consent form for the [MEDICATION NAME] medication, however, the form was not dated. This form also included a box to check if the resident consented for the antidepressant medication and a box to check if the resident did not consent to receive the medication. This form was signed by the resident, however, neither box was checked to indicate if the resident desired to receive or not to receive the antidepressant. An interview was conducted on (MONTH) 11, (YEAR) at 3:39 p.m. with the Director of Nursing (staff #1), who stated that consents are expected to be completed with dates and the appropriate boxes checked. She stated the consent for the [MEDICATION NAME] for resident #54 did not have a date and the box was not checked to indicate the resident's wishes.",2020-09-01
196,MISSION PALMS POST ACUTE,35071,6461 EAST BAYWOOD AVENUE,MESA,AZ,85206,2017-12-13,880,E,0,1,LQN111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, facility documentation and policy and procedures, the facility failed to ensure that staff followed infection control practices during the provision of wound care, and failed to ensure that two staff members (#134 and #135) had evidence of freedom from [MEDICAL CONDITION] (TB). Findings include: -An observation of wound care was conducted on (MONTH) 11, (YEAR) at 9:31 a.m., with a registered nurse (staff #82). Staff #82 gathered the necessary supplies and entered a resident's room. Staff #82 was not observed to wash her hands, prior to providing the wound care. Staff #82 then placed a washcloth on the resident's over-bedside table and set a plastic cup, loose gauze, and a dry dressing on the wash cloth. Staff #82 set the multi-use bottles of wound cleanser and Dakin's Solution on the resident's over-bedside table, with no barrier. Staff #82 then donned gloves and removed the soiled dressing, which had serosanguinous drainage on it. Staff #82 then changed her gloves, however, did not wash her hands. Staff #82 then cleansed the wound with wound cleanser. Staff #82 then used wet wipes to clean around the perianal area, and then used the same wet wipes to clean the skin around the wound. Staff #82 then changed gloves and placed the Dakin's soaked non-sterile gauze in the wound and covered the wound with a dry dressing. Following the wound care, staff #82 placed the multi-use bottle of wound cleanser back in the drawer of the treatment cart, without cleaning the bottle. She stated that she was going to return the Dakin's Solution to another treatment cart. Staff #82 also was not observed to wash her hands after providing wound care to the resident. In an interview with staff #82 conducted on (MONTH) 12, (YEAR) at 9:50 a.m., staff #82 had no comments or concerns regarding the above infection control issues. In an interview with the Director of Nursing (DON/staff #1) conducted on (MONTH) 11, (YEAR) at 10:00 a.m., the DON stated if the wound nurse is not here, the floor nurses complete the wound treatments. Staff #1 stated the nurses should wash down the surface area, then set down their supplies, and then clean the area afterwards. The DON stated they have disinfectant wipes for that purpose. The DON further stated the nurse performing the wound care should have washed her hands before, after removing the dirty dressing, and after the procedure. Staff #1 also stated the multi-use bottles should not be on unclean surfaces in a resident's room and should be cleaned, prior to placing them back in the cart. Review of the facility policy titled, Wound Care revealed the purpose was to provide guidelines for the care of wounds to promote healing. The steps in the procedure included the following: -Use disposable cloth (paper towel is adequate) to establish a clean field on the resident's overbed table. Place all items to be used during procedure on the clean field. -Wash and dry your hands thoroughly. -Put on exam gloves. Loosen tape and remove dressing. -Wash and dry your hands thoroughly. -Put on gloves. -Wear sterile gloves when physically touching the wound or holding a moist surface over the wound. -Wash tissue around the wound that is usually covered by the dressing, tape, or gauze with antiseptic or soap and water. -Review of the personnel file for staff #134 (Speech-language pathologist) revealed a hire date of (MONTH) 7, 2013. Further review of the personnel file revealed that staff #134 had a chest x-ray dated (MONTH) 6, (YEAR). However, there was no current documentation that staff #134 was free of TB. A review of the personnel file for staff #135 (Occupational Therapist) revealed a hire date of (MONTH) 15, (YEAR). Further review of the personnel file reveled that staff #135 had a chest x-ray dated (MONTH) 22, (YEAR). However, there was no evidence that staff #135 was currently free of TB. During an interview conducted at 9:20 a.m. on (MONTH) 13, (YEAR), the human resource manager (staff #106) stated that staff who had chest x-rays as evidence of freedom from TB, should be screened annually to ensure they are free from infectious TB. She stated the therapy company that employees staff member #134 and #135 contracts with the facility, and does not require their staff to be screened annually. She stated that these two staff members provide direct care to the residents in the facility full time. A review of the [MEDICAL CONDITION] Screening Policy for Employees, Residents and Volunteers revealed All employees and volunteers will receive a [MEDICAL CONDITION] Screen and a TB skin test (ST) prior to working and a single TB test and screening yearly thereafter.",2020-09-01
197,MISSION PALMS POST ACUTE,35071,6461 EAST BAYWOOD AVENUE,MESA,AZ,85206,2017-12-13,908,D,0,1,LQN111,"Based on observations, staff interviews and policy review, the facility failed to ensure two nourishment refrigerators were in good operating condition. Findings include: An observation was conducted on (MONTH) 7, (YEAR) at 10:07 a.m. of the Unit 1 nourishment refrigerator. The bottom tray that covered the vegetable storage bins was cracked. At this time, an interview was conducted with a LPN (licensed practical nurse/staff #69). Staff #69 stated that the shelf on the bottom of the refrigerator was broken and should have been reported to maintenance. An observation was conducted on (MONTH) 7, (YEAR) at 10:40 a.m., of the nourishment refrigerator on Unit 2, with a dietary staff member (staff #117). The bottom shelf of the refrigerator was cracked. Staff #117 stated the bottom shelf of the refrigerator was cracked and needed to be replaced. A review of the facility policy regarding Food Storage of Resident Food revealed the refrigerator/freezers for storage of resident foods should be properly maintained.",2020-09-01
198,PHOENIX MOUNTAIN POST ACUTE,35072,13232 NORTH TATUM BLVD,PHOENIX,AZ,85032,2020-01-17,641,D,0,1,MNCW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, review of the Resident Assessment Instrument (RAI) manual and policies and procedures, the facility failed to ensure the MDS (Minimum Data Set) assessments for three residents (#2, #71 and #267) were accurate. The deficient practice could result in not identifying care needs and treatment. Findings include: -Resident #71 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the Admission Nursing assessment dated [DATE] revealed the resident had a Permacath ([MEDICAL TREATMENT] access catheter) in his left upper chest. A review of the physician's orders [REDACTED]. A baseline care plan regarding [MEDICAL TREATMENT] revealed the following: encourage resident to go for scheduled [MEDICAL TREATMENT] treatments, monitor access site for s/s of infection daily; document any redness, swelling, pain, fever and oozing, monitor permacath to ensure site is intact daily and to check vital signs pre and post on [MEDICAL TREATMENT] days. However, review of the admission MDS assessment dated [DATE] revealed the MDS was coded that the resident was not receiving [MEDICAL TREATMENT] services. Review of documentation from the [MEDICAL TREATMENT] center revealed the resident received [MEDICAL TREATMENT] from 12/06/19 to 1/13/20. An interview was conducted with the MDS Coordinator (staff#26) on 1/15/20 at 12:40 PM. She stated that when she is completing Section O of the MDS, she looks for information in the clinical record including MAR/TAR records, physician notes and ancillary services notes. She reviewed Section O of this resident's MDS for [MEDICAL TREATMENT] and said that Section O was not coded for [MEDICAL TREATMENT] and it should have been. She said that she was going to submit a corrected MDS assessment. In an interview with the Director of Nursing (DON/staff#145) on 1/17/20 at 8:51 AM, she stated that she really is not involved in the MDS assessments since the MDS Coordinator (staff #26) is a Registered Nurse. She stated the MDS assessment was not coded for [MEDICAL TREATMENT] and it should have been. -Resident #267 was admitted to the facility on [DATE] and discharged on [DATE], with [DIAGNOSES REDACTED]. A nurse's progress note dated May 8, 2019 included the resident was being transported via wheelchair into a transport vehicle and when being pushed up the ramp, the wheelchair tipped backward. The note included that the driver, still holding onto the resident's wheelchair, lost his balance and tried to protect the resident's head as they went down. The resident sustained [REDACTED]. Review of a provider note dated May 8, 2019 revealed the resident was seen for an acute visit, due to a fall hitting his head in the a.m. The note included that the resident had a small bump on the back of his head and a small abrasion on his right scapula. Review of the quarterly MDS assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The MDS also indicated that the resident had one fall with no injury since admission or reentry or prior assessment. However, the MDS did not reflect the fall with injury from the transport van that occurred on May 8, 2019. An interview was conducted with the MDS nurse (Registered Nurse (staff #26) on January 16, 2020 at 9:36 AM. The nurse reviewed the clinical records for resident #267 including the quarterly MDS assessment dated [DATE], the progress notes from May 8, 2019, and the RAI manual's definition of a fall. She stated that the MDS assessment was inaccurate as the resident had a fall with injury, which was not documented on the MDS assessment. She stated the MDS is expected to be accurate related to patient's care and that the MDS for resident #267 did not meet facility expectations for accuracy. An interview was conducted with the Director of Nursing (DON/staff #145 on January 16, 2019 at 10:46 AM. She stated that she expects the MDS assessment to be accurate. She stated that accuracy is important for reimbursement, the care of the patient, and to make sure the facility is doing everything that the patient needs. She stated the facility uses the RAI manual for guidance in completing the MDS assessment. She stated the MDS assessment was inaccurate and did not meet her expectations for resident #267, because the documentation did not include the fall with injuries. -Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the initial admission record dated September 30, 2019 revealed the resident had an indwelling urinary catheter in place for chronic [MEDICAL CONDITION]. A physician's orders [REDACTED].#16 French with a 10 milliliter (ml) balloon to a closed drainage system for a [DIAGNOSES REDACTED]. Review of a physician's progress note dated October 1, 2019 revealed the resident had a chronic Foley catheter that was placed before surgery for [REDACTED]. According to a nurse's progress note dated October 5, 2019, the resident had a Foley 16 French with a 10 ml balloon, which was patent and intact with yellow urine draining into the bag. A physician's progress note dated October 7, 2019 included the resident was having no pain related to the Foley catheter. Review of the admission MDS assessment dated [DATE] revealed the resident had a BIMS score of 5, which indicated severe cognitive impairment. The MDS also indicated that the resident did not have an indwelling catheter. However, review of the clinical record revealed that the resident had the indwelling urinary catheter in place during the lookback period for this MDS assessment. An interview was conducted with the MDS nurse (staff #26) on January 16, 2020 at 9:20 AM. She stated that the MDS is expected to be accurate and it is important for the care of the resident. She stated if the MDS is inaccurate it could impact the care of the resident through the care plan. She stated the facility uses the RAI manual for direction/questions and a clinical support resource from the company. She stated that if a resident had a catheter, it should have been coded in the MDS assessment. She stated that she missed coding the catheter on resident #2 and therefore; the MDS was inaccurate and it did not meet facility expectations for MDS assessment accuracy. An interview was conducted with the Director of Nursing (DON/staff #145) on January 16, 2020 at 11:00 AM. She stated that the coding on the MDS assessment for resident #2 was inaccurate, as the indwelling catheter should have been marked. Review of the policy titled, Accuracy of Assessment (MDS 3.0) revealed It is the policy of this facility to ensure that the assessment accurately reflects the resident's status and that the RN Assessment Coordinator is responsible for certifying overall completion once all individual assessors have completed and signed their portion(s) of the MDS. The RAI Manual also included that it is required that the assessment accurately reflects the resident's status and that the importance of accurately completing and submitting the MDS assessment cannot be over emphasized.",2020-09-01
199,PHOENIX MOUNTAIN POST ACUTE,35072,13232 NORTH TATUM BLVD,PHOENIX,AZ,85032,2020-01-17,655,D,0,1,MNCW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and policy review, the facility failed to ensure the baseline care plan included the minimum healthcare information necessary to properly care for one resident (#24) related to activities of daily living. The deficient practice could result in baseline care plans not having the necessary information to care for residents. Findings include: Resident #24 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. The initial nursing assessment with an effective date of November 1, 2019 revealed the resident was incontinent of urine. Review of the initial care plan dated November 1, 2019 revealed the resident had decreased ability to perform self-care Activities of Daily Living (ADL) related to decreased mobility, strength, balance, coordination, impaired cognition, etc. The goal was that the resident would show improvement in ADLs and mobility and would require no more than extensive assistance of one person for ADLs and ambulation. Interventions that were checked with a check mark included encouraging the resident to participate to the fullest extent possible with each interaction. The interventions indicating the assistance the resident required for eating, toilet use, and transfer were not checked. Continued review of the initial care plan dated November 1, 2019 revealed the resident was at increased nutritional risk related to dysphagia and had swallowing difficulty related to conditions associated with dysphagia. No goal was checked. Interventions checked with a check mark included diet as ordered by the physician and providing supplements as ordered. Interventions indicating the assistance the resident required with meals were not checked. Review of the Functional Performance Evaluation dated November 2, 2019 revealed the resident was dependent for eating, oral hygiene, toileting hygiene, and mobility. The nursing Daily Skilled Note dated November 2, 2019 revealed the resident required extensive assistance of one person for bed mobility, transfer, eating, and toilet use. Review of the Functional Performance Evaluation dated November 3, 2019 revealed the resident required partial/moderate assistance for eating and substantial/maximal assistance for oral hygiene, and was dependent for toileting hygiene and mobility. The nursing Daily Skilled Note dated November 3, 2019 revealed the resident required extensive assistance of one person for bed mobility, limited assistance of one person for eating, was dependent for toilet use with one person assistance, and was dependent with transfer requiring set up help support only. Review of the Functional Performance Evaluation dated November 4, 2019 revealed the resident required substantial/maximal assistance for eating, oral hygiene, and mobility and was dependent for toileting hygiene. However, no evidence was revealed the initial care plan included instructions regarding the assistance the resident required for ADLs and mobility. An interview was conducted with the Director of Nursing (DON/staff #145) on January 17, 2020 at 12:13 p.m. She stated physician orders [REDACTED]. She stated care plans are updated as needed. The DON also stated she is responsible for verifying care plans. The facility's policy titled Care Planning reviewed September 2019 revealed the baseline care plan will be developed and implemented within 48 hours of admission. The policy also revealed the baseline care plan will include but is not limited to initial goals of the resident, dietary instructions and any services and/or treatments provided.",2020-09-01
200,PHOENIX MOUNTAIN POST ACUTE,35072,13232 NORTH TATUM BLVD,PHOENIX,AZ,85032,2020-01-17,684,E,0,1,MNCW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, hospital documentation and policy review, the facility failed to provide care and treatment to one resident (#24) who experienced a change of condition, by failing to ensure that vital signs were taken. The deficient practice could result in residents not being monitored for vital sign changes and a delay in implementing interventions. Findings include: Resident #24 was admitted on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Per the MDS, the resident required extensive assistance with activities of daily living. Review of the physicians orders for October 2019 revealed the following: [MEDICATION NAME] Tablet (given for hypertension) 50 milligrams, give 1 tablet by mouth two times a day, hold if systolic blood pressure is below 100 or heart rate is less than [AGE]. Review of the Treatment Administration Record (TAR) for October 2019 revealed a set of vitals was charted on October 4 as follows: blood pressure 113/62; pulse [AGE] and respirations 18 A nursing monthly summary note dated October 7, 2019 included a set of vitals, however; the vital signs documented were from 3 days prior: blood pressure 113/62 (October 4, 2019); pulse [AGE] (October 4, 2019) and respirations 18 (October 4, 2019) A nursing note dated October 27, 2019 at 1:56 p.m. by a Licensed Practical Nurse (LPN/staff #147) included the resident had a change in condition. Per the note, the resident was in the dining room prior to lunch being served, when a CNA found the resident unresponsive. The LPN called 911 and the resident was transported to the hospital. This note did not include any vital signs that were taken when the resident was unresponsive. Review of the Transfer form to the hospital dated October 27, 2019 revealed documentation of a set of vital signs, however; next to each vital sign was a previous date as follows: -blood pressure 122/52 (October 9, 2019) -pulse 70 (October 9, 2019) -respirations 18 (October 9, 2019) There was no documentation on the Transfer form of any vital signs which were taken at the time of the resident's change of condition or upon transfer from the facility to the hospital. In addition, there was no documentation in the clinical record or on the MAR/TAR of any vital signs which were taken at the time of the resident's change of condition or up until the resident was transferred to the hospital. A history and physical from the hospital dated October 27, 2019 included the resident had lethargy and altered mental status. The resident's heart rate was 132 beats per minute and blood pressure was 81/46. The resident was found to have severe dehydration, pyuria (pus in the urine) and [MEDICAL CONDITION] with rapid ventricular response in the ER. Under Assessment and Plan, the documentation included the resident had acute metabolic [MEDICAL CONDITION] due to severe [MEDICAL CONDITION], acute non-traumatic kidney injury due to hypovolemia with dehydration, and [MEDICAL CONDITION] on presentation due to hypovolemia [MEDICAL CONDITION]. A nursing note dated October 28, 2019 at 1:35 a.m. by a LPN (staff #149) included the resident was admitted to the Intensive Care Unit with a UTI, A-Fib, acute metabolic [MEDICAL CONDITION] and acute kidney injury due to severe dehydration According to the clinical record, the resident was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An interview was conducted with the Director of Nursing (DON/staff #145) on January 17, 2020 at 12:13 p.m. She stated that when a resident has a change in condition, staff are to take a set of vitals signs, check the resident's blood sugar and place the resident on oxygen. She said when the paramedics arrive, they are to take over. She stated that information would be placed on the transfer form and added into the electronic medical record. The DON said that she had completed this documentation for this resident's transfer and does not know why she cannot locate the blood sugar result for the transfer on October 27 and that she cannot explain why there are no vital sign records for the resident after October 9. She stated that the last full set of vitals documented were on October 9. An interview was conducted with a Certified Nursing Assistant (staff #[AGE]) on January 17, 2020 at 2:34 p.m. She stated that when the resident became unresponsive, the nurse (registered nurse/staff #147) told her to get a set of vitals. She stated she does not remember what those numbers were but she gave them to staff #147. An interview was conducted with staff #147 on January 17, 2020 at 3:19 p.m. She stated the resident did not look good and that they got a set of vitals and called 911. She said the vitals did not look good and were off. She said the vitals would be in the electronic chart, or maybe in a note. She stated that because it was a 911 situation, someone may have forgotten to document something. She stated the norm would be to try and document somewhere, so the information could be presented to the paramedics. She stated that the paramedics got there very quickly and she does not recall if the resident was responsive or not when she left the facility. She further stated that she knows they got vital signs, but they say if it was not documented it was not done. Review of a policy and procedure titled Vital Signs revealed a statement that it is the policy of this facility that the resident's vital signs shall be recorded as the physician orders [REDACTED]. Vital signs shall be taken and recorded in accordance with the resident's condition and current treatment plan, and as prescribed by the attending physician.",2020-09-01
201,PHOENIX MOUNTAIN POST ACUTE,35072,13232 NORTH TATUM BLVD,PHOENIX,AZ,85032,2020-01-17,686,D,0,1,MNCW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, staff interviews and policy review, the facility failed to ensure one resident's (#92) pressure ulcer was thoroughly assessed timely. The deficient practice could result in pressure ulcers not being thoroughly assessed. Findings include: Resident #92 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the clinical record revealed a physician order [REDACTED]. The Braden scale dated December 13, 2019 included a score of 13 indicating the resident was at moderate risk for pressure sore. The initial admission record dated December 13, 2019 included the resident was alert and oriented to time and was able to follow simple commands. Per the documentation, the resident had a pressure wound to the sacrum. However, the documentation did not include the stage, measurements, description of the wound bed/edges, surrounding skin, and presence/absence of exudate, tunneling or undermining. Another Braden scale dated December 14, 2019 included a score of 19 indicating the resident was at low risk for pressure sore. The weekly skin evaluation dated December 14, 2019 included the resident had an open area to the coccyx with treatment in place. Review of the care plan dated December 16, 2019 revealed the resident had actual impairment to skin integrity related to an unstageable wound on the sacrum. The goal was the resident would have no complications related to the sacral wound. Interventions included treatment to the wound on the sacrum as ordered and for the wound nurse to see the wound weekly. Despite documentation that the resident had a sacral wound, there was no evidence found in the clinical record that the resident's wound was thoroughly assessed from December 13, 2019 through December 16, 2019. Review of the Medication Administration Record [REDACTED]. The Weekly Skin/Pressure Ulcer note dated December 17, 2019 revealed the resident had an unstageable pressure ulcer to the sacrum with 76-100% slough, measured 1.7 centimeters (cm) x 1.5 cm, scant amount serous exudate, no odor, with attached wound edges and normal surrounding tissue. Per the documentation, this wound was present on admission with an unknown onset date. A wound treatment observation was conducted on January 16, 2020 at 9:07 a.m. with the wound nurse/registered nurse (RN/staff #132) and a certified nurse assistant (CNA/staff #35). Staff #132 stated the resident was admitted with a pressure injury which has healed. She stated the treatment continued to be provided to the area for prevention. The wound treatment observation revealed no open areas and the right center sacral area was observed to be dark pink new skin. An interview was conducted with a licensed practical nurse (LPN/staff #39) on January 16, 2019 at 12:42 p.m. Staff #39 stated that when a resident is admitted with a wound or open area, she assesses the wound right away which would include describing and documenting what she observed such as slough, measurements, and identifying if the wound is a pressure ulcer. The LPN stated she cannot stage a pressure ulcer. She stated that if there are no treatment orders, she will call the physician for orders and follow the wound protocol while waiting for orders. The LPN also stated she will notify the wound nurse who will conduct an assessment of the wound and stage the wound if it is a pressure ulcer the day after the resident's admission. In an interview conducted with a unit manager (LPN/staff #[AGE]) on January 17, 2019 at 12:18 p.m., he stated the wound nurse does not work on weekends. He said when a resident is admitted ; the nurse will conduct a full body assessment and describe any wound the resident has, including the site/location and measurements. The manager stated the nurse cannot identify or stage the wound; that is done by the wound nurse or wound nurse practitioner (NP). He stated the wound nurse will assess the wound the day after admission. During an interview conducted with the wound nurse (RN/staff #132) on January 17, 2020 at 12:49 p.m., she stated that she works Monday through Friday and that if she is not in the building, the nurses have a standard treatment available for wounds. She stated she checks her dashboard daily for residents admitted with wounds and will schedule an assessment. She stated she will conduct and document her assessment in the clinical record and will ensure the treatment in place is appropriate. The RN stated her documentation will include the type, stage, measurement and wound descriptors. She said wounds are measured weekly by her and/or the wound NP. Regarding resident #92, staff #132 stated the resident was admitted with the wound, treatment was provided and the wound healed. She stated the first wound assessment was done by the admitting nurse on December 13, 2019. She stated the post admission skin assessment conducted on December 14, 2019 revealed an open area to the coccyx with a treatment in place but did not include a description of wound. The RN stated that per the clinical record, her first assessment of the wound was on December 17, 2019. She also stated she may have seen the wound prior to December 17 and did not document her observation because she saw the treatment in place was appropriate. During an interview with the Director of Nursing (DON/staff #145) conducted on January 17, 2020 at 1:42 p.m., the DON stated the assessments conducted by the nurses on December 13 and 14, 2019 were complete wound assessments and the nurses documented what they saw. The facility's policy on Wound Management revised August 2019 revealed the nurse responsible for assessing and evaluating the resident's condition on admission is expected to complete a comprehensive admission assessment/evaluation and identify any alterations in the skin integrity noted at that time. The policy also included that once a wound has been identified, assessed, and documented, nursing shall administer treatment to each affected areas as per the physician's orders [REDACTED].",2020-09-01
202,PHOENIX MOUNTAIN POST ACUTE,35072,13232 NORTH TATUM BLVD,PHOENIX,AZ,85032,2020-01-17,692,G,0,1,MNCW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, hospital documentation and policies and procedures, the facility failed to ensure that one sampled resident (#24) maintained sufficient fluid intake to maintain proper hydration and health. The deficient practice resulted in a lack of interventions to address ongoing low fluid intakes and administering an as needed diuretic. The resident was subsequently hospitalized . Findings include: Resident #24 was admitted on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. The MDS included the resident had the ability to express ideas, wants and understood verbal content, responding adequately to simple, direct communication. The resident ate and drank with encouragement or cueing and required set-up assistance. No issues with swallowing were identified in the assessment and the resident did not have any natural teeth. A care plan for cognition related to advanced dementia dated April 22, 2019 included a goal for the resident to have positive experiences in daily routines. Interventions were providing cues and supervision with activities of daily living needs. A care plan related to a potential for increased nutritional risk associated with dementia, Alzheimer's and fluid shifts due to diuretics was initiated on April 26, 2019. The goal was for the resident to maintain adequate nutritional status, as evidenced by consumption of more than or equal to [AGE] percent of meals. Interventions were to encourage the resident with fluid intake, monitor intake, recording every meal, assist with meals as needed and provide supplements as ordered. The quarterly MDS assessment dated [DATE] included a BIMS score of 3, which indicated severe cognitive impairment. Per the MDS, the resident required extensive assistance with activities of daily living. Review of the physicians orders for October 2019 revealed the following: -Regular diet, pureed texture, thin liquids consistency -Pro-Mod two times daily, give 30 milliliters (ml) by mouth. -[MEDICATION NAME] ([MEDICATION NAME]/a diuretic) 20 milligrams by mouth every 24 hours as needed for [MEDICAL CONDITION]. A nursing summary dated October 7, 2019 included the resident required assistance with eating including set-up, cueing and encouragement to eat. Per the note, the resident was eating 50% or less intake of meals and was only eating 1 meal on some days. Review of the Documentation Survey Report for Fluid Intake and the MAR from October 10 through October 18, 2019 revealed the resident received the following amounts of fluid per day: October 10: daily fluid intake total was 14[AGE] ml October 11: daily fluid intake total was 13[AGE] ml October 12: daily fluid intake total was 1410 ml October 13: daily fluid intake total was 13[AGE] ml October 14: daily fluid intake total was 15[AGE] ml October 15: daily fluid intake total was 1420 ml October 16: daily fluid intake total was 15[AGE] ml October 17: daily fluid intake total was 1590 ml October 18: daily fluid intake total was 1540 ml According to a Nutrition Interdisciplinary Team update assessment dated and signed October 18, 2019, the resident required 2010 ml per day of fluids and consumed an average of [AGE]% of her meals and was currently meeting per day caloric needs. Per the assessment, the resident was at risk for further weight loss related to her advanced age, dementia, dysphagia and having a wound. Further review of the Documentation Survey Report for Fluid Intake and the MAR indicated [REDACTED] October 19: daily fluid intake total was 13[AGE] ml. October 20: am fluid intake amount was 890 ml; pm fluid intake amount was 150 ml and night fluid intake amount was 120 ml. The daily total fluid intake amount was 11[AGE] ml. October 21: am fluid intake amount was [AGE]0 ml; pm fluid intake amount was 398 ml; and night fluid intake amount was 120 ml. The total daily fluid intake amount was 1408 ml. A nutrition quarterly evaluation dated October 21, 2019 included the resident had her own teeth, feeds herself with set-up, and was at risk for weight fluctuations. These fluctuations were related to fluid shifts, as evidenced by diuretic treatment. The evaluation included that the resident's current nutritional interventions were appropriate. The evaluation also included that the resident required a total of 2010 ml of fluids per day. A mini nutritional assessment was completed on October 21, 2019 and revealed the resident was at risk for malnutrition. Continued review of the Documentation Survey Report for Fluid Intake and the MAR indicated [REDACTED] October 22: am fluid intake amount was 990 ml; pm fluid intake amount was 430 ml and night fluid intake amount was 0. The total daily fluid intake amount was 1420 ml. October 23: am fluid intake amount was 1010 ml; pm fluid intake amount was 510 ml and night fluid intake amount was 240 ml. The total daily fluid intake amount was 17[AGE] ml. October 24: am fluid intake amount was 1010 ml; pm fluid intake amount was 430 ml and night fluid intake amount was 120 ml. The total daily fluid intake amount was 15[AGE] ml. October 25: am fluid intake amount was 442.5 ml; pm fluid intake amount was total intake 422.5 ml and the night fluid intake amount was 120 ml. The total daily fluid intake amount was 9[AGE] ml. October 26: am fluid intake amount was 30 ml; pm fluid intake amount was 390 ml and the night fluid intake amount was 120 ml. The total daily fluid intake amount was 540 ml. October 27: am fluid intake amount was 270 ml; pm fluid intake amount was 0 and the night fluid intake amount was 0 ml. The total daily fluid intake amount was 270 ml. A review of the October 2019 Medication Administration Record [REDACTED]. According to the Documentation Survey Report for Amount Eaten revealed the resident was provided [AGE] meals in October 2019. Forty-nine meals were documented as being 76-100% consumed, 25 meals were documented as being 51-[AGE]% consumed and 5 meals were documented as being 26-50% consumed. Despite documentation that the resident required a daily fluid intake amount of 2010 ml, there were no interventions to address the resident's low fluid intake for 2 1/2 weeks prior to being hospitalized (on October 27). A nursing note dated October 27, 2019 at 1:56 p.m. by a Licensed Practical Nurse (LPN/staff #147) included a change in the resident's condition. The resident was in the dining room prior to lunch, when a CNA found the resident unresponsive. The LPN called 911 and the resident was transported to the hospital. A history and physical from the hospital dated October 27, 2019 included the resident had lethargy and altered mental status. The resident's heart rate was 132 beats per minute and blood pressure was 81/46. The resident was found to have severe dehydration, pyuria (pus in the urine) and [MEDICAL CONDITION] with rapid ventricular response in the ER. Under Assessment and Plan, the documentation included the resident had acute metabolic [MEDICAL CONDITION] due to severe [MEDICAL CONDITION], acute non-traumatic kidney injury due to hypovolemia with dehydration, and [MEDICAL CONDITION] on presentation due to hypovolemia [MEDICAL CONDITION]. The ER laboratory results revealed the following: -[MED] 161 milliequivalents per liter (mEq/L) (normal range 135 to 145 mEq/L) -Chloride 128 mEq/L (normal range 96 and 106 mEq/L) -BUN 81 milligrams per deciliter (mg/dL) (normal range 7 to 20 mg/dL) -Creatinine 1.[AGE] mg/dL (normal range 0.5 to 1.1 mg/dL) -Osmolality 363 milliosmoles per kilogram (normal range 2[AGE] to 295 milliosmoles per kilogram) -Lactic Acid 2.2 milliosmoles per Liter (mmol/L) (normal range 0.5-1 mmol/L) A nursing note dated October 28, 2019 at 1:35 a.m. by a LPN (staff #149) included the resident was admitted to the Intensive Care Unit with a UTI, A-Fib, acute metabolic [MEDICAL CONDITION], and acute kidney injury due to severe dehydration. Per the clinical record, the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Nutrition/Hydration Risk Evaluation completed on November 4, 2019 by a LPN (staff #29) revealed the resident had a daily fluid intake of 50-1000 ml a day. The evaluation indicated that the resident was at high risk. An interview was conducted with a Registered Nurse (RN/staff #129) on January 17, 2020 at 10:38 a.m. She stated the resident always sat at the assistance table for meals and required cuing and extensive assistance for fluid intake. She stated the resident would not usually just pick up a drink on her bedside table, as she needed cuing. She stated that the nurses document fluids on the MAR indicated [REDACTED] An interview was conducted with a Certified Nursing Assistant (CNA/staff #23) on January 17, 2020 at 12:13 p.m. She stated that the resident has a pitcher of water on her bedside table, but needs cuing to drink. She stated that once you give her water and cue her, she will drink but needs to have a little bit of instruction. The CNA stated the resident doesn't usually reach for a glass of water on her own, but will drink everything you give her. An interview was conducted with the Director of Nursing (DON/staff #145) on January 17, 2020. The DON stated that it is her expectation that the staff follow facility policy in the care of a resident at risk for dehydration. She stated the dietary department assesses the resident's needs upon admission, quarterly, and as needed to identify any potential risks to the resident. She stated the CNA's monitor fluids ingested during meals and additional fluid intake in the task tab in the EMR. The DON said that the nurses chart meal supplements, like Pro-Mod, in the MAR but the volume would not be reflected in the intake under the Task tab. She stated that unless the resident is on strict intake and output, there is no way to accurately know the total fluid intake or output. An interview was conducted with a Registered Dietitian (staff #150) on January 17, 2020 at 3:30 p.m. She stated the resident is provided over 3000 milliliters in liquids per day. However, she said there is not an accurate method of tracking if the resident actually consumes what she is given. She stated that unless the resident is on a strict intake and output order there is no way to monitor if she actually ingests everything she is offered. A policy and procedure titled Nutrition included it is the policy of this facility to ensure that all residents maintain acceptable parameters of nutritional status unless the resident's clinical condition demonstrates that this is not possible. Evaluations of the residents include percentage of food eaten that may impact weight gain or loss. Once the resident has been evaluated for nutrition status, the registered dietitian, dietary technician and/or designee will determine if there is a significant change in the resident's condition. Nutritional assessment may include oral intake of food, fluids, and functional status including the need for cues and assistance. A policy and procedure titled Hydration revealed that this facility will provide each resident with sufficient fluid intake to maintain proper hydration and health. The purpose of this policy is to ensure that the resident receives a sufficient amount of fluids based on individual needs to prevent dehydration. The definition of sufficient fluid means the amount of fluid needed to prevent dehydration and maintain health. Risk factors for dehydration include functional impairments that make it difficult to drink fluids and dementia, in which the resident forgets to drink or forgets how to drink. A policy and procedure titled Food and Fluid Intake Documentation stated that it is the policy of this facility that a record of food and fluid intake shall be maintained for all residents receiving oral nourishment. The purpose of this is to record the oral intake for residents and utilized when accessing nutritional state. If a pattern of low food or fluid intake exists, the Charge Nurse will notify the resident's physician. The Charge Nurse will document this evaluation and steps taken in progress notes and will adjust the care plan appropriately.",2020-09-01
203,PHOENIX MOUNTAIN POST ACUTE,35072,13232 NORTH TATUM BLVD,PHOENIX,AZ,85032,2020-01-17,761,D,0,1,MNCW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and policy review, the facility failed to ensure expired medications in one medication cart was not available for resident use and one medication cart was locked when unattended. The deficient practice could result in expired medications being administered and misappropriation of resident medications. Findings include: -During an observation of the medication cart on the 100 hallway conducted with a Licensed Practical Nurse (staff #[AGE]) on 01/14/20 at 12:00 PM, three bottles of [MEDICATION NAME] ([MEDICATION NAME]) 0.4 milligram tablets were observed expired. One bottle had an expiration date of October 2019 and two bottles had expiration dates of December 2019. In an interview conducted with the Director of Nursing (DON/staff #145) on 01/14/20 at 1:10 PM, the DON said she and another nurse review the medication carts every month and remove any expired medications. The DON stated that she most likely missed the three expired bottles of [MEDICATION NAME] tablets because they were mixed in a bag with three non-expired bottles. The DON stated there had been no recent administrations of [MEDICATION NAME] tablets and that no residents in the facility were prescribed [MEDICATION NAME] tablets. Review of the facility's policy titled Medication Access and Storage, E-Kit Access revealed Outdated, contaminated, or deteriorated medications and those that are cracked, spoiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction. -During an observation conducted on January 15, 2020 at 8:35 a.m., the medication cart on hall 300 was observed unattended and unlocked. A resident was observed next to the cart. At 8:42 a.m., the Licensed Practical Nurse (staff #151) returned to the unlocked cart. Following the observation, an interview was conducted with staff #151. She stated she left the medication cart to assist another resident with an oxygen tank. She stated the procedure is to lock the medication cart before leaving the cart. An interview was conducted on January 15, 2020 at 9:00 a.m. with the Director of Nursing (staff #145). She stated their policy for medication storage should be followed at all times. She stated the medication carts should be locked whenever a staff leaves the cart for any reason. The facility's policy and procedure titled Medication Access and Storage, E kit access revealed medication carts are to be locked or attended by persons with authorized access.",2020-09-01
204,PHOENIX MOUNTAIN POST ACUTE,35072,13232 NORTH TATUM BLVD,PHOENIX,AZ,85032,2017-08-03,154,D,0,1,29BT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, review of the Saunders Nursing Drug Handbook (YEAR) edition and policy review, the facility failed to inform one resident's (#55) representative of the risks and benefits of a hypnotic medication, prior to the administering. Findings include: Resident #55 was admitted to the facility on (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. A pharmacy medication regimen review dated (MONTH) 9, (YEAR) included a recommendation that ramelteon required informed consent to be given and that there was not one available in the resident's chart. According to the Medication Administration Record [REDACTED]. Review of the clinical record revealed no evidence that the resident's representative had been informed of the risks and benefits of the medication. Review of the 30-day Minimum Data Set (MDS) assessment dated (MONTH) 22, (YEAR), revealed the resident's Brief Interview for Mental Status (BIMS) score was 4, which indicated severe cognitive impairment. Review of the Saunders Nursing Drug book (YEAR) edition revealed the clinical classification for ramelteon was hypnotic. An interview was conducted with a unit nurse manager (staff #79) at 10:30 a.m. on (MONTH) 3, (YEAR). She stated that when a resident is admitted on a medication such as a hypnotic, the admitting nurse reviews the medications to determine if any psychoactive medications require an informed consent, which consists of educating the resident and the family about the risks and benefits of the medication and obtaining their consent, prior to administering the medication. She stated that she was not familiar with ramelteon, but if it was a hypnotic medication, an informed consent should have been done. In an interview with the Director of Nursing (DON/staff #35) at 10:45 a.m. on (MONTH) 3, (YEAR), she stated that the risks and benefits of psychoactive medications should be explained to the resident and this should be documented in the clinical record on the facility's informed consent document. She said that she believed this should have been done for this medication. During an interview with a pharmacy consultant (staff #164) at 11:20 a.m. on (MONTH) 3, (YEAR), she stated that she asked the facility to obtain informed consent for the ramelteon medication in (MONTH) (YEAR), as she wanted the facility to provide the risks and benefits of the medication to the resident/resident representative. Review of the medication administration policy regarding [MEDICAL CONDITION] medications revealed that in order to uphold the fundamental right of all residents and/or responsible parties and exercise informed decision of their care, it is the policy of this facility to obtain consent for the use of psychoactive medications. The policy noted that the resident and/or the responsible party will be notified, either in person or by phone, prior to the initiation of a psychoactive medication to inform, educate, and participate in the coordination of care. The policy further included that the nurse will document in the individual resident record, agreement or decline of the medication under consideration.",2020-09-01
205,PHOENIX MOUNTAIN POST ACUTE,35072,13232 NORTH TATUM BLVD,PHOENIX,AZ,85032,2017-08-03,278,D,0,1,29BT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, review of the Resident Assessment Instrument manual (RAI), Saunders Nursing Drug Handbook (YEAR) edition and policy and procedures, the facility failed to ensure that a Minimum Data Set (MDS) assessment was coded accurately for one resident (#55). Findings include: Resident #55 was admitted to the facility on (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. According to the Medication Administration Record [REDACTED]. However, review of the admission MDS assessment dated (MONTH) 3, (YEAR) revealed the resident was coded as not having received a hypnotic medication, during the 7 day look-back period. Review of the Saunders Nursing Drug book (YEAR) edition revealed the clinical classification for ramelteon was hypnotic. An interview was conducted with the MDS coordinator (staff #141) at 10:15 a.m. on (MONTH) 3, (YEAR). She said that when coding the MDS for medications, she looks at the orders to see which medications are prescribed for a resident and looks at the MAR indicated [REDACTED]. She stated that she did the MDS assessment for this resident and looked up ramelteon and it was classified as a [MEDICATION NAME] receptor agonist, so she did not think it was classified as a hypnotic. In an interview with the Director of Nursing (DON/staff #35) at 10:45 a.m. on (MONTH) 3, (YEAR), she said that she is not familiar with this drug, but it likely would be considered a hypnotic and so it should have been coded on the MDS assessment. Review of the Resident Assessment policy regarding MDS assessments revealed the facility uses the RAI manual to complete the MDS assessment. The RAI assists facility staff to consistently and accurately gather information regarding resident needs and strengths, and provides the foundation for an individualized interdisciplinary plan of care. The RAI manual indicated that when coding medications on the MDS assessment, they should be coded according to the medications therapeutic category and/or the pharmacological classification, not how it is used.",2020-09-01
206,PHOENIX MOUNTAIN POST ACUTE,35072,13232 NORTH TATUM BLVD,PHOENIX,AZ,85032,2017-08-03,329,D,0,1,29BT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, review of the Saunders Nursing Drug Handbook (YEAR) edition and policy review, the facility failed to ensure one resident's (#55) drug regimen was free of unnecessary drugs, by failing to monitor the effectiveness of a hypnotic medication. Findings include: Resident #55 was admitted to the facility on (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. According to the Medication Administration Record [REDACTED]. Review of an Activity of Daily Living (ADL) care plan revealed that one of the interventions was to administer the ramelteon as ordered to promote sleep. Further review of the clinical record revealed there was no evidence that the resident was being monitored for the effectiveness of the hypnotic medication. Review of the Saunders Nursing Drug book (YEAR) edition revealed the clinical classification for ramelteon was hypnotic. An interview was conducted with a unit nurse manager (staff #79) at 10:30 a.m. on (MONTH) 3, (YEAR). She stated that she was not familiar with ramelteon, but said that if it is a hypnotic, then behavior monitoring should be completed to determine if the medication is being effective. She said they usually monitor the hours of sleep for a hypnotic medication. Staff #79 stated that this information is used when they meet with the physician and the pharmacist to determine if the psychoactive medication dose needs to be adjusted. She stated they determine what behaviors are to be monitored and then they document the behavior each shift on a behavior tracking sheet, which is in the resident's MAR. In an interview with the Director of Nursing (DON/staff #35) at 10:45 a.m. on (MONTH) 3, (YEAR), the DON stated that since this medication is being used for [MEDICAL CONDITION], the nurse's should document this each shift on a behavior sheet and monitor the resident's sleeping to determine the effectiveness of the medication. An interview was conducted with the consulting pharmacist (staff #164) at 11:20 a.m. on (MONTH) 3, (YEAR). She stated that she would expect the facility to monitor the effectiveness of this medication and would be documenting this using their behavior monitoring system. Review of the facility's Resident Assessment policy regarding behavior management revealed that the facility was to identify and address resident behavior that impacts their quality of life, poses a safety issue or interferes/disrupts the resident's or other resident's quality of life. The policy noted that behavior monitoring is viewed as a means of evaluating resident quality of life. The policy included the following behavior management goals: 1. Develop and monitor a system for monitoring and documenting behavioral and mood symptoms as they occur. 2. Evaluate frequency of target behaviors and environmental triggers to establish patterns of behavior. 3. Develop and document effective multidisciplinary interventions. 4. Increase staff knowledge of and competency in using effective techniques that decrease the occurrence of behavioral symptoms.",2020-09-01
207,PHOENIX MOUNTAIN POST ACUTE,35072,13232 NORTH TATUM BLVD,PHOENIX,AZ,85032,2017-08-03,428,D,0,1,29BT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, review of the Saunders Nursing Drug Handbook (YEAR) edition and policy review, the facility failed to ensure that a pharmacy recommendation was acted upon for one resident (#55). Findings include: Resident #55 was admitted to the facility on (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of a pharmacy medication regimen review dated (MONTH) 9, (YEAR) revealed a recommendation that the medication ramelteon required documented informed consent and that there was not one available in the chart. This recommendation had an area for the facility to document a response, however, this area was left blank. According to the Medication Administration Record [REDACTED]. Review of the Saunders Nursing Drug book (YEAR) edition revealed the clinical classification for ramelteon was hypnotic. During an interview with a pharmacy consultant (staff #164) at 11:20 a.m. on (MONTH) 3, (YEAR), she stated that she asked the facility to obtain informed consent for the ramelteon medication in (MONTH) (YEAR), as she wanted the facility to provide the risks and benefits of the medication to the resident. An interview was conducted with the DON (Director of Nursing/staff #35) at 11:45 a.m. on (MONTH) 3, (YEAR). She stated that the pharmacists did recommend that the facility obtain informed consent regarding the ramelteon medication in June, but the recommendation did not get printed out and therefore, she and the physician were unaware of the recommendation. She said that it was not printed out, because it was sent in an email with multiple attachments and the attachment containing this recommendation was missed. Review of the medication regimen review policy revealed that each residents medication regimen will be reviewed at least monthly by the consulting pharmacist. Any irregularities will be reported to the attending physician and the Director of Nursing and these reports will be reconciled. The policy further noted the following: -The pharmacist will review the resident's clinical record and will document and store any findings in the progress note section of the individual resident record. Additionally, a copy will be provided to the director of nursing at exit. -The director of nursing will forward all findings to the respective nurse manager for timely follow up with contact with the attending physician. -The attending physician must address the issues identified by the consulting pharmacist either by accepting and ordering recommended alterations in medication regimen or by providing justification for the decision to not accept the recommendations in the resident's record. -When the attending physician either does not timely (less that one week but not more than one week) respond or refuses to address issues identified by the consulting pharmacist, the director of nursing will consult with the facility medical director. -For those recommendations that do not require a physician intervention, the director of nursing or the designated nurse manager will address and document actions taken.",2020-09-01
208,PHOENIX MOUNTAIN POST ACUTE,35072,13232 NORTH TATUM BLVD,PHOENIX,AZ,85032,2018-11-09,551,D,0,1,66CG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, and policy, the facility failed to obtain signatures of the resident's court appointed guardian on advance directives and on informed consent documentation for medications and vaccines for one resident (#58). Findings include: Resident #58 was readmitted on (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. A review of the clinical record revealed documentation that the resident had a court appointed fiduciary/guardian for medical and financial decision making. Further review of the clinical record revealed an Advance Directives dated (MONTH) 27, (YEAR) that the resident was a DNR (do not resuscitate), a decline of the influenza vaccine dated (MONTH) 27, (YEAR), an informed consent for the use of [MEDICAL CONDITION] medications ([MEDICATION NAME] and [MEDICATION NAME]) dated (MONTH) 27, (YEAR), an informed consent for the use of opioid therapy dated (MONTH) 27, (YEAR), and a consent for the Prevnar 12 and [MEDICATION NAME] 23 (pneumococcal vaccines) dated (MONTH) 29, (YEAR) that were all signed by the resident but did not include the guardian's signature. During an interview conducted with the resident on (MONTH) 6, (YEAR) at 1:54 p.m., the resident stated that a family member who lives out of state is her Power of Attorney. She stated that due to her severe medical condition, the physician wanted a local responsible party available to make medical and financial decisions on her behalf. The resident stated that the court appointed her a private fiduciary to act as her guardian for both medical and financial decisions. She stated that she currently has a private fiduciary who visits frequently and manages her care. On (MONTH) 6, (YEAR) at 2:07 p.m., an interview was conducted with the Social Services Director (staff #8). Staff #8 stated that they are aware resident #58 has an appointed guardian/fiduciary. Staff #8 further stated that if a resident has a guardian then the guardian should be the person signing consents, etc. After reviewing the clinical record, staff #8 stated that the resident's court appointed guardian's paper work is in the resident's clinical record and that the consents for psycho-active medications and opioid therapy and the resident's advance directive for DNR should have been signed by the resident's guardian and not the resident. A review of the facility's Residents' Rights policy regarding the resident representative revealed it is the policy of the facility to recognize and acknowledge the resident's representative per state and federal regulations. The policy included that a court-appointed guardian is to be recognized as the resident's representative. The policy further included that the facility would treat the decisions of the resident representative as the decisions of the resident to the extent required by the court or delegated by the resident, in accordance with applicable law.",2020-09-01
209,PHOENIX MOUNTAIN POST ACUTE,35072,13232 NORTH TATUM BLVD,PHOENIX,AZ,85032,2018-11-09,552,D,0,1,66CG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and policy, the facility failed to have documented evidence that one resident (#55) was provided the risks and benefits for the use of an antidepressant. Findings include: Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. The Informed Consent Form for [MEDICAL CONDITION] Medications was signed and dated on 09/12/18 by the resident and a staff Registered Nurse (RN); however the form did not have the name of the medication, a [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. The care plan regarding depression initiated on 9/25/18 included an intervention to obtain signed consent for the use of [MEDICAL CONDITION] medications. An interview was conducted on 11/08/18 at 09:49 AM with the Director of Nursing (DON/staff #38), who stated that when there is a new physician's orders [REDACTED]. Review of the facility's policy titled Consent for Psychoactive Medications included, In order to uphold the fundamental right of all residents and/or responsible parties and exercise informed decision of their care, it is the policy of this facility to obtain consent for the use of psychoactive medications.",2020-09-01
210,PHOENIX MOUNTAIN POST ACUTE,35072,13232 NORTH TATUM BLVD,PHOENIX,AZ,85032,2018-11-09,558,D,0,1,66CG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and documents, the facility failed to ensure one resident's (#17) call light was accessible. Findings include: Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6 which indicated the resident had severe cognitive impairment. The assessment included the resident required total dependence or extensive assistance of 1-2 persons for most activities. An observation was conducted of the resident on 11/05/18 at 02:46 PM The resident was observed lying in bed with a mat on the side of the bed. The resident's bed was observed against the wall with the head of the bed at the far end of the room near the window. A chair was observed at the foot of the bed with the back of the chair against the foot of the bed. A recliner was observed next to the chair in a nearly perpendicular position. The resident's call light was observed on the recliner out of the reach of the resident. During an observation conducted on 11/07/18 at 11:30 AM with the Maintenance Manager (staff #78) and the Administrator (staff #81), the resident's call light was again observed in the recliner. When the call light was extended by staff #78, the call light did not extend far enough to reach the resident's hands when in bed. It only reached approximately 2.5 feet into the bed from the bottom. The Maintenance Manager stated that if he had known, he would have ordered a longer cord. The Manager stated the call lights are checked for operation each month, not checked to see if the residents can reach them or not. An interview was conducted on 11/07/18 at 11:40 AM with a Certified Nursing Assistant (CNA/staff #164). The CNA stated that the chair at the bottom of the bed is always there because the resident wants to keep her purse here. She further stated that the bed and chairs have been in that position for quite a while. She stated that she did not realize the call light cord did not extend far enough for the resident to reach the call light when in bed. During an interview conducted on 11/07/18 at 02:55 PM with resident #17, the resident was observed in the recliner with her feet up and the call light within reach. She stated that she uses the call bell to call for assistance. She also stated that staff usually come in every so often. The resident stated that she has not wanted for anything and that she likes and wants her room and chairs the way they are. Review of facility's Call Light Checklist logs for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) revealed no concerns were identified with the call light for the room of resident #17.",2020-09-01
211,PHOENIX MOUNTAIN POST ACUTE,35072,13232 NORTH TATUM BLVD,PHOENIX,AZ,85032,2018-11-09,573,B,1,1,66CG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, and policy and procedures, the facility failed to provide medical records within the required time frame to one resident (#354). Findings include: Resident #354 was admitted to the facility on (MONTH) 15, (YEAR) with [DIAGNOSES REDACTED]. The discharge MDS (Minimum Data Set) assessment dated (MONTH) 12, (YEAR) revealed the resident had a BIMS (Brief Interview of Mental Status) score of 13 indicating the resident was cognitively intact. Review of the Authorization for Release of Health Information form revealed the resident requested all of his medical records and signed and dated the request form on (MONTH) 13, (YEAR). However, the resident did not receive a copy of his medical records within the required time frame of two working days. An interview was conducted on (MONTH) 7, (YEAR) at 8:39 a.m. with the Medical Records Director (staff #144) who stated that the process of requesting medical records consisted of the resident informing their nurse or the medical records office of the request. Staff #144 stated that the resident then completes a release form and gives it to the medical records staff along with the fee required for the process. The Director stated that the form is then scanned to the facility's attorney for review. Staff #144 stated that after the attorney gives the okay to release the records, the resident is provided with the records requested. Staff #144 stated that a time frame for picking up the records is not stated because it depends on how long it takes for the attorney to respond. The Director stated that the estimated turnaround time for records to be ready for pick up is 2-3 weeks and that the person who made the request will be notify when the records are available for pick up. On (MONTH) 7, (YEAR) at 9:06 a.m., staff #144 stated that the resident #354 and the resident's family were not given a specific time frame when the medical record would to be ready to pick. Staff #144 stated that the request was signed on (MONTH) 13, (YEAR) and that the medical records were available for pick up on (MONTH) 7, (YEAR). The Director also stated the resident was notified the records were ready. During an interview conducted on (MONTH) 7, (YEAR) at 12:34 p.m. with staff #144, she stated that she was unaware of their facility's policy regarding the time frame for providing residents a copy of their medical records. Staff #144 stated that the current procedure of sending the request to the facility attorney was initiated by the previous administrator and has been followed since. An interview was conducted on (MONTH) 7, (YEAR) at 12: 41 p.m. with the Administrator (staff #81) who stated that the expectation of the facility would be to follow their written policy and procedure for medical records. Staff #81 stated that their current practice is to send the record request to the facility's attorney first to ensure HIPPA is followed, the attorney will send it back as quickly as they can and that medical records handles this procedure. Staff #81 stated that this process was started prior to his time at the facility and that he is unaware of why this is the current practice. Staff #81 stated that he is unsure of the turnaround time to complete medical record requests and that he was unaware of the existence of the current facility policy regarding medical records. The facility policy titled Medical Records states that the resident has the right to access personal and medical records pertaining to him or herself. It states the facility will provide the resident access, upon a written or oral request, in the form and format requested by the individual within 24 hours (excluding weekends and holidays). The policy included the facility will allow the resident to obtain a copy of the records upon request and 2 working days advance notice to the facility.",2020-09-01
212,PHOENIX MOUNTAIN POST ACUTE,35072,13232 NORTH TATUM BLVD,PHOENIX,AZ,85032,2018-11-09,583,B,1,1,66CG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interviews, and facility policy review, the facility failed to ensure meal tickets containing resident information were not thrown into the trash for multiple residents. Findings include: A lunch observation was conducted on (MONTH) 5, (YEAR) at 12:56 p.m. in the 600 hall dining room. A certified nursing assistant (CNA/staff #162) was observed to take a small stack of lunch meal tickets, fold them in half, and throw them in a trash can in the dining room. The meal tickets thrown in the trash included resident information for four residents. The information on the slips included the residents' names, room numbers, allergies [REDACTED]. During an interview conducted with staff #162 on (MONTH) 8, (YEAR) at 12:32 p.m., she that stated meal tickets are collected and then put into a shred bin in the locked supply room. During an interview conducted with a CNA (staff #134) on (MONTH) 8, (YEAR) at 12:35 p.m., she stated that the meal tickets are used to ensure the proper meal is given to the resident. The CNA stated that the tickets are then collected and shredded because they contain personal resident information. An interview was conducted with the dietary manager (staff #105) on (MONTH) 8, (YEAR) at 2:02 p.m. She stated that meal tickets should be collected after the meal service and placed into a shredder bin. She also stated that staff from other dining rooms are to collect meal tickets and bring them to the kitchen in a bag which will then be disposed of properly in a shredder bin by the dietary staff. Staff #105 further stated that this is done to protect resident confidentiality of personal information. An interview was conducted with the Director of Nursing (DON/staff #38) on (MONTH) 9, (YEAR) at 11:19 a.m. She stated that the meal tickets should be collected by staff and then given to the dietary department or put into a shred bin. The DON stated that if the meal tickets are taken to the dietary department, the staff there are aware that the meal tickets are to be shredded. She further stated that the tickets need to be shredded in order to protect the privacy and confidentiality of the residents' personal information. The DON stated that nothing with a resident's name on it should be thrown in the trash, it should be shredded. Review of the facility's policy regarding medical records included, The resident has a right to personal privacy and confidentiality of his or her personal and medical records and a right to secure and confidential personal and medical records .The facility must keep confidential all information contained in the resident's records .",2020-09-01
213,PHOENIX MOUNTAIN POST ACUTE,35072,13232 NORTH TATUM BLVD,PHOENIX,AZ,85032,2018-11-09,600,K,1,1,66CG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, clinical record reviews, staff and resident interviews, facility documentation and policy and procedures, the facility failed to protect three residents (#9, #10 and #58) from one resident (#56), who displayed known sexually inappropriate behaviors. As a result, the Condition of Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified. The facility also failed to protect one resident (#204) from verbal abuse by a staff member. Findings include: On (MONTH) 5, (YEAR) at 10:20 a.m., the Administrator (staff # 81) was informed that resident #9 reported to a surveyor that while resident #56 was shaking her hand in the hall, he stated that he was going to f--- her. Resident #9 reported that this incident occurred on (MONTH) 2, (YEAR). Two additional reports of sexually inappropriate behaviors by resident #56 were also received on (MONTH) 5, (YEAR) from resident #10 and resident #58. In addition, it was identified that staff members were aware of some of the sexually inappropriate behaviors of resident #56 and did not report these behaviors to administration or implement measures to protect the other residents. As a result, the Condition of Immediate Jeopardy and Substandard Quality of Care (SQC) were identified on (MONTH) 5, (YEAR) at 5:00 p.m. The Administrator was informed of the facility's failure to protect residents from resident #56, who exhibited sexually explicit and inappropriate behaviors. The Administrator presented a plan of correction on (MONTH) 5, (YEAR) at 6:47 p.m. The Administrator was informed that the plan of correction did not include all of the necessary components to ensure the safety of residents and provide care to those residents, who may have been affected by resident #56's sexually inappropriate behaviors. At 7:35 p.m., a revised plan of correction was presented and accepted. Observations were conducted on (MONTH) 5, (YEAR) at 7:40 p.m. of the facility implementing their plan of correction. Staff in-services were being conducted regarding abuse and sexually inappropriate behaviors. The facility also implemented 1:1 monitoring for resident #56. Additional observations were conducted on (MONTH) 6, (YEAR), of the facility continuing to implement their plan of correction. Staff in-services continued to be conducted and staff interviewed were knowledgeable of the different kinds of abuse, the reporting process, and of the measures which were being implemented to protect the residents. Resident #56 also remained on 1:1 monitoring. As a result, the Condition of Immediate Jeopardy was abated on (MONTH) 6, (YEAR) at 10:39 a.m. -Resident #56 was admitted to the facility on (MONTH) 20, 2012, with [DIAGNOSES REDACTED]. Review of the nursing monthly summaries dated (MONTH) 27, (MONTH) 24, and (MONTH) 11, (YEAR), revealed that resident #56 had moderate cognitive impairment, delusions, hallucinations, wanders in the facility, uses a wheelchair and displays sexual behaviors toward female staff. A nursing monthly summary dated (MONTH) 11, (YEAR) included that resident #56 had severe cognitive impairment, uses a wheelchair, continues to be sexually inappropriate and makes inappropriate comments to female staff and visitors. A nursing monthly summary dated (MONTH) 10, (YEAR) revealed that resident #56 has disorganized thinking and memory problems, uses a wheelchair, and is sexually inappropriate with female staff and is redirected. Review of a nursing monthly summary dated (MONTH) 10, (YEAR) revealed the resident had severe cognitive impairment, memory problems, uses a wheelchair, and that behavior monitoring is in process for sexually inappropriate behaviors at times. According to the annual Minimum Data Set (MDS) assessment dated (MONTH) 30, (YEAR), the resident had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. The MDS included the resident required extensive assistance of one person with transfers, bed mobility, bathing and eating and was able to use a wheelchair for locomotion. Under the behavior section, the documentation included that the resident did not have any physical or verbal behaviors, and did not have any behaviors which were directed toward others; such as public sexual acts. Review of an activity care plan dated (MONTH) 2, (YEAR) revealed that resident #56 was unable to complete simple program tasks and has little speech during activities, with the exception of episodes of inappropriate sexual remarks. Interventions included the following: quickly redirect at the first show of behaviors and be aware of the surroundings or seating of resident #56 related to the potential for inappropriate verbal behaviors with other residents. A care plan dated (MONTH) 3, (YEAR) included the resident has long and short term memory deficits, with poor cognitive decision making abilities related to Alzheimer's. The care plan included the resident makes sexually inappropriate gestures and comments towards female staff. Interventions were as follows: attempt to redirect the resident when sexually inappropriate gestures or comments are made towards staff by talking with him about his family, assign consistent caregivers whenever possible, and approach the resident in a calm manner. Review of a care plan dated (MONTH) 3, (YEAR) revealed the resident has a [DIAGNOSES REDACTED].e. grabbing genitals) and comments (advances for oral sex) toward female staff. Interventions listed included the following: Do not respond or react to inappropriate comments, instead distract to more appropriate conversation, if the behavior continues offer reminders of respectful talk or use sterile attention, reinforce with staff that firm and clear limits are healthy and required when the resident makes inappropriate gestures or statements, when resident #56 engages in inappropriate gestures (grabbing genitals) distract him and engage in an activity, offer a snack to occupy his hands, or escort him to his room if safe. Review of the resident assessment change of condition-alert charting dated (MONTH) 6, (YEAR), revealed documentation that the physician stated that resident #56 made sexual inappropriate comments to her, during her visit with him. A physician progress notes [REDACTED]. The physician questioned resident #56 regarding his behaviors in his room and in common areas to see if he knows right from wrong, but made sexually inappropriate comments to the female physician instead. The documentation included that the resident was alert, but was not appropriate in conversation or behaviors. -Resident #9 was admitted to the facility on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. Review of a quarterly MDS assessment dated (MONTH) 6, (YEAR) revealed that resident #9 had a BIMS score of 12, indicating moderate cognitive impairment. The MDS included that resident #9 walks independently with her walker. An interview was conducted on (MONTH) 5, (YEAR) at 9:26 a.m. with resident #9, who stated that last week either Thursday or Friday (November 1 or (MONTH) 2), a man (resident #56) was sitting in his wheelchair in the hallway and held out his hand to her. Resident #9 stated she thought he was being friendly and went to shake his hand, but he grabbed her hand and pulled it toward his chest and stated I'm going to F--- you. Resident #9 stated that there was a nurse in the hall at the time (staff #115) and believes the nurse witnessed the incident. Resident #9 stated that resident #56 wanders that hall in his wheelchair and has wandered into her room on multiple occasions. She stated that she now uses her wheelchair and walker to build a fence around her bed at night to feel safe. An interview was conducted on (MONTH) 5, (YEAR) at 10:20 a.m., with the Administrator (staff #81). Staff #81 stated that he became aware of the incident this morning when interviewing resident #9, and that resident #9 said she was fine. Staff #81 was informed that resident #9 felt that the incident was abuse. Another interview was conducted on (MONTH) 6, (YEAR) at 9:31 a.m., with resident #9. The resident stated that she began barricading herself in bed the night after the incident with resident #56, when he made the sexual comment to her. Resident #9 stated that she was not afraid of him prior to the incident, even though he has wandered into her room multiple times in the past. Resident #9 stated the comment that resident #56 said to her has now made her afraid of him, so she sets up her wheelchair and walker by her bed to ensure he does not come near her, while she is sleeping. An interview was conducted on (MONTH) 6, (YEAR) at 3:02 p.m. with a LPN (staff #115), who was on the hallway at the time of the incident on (MONTH) 2. Staff #115 said that she turned around and saw resident #56 holding the right forearm arm of resident #9. Staff #115 stated that she thought resident #9 was trying to pull her arm away. She said that she did not hear anything verbally, as she was standing at her medication cart which was down the hallway. She stated that she was orienting a student nurse and sent the student over to the residents, but she also went with the student. She said that resident #9 told her that she was fine, walked away and laughed. Staff #115 stated that she informed the social worker (staff #43), because she saw resident #56 holding the arm of resident #9, but she did not feel that abuse had occurred. On (MONTH) 8, (YEAR), the Administrator provided a review of the video recording of the incident which had occurred on (MONTH) 2, (YEAR) at approximately 7:27 a.m. in the 400 hallway, between resident #9 and resident #56. Per the video, resident #9 was walking down the hallway with her walker and resident #56 was sitting in his wheelchair in the hallway holding his hand out. Staff #115 was standing at the far end of the hallway by her medication cart with a student nurse. As resident #9 reached resident #56, the two residents shook hands and resident #56 pulled resident #9 close to him and talked to her. Staff #115 remained at the medication cart and the student nurse walked toward the two residents, and within a few seconds the resident's released their hands, without any staff intervention. An interview was conducted on (MONTH) 9, (YEAR) at 11:36 a.m. with Social Services (staff #43). Staff #43 stated the resident approached him Friday morning (November 2, (YEAR)) and wanted to talk with him. Staff #43 said that resident #9 stated that when she was walking past resident #56, he reached out to shake her hand and then took her hand and pulled her close to him stating I want to f--- you. Staff #43 said that resident #9 originally said she was shocked about the incident, but said no when asked if she felt abused or assaulted. Staff #43 stated that he told her if she changed her mind, the facility will need to report it and call the police. Staff #43 stated that resident #9 replied Well that's just (resident #56), but if it happens again, she would file a police report. Staff #43 stated he was surprised that the incident occurred and the language used by resident #56, but did not think any more about it. Staff #43 stated that he did not consider the incident to be abuse, because resident #9's skin was intact, and she did not seem to be offended. He said that he is aware of the care plan for resident #56 regarding comments toward staff, but has never heard anything regarding comments or actions toward peers. Staff #43 stated he informed his supervisor (the Social Service Manager/staff #8), who told him to inform the Director of Nursing (DON/staff #38) right away, which he did. Staff #43 stated he had been educated on the types of abuse and the steps of reporting abuse. He said that sexual abuse would be unwanted physical contact or innuendos, things like that. He said looking back on the incident between resident #9 and resident #56 and based on his definition of sexual abuse, that incident would be considered sexual abuse. -Resident #58 was admitted to the facility on (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated (MONTH) 1, (YEAR) revealed the resident has a BIMS score of 15, which indicated intact cognition. The MDS included the resident required one person extensive assistance with transfers, bed mobility, bathing, dressing and was independent in her wheelchair. An interview was conducted on (MONTH) 5, (YEAR) at 3:29 p.m. with resident #58, who stated that there is a male resident (resident #56) who has been sexually inappropriate for a long time. Resident #58 stated that approximately three weeks ago, resident #56 was in the dining room during meal time, when he started to remove his shirt and started masturbating. Resident #58 stated that she had to get the attention of a staff member, who removed resident #56 from the dining room. She said that resident #56 has behaved like this for a long time and she tries not to look when he does it because it's not something she wants to see. Another interview was conducted on (MONTH) 6, (YEAR) at 9:03 a.m. with resident #58, who stated that at the time of the incident approximately three weeks ago, there were multiple female residents who were present in the dining room, when he was masturbating. Resident #58 stated that she was the one who notified a staff member, because she thinks the other female residents have dementia and are not very with it and are unable to speak for themselves. Resident #58 stated that resident #56 displays this behavior often and she wishes not to see it, so when it happens in a public area, she will take herself elsewhere. Resident #58 also recalled an incident when resident #56 was sitting close to the nurses station in his wheelchair masturbating. She could not recall the date, but stated that there were multiple staff members who saw resident #56 masturbating and they did not do anything about it, until she intervened and asked resident #56 to stop. Resident #58 stated it was only then that a staff member removed resident #56 from the nurses station area. Resident #58 stated that she feels like the staff do not care about his behavior in public, because they do not do anything to help or stop the behavior from happening. -Resident #10 was admitted to the facility on (MONTH) 12, (YEAR), with [DIAGNOSES REDACTED]. Review of the annual MDS assessment dated (MONTH) 7, (YEAR) revealed that resident #10 had a BIMS score of 14, indicating intact cognition. The MDS also revealed that resident #10 required one person limited assistance with walking and bathing, and required supervision and/or was independent with eating, transfers and bed mobility. The MDS also included that resident #10 required extensive assistance of one person while going on and off the unit. An interview was conducted on (MONTH) 5, (YEAR) at 12:53 p.m. with resident #10, who stated that approximately one month ago she was walking down the hallway going back to her room, and resident #56 was sitting in his wheelchair in the door way. Resident #10 stated that resident #56 yelled out to her that he wanted to see her tits. Resident #10 stated that she has seen resident #56 touch the nurses inappropriately and that he has behaved this way for a long time. An interview was conducted on (MONTH) 5, (YEAR) at 3:14 p.m. with a Certified Nursing Assistant (CNA/staff #18), who stated that she has witnessed resident #56 display behaviors. Staff #18 stated there was an incident in the dining room where resident #56 was saying inappropriate things and that she told resident #56 it was not okay to do that. An interview was conducted on (MONTH) 5, (YEAR) at 3:21 p.m. with a CNA (staff #82), who stated that she has worked with resident #56 for a year and he is confused and that he wanders into other resident's rooms. Staff #82 stated that some residents are fearful, because resident #56 will park himself in his wheelchair at the doorway to their rooms. Staff #82 stated that resident #56 is sometimes sexually inappropriate and will use the F word or will say to other residents come touch me. Staff #82 stated that resident #56's sexually inappropriate behaviors are directed to both staff and other residents. An interview was conducted on (MONTH) 5, (YEAR) at 4:07 p.m. with the Administrator, who stated that he had no knowledge of resident #56's sexually inappropriate behaviors. He stated that now there is a staff member with resident #56 at all times. An interview was conducted on (MONTH) 5, (YEAR), with the Director of Nursing (DON/staff #38). Staff #38 stated that she recently became aware that resident #56 had inappropriate behaviors, but did not investigate what the inappropriate behaviors consisted of. An interview was conducted on (MONTH) 5, (YEAR) at 4:47 p.m., with a LPN unit manager (staff #90). Staff #90 stated that resident #56's behaviors consist of being verbally and sexually inappropriate during care and would use phrases such as I want to F--- you or hold my privates. Staff #90 stated that last week she sat with resident #56 at the nurses station for a 1:1 and that he stated to her Let me hold your hand, take my c---. Staff #90 stated that resident #56 has been sexually inappropriate since admission to the facility in 2012. She further stated that she does feel the other residents in the facility have the right to be free from sexual verbal comments or gestures. An interview was conducted on (MONTH) 6, (YEAR) at 9:25 a.m. with a CNA (staff #93), who stated that resident #56 does say sexual comments, such as I want to touch you. She said these behaviors have been occurring for the two years that she has worked at the facility. An interview was conducted on (MONTH) 7, (YEAR) at 8:17 a.m. with a CNA (staff #119), who stated that resident #56 has displayed sexually inappropriate behaviors mostly verbal, but will occasionally start to masturbate while in the dining room and at the nurses station. Staff #119 said that she will place a blanket on his lap with his hands outside of the blanket to try and prevent this behavior from occurring. A later interview was conducted on (MONTH) 7, (YEAR) at 9:51 a.m. with staff #119. She said there was an incident approximately three weeks ago where resident #56 was in the dining room and she was assisting him to eat. She said that resident #56 yelled out F--- me and suck my c----, then proceeded to remove his shirt and brief and pulled his private parts out. She said that she immediately covered resident #56 with a blanket and removed him from the dining room. Staff #119 stated that she reported this to the nurse (staff #115), but did not report the incident to anyone else. Staff #119 stated that resident #56 has had behaviors such as masturbating in public areas and has made inappropriate sexual comments for a long time. -Resident #204 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was discharged on [DATE] to Hospice. Review of a quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 4, which indicated the resident had severe cognitive impairment. Review of the facility's investigative summary included that on 2/01/18 at approximately 9:30 a.m., three staff (CNA/staff #132, CNA/staff #187, housekeeper/staff #131) and a visitor, witnessed a Licensed Practical Nurse (LPN/staff #188) yell at resident #204 saying at least three times You can go to hell. The incident was reported to the Director of Nursing and the Administrator. Staff #188 was suspended immediately. According to the summary, staff #187 reported that she was taking the resident down the hall, when he started cursing at staff. Staff #187 reported that immediately staff #188 started yelling at the resident saying not to talk to her like that and that he is an educated man and should start to behave like one. The documentation included that the visitor who witnessed the incident reported that the nurse came up the hall saying, You don't treat people that way, I an not putting up with it and this if f--- BS. A statement by staff #131 included that staff #188 yelled at resident #204 saying, You go to hell, you go to hell. I thought you were more intelligent than that. Per the report, a statement by staff #188 included that staff #187 was taking resident #204 down the hall, when he started using profanity and she replied, Please Mr. (resident's name) you are a fine educated gentleman, so please do not speak that way to me or my staff. She said that she repeated this three times and then the resident calmed down and stopped using profanity. Review of an e-mail dated 2/1/18 at 10:29 a.m. written by the Business office Administrator (staff #54) to the Director of Nursing (DON/staff #38) and Administrator (staff #81), revealed documentation that staff #131 came to her office on 2/1/18 around 10 a.m. to report that staff #187 was taking resident #204 by the station, and the resident told staff #187 to go to hell. Staff #188 followed them and then told resident #204 to go to hell, you are a more educated man than that. The documentation included that a family member of another resident heard the encounter. In a telephone interview on 11/06/18 at 2:13 p.m. with CNA (staff #134), she stated that resident #204 was being very loud and very disrespectful and the nurse (staff #188) lashed out and yelled at him. Staff #134 stated everybody heard it, but she did not recall the exact words said by the resident or the nurse. She said she was shocked by what the nurse had said to the resident. She said that resident #204 was very upset and he started to shake. Staff #134 stated the staff then had to comfort the resident to get him to relax. She further stated that she did witness abuse when the nurse lashed out and was disrespectful to the resident and that is wrong. An interview was conducted on 11/06/18 at 2:33 p.m. with staff #131, who stated that she was on the 300 hall buffing the floor on 2/01/18 at approximately 9:30 a.m. She stated that resident #204 was sitting on one side of her saying some things, when the nurse on the unit took her finger and pointed it at him and said, Who do you think you are. You don't F------ talk to anybody like that. You can F------ go to hell. Staff #131 stated the resident felt bad, as his head went down. Staff #131 also said that there was a family member in another room who heard the whole thing. Staff #131 stated at that point she knew she had to report it because it upset her. An interview was conducted on 11/07/18 at 8:46 a.m. with staff #54, who stated that staff #131 came to her office on 2/01/18 and reported that staff #188 had said something to resident #204. Staff #54 stated she sent an e-mail to the DON and the Administrator, but the DON never had her e-mail set up to her phone, and that she had entered the Administrator's e-mail address incorrectly, so neither of them received the e-mail. Staff #54 stated she didn't see it as abuse, but thought it was more like a dignity thing. Staff #54 stated she now knows it was abuse and that it should have been reported immediately. An interview was conducted on 11/07/18 at 8:44 a.m. with the DON, who stated that she was not notified immediately, but found out the next day (2/02/18) when she received the e-mail from staff #54. She stated that staff #188 was suspended while the investigation was completed, and after the allegation was substantiated, staff #188 was terminated. However, according to the time sheet punches, staff #188 worked her entire shift until 3:25 p.m. on 2/01/18, and was not removed from further contact from residents on the day of the verbal abuse incident with resident #204. An interview was conducted on (MONTH) 8, (YEAR) at 12:36 p.m. with the Administrator (Abuse Prohibition Officer/staff #81), who stated that part of new hire orientation and prior to staff working with residents, they receive training on abuse, abuse prevention, types of abuse and the reporting process to ensure they are keeping residents safe. Staff #81 stated if a staff member witnessed or was informed of abuse, they should protect the resident and report it immediately. Staff #81 said if a staff member is involved then that person is suspended, pending completion of the investigation. Staff #81 further stated that a report should be made to the State Agency, APS and the police. Review of the facility's policy titled, Resident Abuse Definitions and Report revealed that residents have the right to be free from mental, physical, sexual, and verbal abuse .and prohibits staff from engaging in any such conduct, as well as sets forth procedures for reporting complaints, concerns, or incidents. The policy included that Emotional/Psychological Abuse includes, but is not limited to harassment, deprivation or conduct that is demeaning, humiliating or threatening .Sexual Abuse includes: Any non consensual sexual contact of any type with a resident and includes but is not limited to sexual harassment, sexual coercion, sexual assault, sexual contact, sexual intercourse, sexual penetration with a foreign object, sexual assault or sodomy. The policy further included that verbal abuse included the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or within their hearing distance, regardless of their age, ability to comprehend or their disability. Examples of verbal abuse include, but are not limited to threats of harm, saying things to frighten a resident or cursing at them.",2020-09-01
214,PHOENIX MOUNTAIN POST ACUTE,35072,13232 NORTH TATUM BLVD,PHOENIX,AZ,85032,2018-11-09,607,E,1,1,66CG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews, facility documentation and policy and procedures, the facility failed to implement their abuse policy, by failing to investigate and/or report allegations of abuse involving three residents (#9, #56 and #58) to Adult Protective Services (APS) and the State Agency within two hours, by failing to report an allegation of verbal abuse immediately to the Administrator and to the State Agency within two hours for one resident (#204) and by failing to protect residents from the potential for further abuse by a staff member. Findings include: -Resident #56 was admitted to the facility on (MONTH) 20, 2012, with [DIAGNOSES REDACTED]. Review of the nursing monthly summaries dated (MONTH) 27, (MONTH) 24, and (MONTH) 11, (YEAR), revealed that resident #56 had moderate cognitive impairment, delusions, hallucinations, wanders in the facility, uses a wheelchair and displays sexual behaviors toward female staff. A nursing monthly summary dated (MONTH) 11, (YEAR) included that resident #56 had severe cognitive impairment, uses a wheelchair, continues to be sexually inappropriate and makes inappropriate comments to female staff and visitors. A nursing monthly summary dated (MONTH) 10, (YEAR) revealed that resident #56 has disorganized thinking and memory problems, uses a wheelchair, and is sexually inappropriate with female staff and is redirected. Review of a nursing monthly summary dated (MONTH) 10, (YEAR) revealed the resident had severe cognitive impairment, memory problems, uses a wheelchair, and that behavior monitoring is in process for sexually inappropriate behaviors at times. According to the annual Minimum Data Set (MDS) assessment dated (MONTH) 30, (YEAR), the resident had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. The MDS included the resident required extensive assistance of one person with transfers, bed mobility, bathing and eating and was able to use a wheelchair for locomotion. Under the behavior section, the documentation included that the resident did not have any physical or verbal behaviors, and did not have any behaviors which were directed toward others; such as public sexual acts. Review of an activity care plan dated (MONTH) 2, (YEAR) revealed that resident #56 was unable to complete simple program tasks and has little speech during activities, with the exception of episodes of inappropriate sexual remarks. Interventions included the following: quickly redirect at the first show of behaviors and be aware of the surroundings or seating of resident #56 related to the potential for inappropriate verbal behaviors with other residents. A care plan dated (MONTH) 3, (YEAR) included the resident has long and short term memory deficits, with poor cognitive decision making abilities related to Alzheimer's. The care plan included the resident makes sexually inappropriate gestures and comments towards female staff. Interventions were as follows: attempt to redirect the resident when sexually inappropriate gestures or comments are made towards staff by talking with him about his family, assign consistent caregivers whenever possible, and approach the resident in a calm manner. Review of a care plan dated (MONTH) 3, (YEAR) revealed the resident has a [DIAGNOSES REDACTED].e. grabbing genitals) and comments (advances for oral sex) toward female staff. Interventions listed included the following: Do not respond or react to inappropriate comments, instead distract to more appropriate conversation, if the behavior continues offer reminders of respectful talk or use sterile attention, reinforce with staff that firm and clear limits are healthy and required when the resident makes inappropriate gestures or statements, when resident #56 engages in inappropriate gestures (grabbing genitals) distract him and engage in an activity, offer a snack to occupy his hands, or escort him to his room if safe. Review of the resident assessment change of condition-alert charting dated (MONTH) 6, (YEAR), revealed documentation that the physician stated that resident #56 made sexual inappropriate comments to her, during her visit with him. A physician progress notes [REDACTED]. The physician questioned resident #56 regarding his behaviors in his room and in common areas to see if he knows right from wrong, but made sexually inappropriate comments to the female physician instead. The documentation included that the resident was alert, but was not appropriate in conversation or behaviors. -Resident #9 was admitted to the facility on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. Review of a quarterly MDS assessment dated (MONTH) 6, (YEAR) revealed that resident #9 had a BIMS score of 12, indicating moderate cognitive impairment. The MDS included that resident #9 walks independently with her walker. An interview was conducted on (MONTH) 5, (YEAR) at 9:26 a.m. with resident #9 who stated that last week, either Thursday or Friday (November 1 or (MONTH) 2, (YEAR)), a man (resident #56) was sitting in his wheelchair in the hallway and held out his hand to her. Resident #9 stated she thought he was being friendly and went to shake his hand but he grabbed her hand and pulled her toward his chest and stated I'm going to F--- you. Resident #9 stated that there was a nurse in the hall at that time (staff #115) and believes the nurse witnessed the incident. Resident #9 stated that resident #56 wanders that hall when he is in his wheelchair and has wandered into her room before on multiple occasions, so she now uses her wheelchair and walker to build a fence by placing them up against her bed at night to feel safe while she sleeps. Following the interview with resident #9, the allegation of abuse was reported immediately to the Administrator (staff #81). Another interview was conducted on (MONTH) 6, (YEAR) at 9:31 a.m., with resident #9. The resident stated that she began barricading herself in bed the night after the incident with resident #56, when he made the sexual comment to her. Resident #9 stated that she was not afraid of him prior to the incident, even though he has wandered into her room multiple times in the past. Resident #9 stated the comment that resident #56 said to her has now made her afraid of him, so she sets up her wheelchair and walker by her bed to ensure he does not come near her, while she is sleeping. An interview was conducted on (MONTH) 9, (YEAR) at 11:36 a.m. with Social Services (staff #43). Staff #43 stated that resident #9 approached him Friday morning (November 2, (YEAR)) and wanted to talk with him. Staff #43 said the resident stated that when she was walking past resident #56, he reached out to shake her hand and then took her hand and pulled her close to him stating I want to f--- you. Staff #43 said that resident #9 originally said she was shocked about the incident, but said no when asked if she felt abused or assaulted. Staff #43 stated that he told her if she changed her mind, the facility will need to report it and call the police. Staff #43 stated that resident #9 replied Well that's just (resident #56), but if it happens again, she would file a police report. Staff #43 stated he was surprised that the incident occurred and the language used by resident #56, but did not think any more about it. Staff #43 stated that he did not consider the incident to be abuse, because resident #9's skin was intact and she did not seem to be offended. He said that he is aware of the care plan for resident #56 regarding comments toward staff, but has never heard anything regarding comments or actions toward peers. Staff #43 stated he informed his supervisor (the Social Service Manager/staff #8), who told him to inform the Director of Nursing (DON/staff #38) right away, which he did. Staff #43 stated he had been educated on the types of abuse and the steps of reporting abuse. He said that sexual abuse would be unwanted physical contact or innuendos, things like that. He said looking back on the incident between resident #9 and resident #56 and based on his definition of sexual abuse, that incident would be considered sexual abuse. The facility was unable to provide any evidence that the allegation of abuse was investigated prior to (MONTH) 5, (YEAR) or that it was reported to Adult Protective Services (APS) and the State Agency within two hours as required. The facility did not notify the State Agency until (MONTH) 5, (YEAR), which was three days after the incident. -Resident #58 was admitted to the facility (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. An interview was conducted on (MONTH) 5, (YEAR) at 3:29 p.m. with resident #58, who stated that there is a male resident (resident #56) who has been sexually inappropriate for a long time. Resident #58 stated that approximately three weeks ago, resident #56 was in the dining room during meal time, when he started to remove his shirt and started masturbating. Resident #58 stated that she had to get the attention of a staff member, who removed resident #56 from the dining room. She said that resident #56 has behaved like this for a long time and she tries not to look when he does it because it's not something she wants to see. An interview was conducted on (MONTH) 5, (YEAR), with the Director of Nursing (DON/staff #38). Staff #38 stated that she recently became aware that resident #56 had inappropriate behaviors, but did not investigate what the inappropriate behaviors consisted of. Another interview was conducted on (MONTH) 6, (YEAR) at 9:03 a.m. with resident #58, who stated that at the time of the incident approximately three weeks ago, there were multiple female residents who were present in the dining room, when he was masturbating. Resident #58 stated that she was the one who notified a staff member, because she thinks the other female residents have dementia and are not very with it and are unable to speak for themselves. Resident #58 stated that resident #56 displays this behavior often and wishes not to see it, so when it happens in a public area, she will take herself elsewhere. Resident #58 also recalled an incident when resident #56 was sitting close to the nurses station in his wheelchair masturbating. She could not recall the date, but stated that there were multiple staff members who saw resident #56 masturbating and they did not do anything about it, until she intervened and asked resident #56 to stop. Resident #58 stated it was only then that a staff member removed resident #56 from the nurses station area. Resident #58 stated that she feels like the staff do not care about his behavior in public, because they do not do anything to help or stop the behavior from happening. An interview was conducted on (MONTH) 7, (YEAR) at 8:17 a.m. with a CNA (staff #119), who stated that resident #56 has displayed sexually inappropriate behaviors mostly verbal, but will occasionally start to masturbate while in the dining room and at the nurses station. Staff #119 said that she will place a blanket on his lap with his hands outside of the blanket to try and prevent this behavior from occurring. A later interview was conducted on (MONTH) 7, (YEAR) at 9:51 a.m. with staff #119. She said there was an incident approximately three weeks ago where resident #56 was in the dining room and she was assisting him to eat. She said that resident #56 yelled out F--- me and suck my c---, then proceeded to remove his shirt and brief and pulled his private parts out. She said that she immediately covered resident #56 with a blanket and removed him from the dining room. Staff #119 stated that she reported this to the nurse (staff #115), but did not report the incident to anyone else. Staff #119 stated that resident #56 has had behaviors such as masturbating in public areas and has made inappropriate sexual comments for a long time. The facility was unable to provide any documentation that the allegations/incidents of resident #56 exhibiting inappropriate sexual behaviors in the dining room/nurses area were investigated or reported to the State Agency. -Resident #204 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was discharged on [DATE] to Hospice. Review of a quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 4, which indicated the resident had severe cognitive impairment. Review of the facility's investigative summary revealed that on 2/01/18 at approximately 9:30 a.m., three staff members (CNA/staff #132, CNA/staff #187 and housekeeper manager/staff #131) and a visitor, witnessed a Licensed Practical Nurse (LPN/staff #188) yell at resident #204 saying at least three times You can go to hell. According to the summary, staff #187 reported that she was taking the resident down the hall when he started cursing. Staff #187 reported that immediately staff #188 started yelling at the resident saying not to talk like that and that he is an educated man and should start to behave like one. The documentation included that the visitor who witnessed the incident reported that the nurse came up the hall saying, You don't treat people that way, I am not putting up with it and this if f------ BS. A statement by staff #131 included that staff #188 yelled at resident #204 saying, You go to hell, you go to hell. I thought you were more intelligent than that. A statement by staff #188 included that staff #187 was taking resident #204 down the hall, when he started using profanity and she replied, Please Mr. (resident's name) you are a fine educated gentleman, so please do not speak that way to me or my staff. She said that she repeated this three times and then the resident calmed down and stopped using profanity. Review of an e-mail dated 2/1/18 at 10:29 a.m. written by the Business office Administrator (staff #54) to the Director of Nursing (DON/staff #38) and Administrator (staff #81), revealed documentation that staff #131 came to her office on 2/1/18 around 10 a.m. to report that staff #187 was taking resident #204 by the station, and the resident told staff #187 to go to hell. Staff #188 followed them and then told resident #204 to go to hell, you are a more educated man than that. The documentation included that a family member of another resident also heard the encounter. An interview was conducted on 11/06/18 at 2:33 p.m. with staff #131, who stated that she was on the 300 hall buffing the floor on 2/01/18 at approximately 9:30 a.m. She stated that resident #204 was sitting on one side of her saying some things, when the nurse on the unit took her finger and pointed it at him and said, Who do you think you are. You don't F------ talk to anybody like that. You can F------ go to hell. Staff #131 also said that there was a family member in another room who heard the whole thing. Staff #131 stated at that point she knew she had to report it because it upset her. An interview was conducted on 11/07/18 at 8:46 a.m. with staff #54, who stated that staff #131 came to her office on 2/01/18 and reported that staff #188 had said something to resident #204. Staff #54 stated she sent an e-mail to the DON and the Administrator, but the DON never had her e-mail set up to her phone, and that she had entered the Administrator's e-mail address incorrectly, so neither of them received the e-mail. Staff #54 stated she didn't see it as abuse, but thought it was more like a dignity thing. Staff #54 stated she now knows it was abuse and that it should have been reported immediately. An interview was conducted on 11/07/18 at 8:44 a.m. with the DON, who stated that she was not notified immediately, but found out the next day (on 2/02/18) when she received the e-mail from staff #54. She stated that staff #188 was suspended while the investigation was completed and after the allegation was substantiated, staff #188 was terminated. However, according to the time sheet punches, staff #188 worked her entire shift until 3:25 p.m. on 2/01/18, and was not removed from further contact with residents, immediately following the incident. An interview was conducted on (MONTH) 8, (YEAR) at 12:36 p.m. with the Administrator (Abuse Prohibition Officer/staff #81), who stated that part of new hire orientation and prior to staff working with residents, they receive training on abuse, abuse prevention, types of abuse and the reporting process to ensure they are keeping residents safe. Staff #81 stated if a staff member witnessed or was informed of abuse, they should protect the resident and report it immediately. Staff #81 said if a staff member is involved then that person is suspended, pending completion of the investigation. Staff #81 further stated that a report should be made to the State Agency, APS and the police. Per the facility's documentation, the incident occurred on 2/1/18 and the Director of Nursing was not notified until 2/02/18, and it was not reported to the State Agency until 2/02/18 at 8:06 a.m. The facility was unable to provide evidence that the staff to resident verbal abuse was reported immediately to the Administrator/designee and to the State Agency within two hours after the allegation was made. Review of the facility's policy regarding Resident Abuse Definitions and Report revealed that residents have the right to be free from mental, physical, sexual, and verbal abuse .and prohibits staff from engaging in any such conduct, as well as sets forth procedures for reporting complaints, concerns or incidents. The policy included to promote a resident's right to be free from verbal, sexual, physical, and mental abuse .by anyone, including .facility staff, other Residents .All allegations, observations, or suspected cases of Abuse .will be thoroughly investigated by the facility. Any staff member .suspected of any kind of Resident Abuse, Neglect, misappropriation of property, Exploitation, or any other form of Resident mistreatment will be placed on administrative leave and restricted from duty pending the outcome of the investigation. The Procedure section included: 2.when a staff member .reasonable suspects Abuse, Neglect, misappropriation of property, or Exploitation of a Resident, has received a report or complaint from a Resident of such treatment, or has actual knowledge a Resident has been a victim of such treatment; he/she shall report it immediately to the Administrator . The Administrator will then initiate an investigation, maintain documentation of the investigation and report it in a timely manner to the appropriate authorities. Allegations that involve Abuse will be reported immediately, but not more than two (2) hours after the allegation is made. Failure to make any report required by this policy is a violation of facility policy and may result in disciplinary action up to, and including termination of employment. According to a policy titled Investigative Process, the facility will conduct a thorough investigation of incidents affecting Resident care. The policy included that an investigation will be conducted for any allegation of abuse. The policy included that self-reporting of abuse or neglect to state agencies is mandatory .If after hours, fax an investigative form to the appropriate state agency and contact the agency at the earliest time the next business day . Any staff member suspected of abuse will be placed on administrative leave and restricted from duty pending the outcome of the investigation. A policy regarding Staff treatment of [REDACTED].Staff is made aware of liability and information related to reporting abuse and notified to report any sign or evidence of abuse to their supervisor immediately .Preventative measures to prevent further abuse initiated.",2020-09-01
215,PHOENIX MOUNTAIN POST ACUTE,35072,13232 NORTH TATUM BLVD,PHOENIX,AZ,85032,2018-11-09,608,D,1,1,66CG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews and policy and procedures, the facility failed to report suspicion of a crime to law enforcement regarding an incident of abuse between resident (#56) and resident (#58). Findings include: -Resident #56 was admitted to the facility on (MONTH) 20, 2012, with [DIAGNOSES REDACTED]. Review of the nursing monthly summaries dated (MONTH) 27, (MONTH) 24, and (MONTH) 11, (YEAR), revealed that resident #56 had moderate cognitive impairment, delusions, hallucinations, wanders in the facility, uses a wheelchair and displays sexual behaviors toward female staff. A nursing monthly summary dated (MONTH) 11, (YEAR) included that resident #56 had severe cognitive impairment, uses a wheelchair, continues to be sexually inappropriate and makes inappropriate comments to female staff and visitors. A nursing monthly summary dated (MONTH) 10, (YEAR) revealed that resident #56 has disorganized thinking and memory problems, uses a wheelchair, and is sexually inappropriate with female staff and is redirected. Review of a nursing monthly summary dated (MONTH) 10, (YEAR) revealed the resident had severe cognitive impairment, memory problems, uses a wheelchair, and that behavior monitoring is in process for sexually inappropriate behaviors at times. According to the annual Minimum Data Set (MDS) assessment dated (MONTH) 30, (YEAR), the resident had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. The MDS included the resident required extensive assistance of one person with transfers, bed mobility, bathing and eating and was able to use a wheelchair for locomotion. Under the behavior section, the documentation included that the resident did not have any physical or verbal behaviors, and did not have any behaviors which were directed toward others; such as public sexual acts. Review of an activity care plan dated (MONTH) 2, (YEAR) revealed that resident #56 was unable to complete simple program tasks and has little speech during activities, with the exception of episodes of inappropriate sexual remarks. Interventions included the following: quickly redirect at the first show of behaviors and be aware of the surroundings or seating of resident #56 related to the potential for inappropriate verbal behaviors with other residents. A care plan dated (MONTH) 3, (YEAR) included the resident has long and short term memory deficits, with poor cognitive decision making abilities related to Alzheimer's. The care plan included the resident makes sexually inappropriate gestures and comments towards female staff. Interventions were as follows: attempt to redirect the resident when sexually inappropriate gestures or comments are made towards staff by talking with him about his family, assign consistent caregivers whenever possible, and approach the resident in a calm manner. Review of a care plan dated (MONTH) 3, (YEAR) revealed the resident has a [DIAGNOSES REDACTED].e. grabbing genitals) and comments (advances for oral sex) toward female staff. Interventions listed included the following: Do not respond or react to inappropriate comments, instead distract to more appropriate conversation, if the behavior continues offer reminders of respectful talk or use sterile attention, reinforce with staff that firm and clear limits are healthy and required when the resident makes inappropriate gestures or statements, when resident #56 engages in inappropriate gestures (grabbing genitals) distract him and engage in an activity, offer a snack to occupy his hands, or escort him to his room if safe. Review of the resident assessment change of condition-alert charting dated (MONTH) 6, (YEAR), revealed documentation that the physician stated that resident #56 made sexual inappropriate comments to her, during her visit with him. A physician progress notes [REDACTED]. The physician questioned resident #56 regarding his behaviors in his room and in common areas to see if he knows right from wrong, but made sexually inappropriate comments to the female physician instead. The documentation included that the resident was alert, but was not appropriate in conversation or behaviors. -Resident #9 was admitted to the facility on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. Review of a quarterly MDS assessment dated (MONTH) 6, (YEAR) revealed that resident #9 had a BIMS score of 12, indicating moderate cognitive impairment. The MDS included that resident #9 walks independently with her walker. An interview was conducted on (MONTH) 5, (YEAR) at 9:26 a.m. with resident #9, who stated that last week either Thursday or Friday (November 1 or (MONTH) 2), a man (resident #56) was sitting in his wheelchair in the hallway and held out his hand to her. Resident #9 stated she thought he was being friendly and went to shake his hand, but he grabbed her hand and pulled it toward his chest and stated I'm going to F--- you. Resident #9 stated that there was a nurse in the hall at the time (staff #115) and believes the nurse witnessed the incident. Resident #9 stated that resident #56 wanders that hall in his wheelchair and has wandered into her room on multiple occasions. She stated that she now uses her wheelchair and walker to build a fence around her bed at night to feel safe. Following the interview with resident #9, the allegation of abuse was reported immediately to the Administrator (staff #81). Another interview was conducted on (MONTH) 6, (YEAR) at 9:31 a.m. with resident #9, who stated that she began barricading herself in bed the night after the incident with resident #56, when he made the sexual comment to her. Resident #9 stated that the comment resident #56 said to her has now made her afraid of him, so she sets up her wheelchair and walker by her bed to ensure he does not come near her bed, while she is sleeping. An interview was conducted on (MONTH) 9, (YEAR) at 11:36 a.m. with Social Services (staff #43). Staff #43 stated that resident #9 approached him Friday morning (November 2, (YEAR)) and wanted to talk with him. Staff #43 said the resident stated that when she was walking past resident #56, he reached out to shake her hand and then took her hand and pulled her close to him stating I want to f--- you. Staff #43 said that resident #9 originally said she was shocked about the incident, but said no when asked if she felt abused or assaulted. Staff #43 stated that he told her if she changed her mind, the facility will need to report it and call the police. Staff #43 stated that resident #9 replied Well that's just (resident #56), but if it happens again, she would file a police report. Staff #43 stated he was surprised that the incident occurred and the language used by resident #56, but did not think any more about it. Staff #43 stated that he did not consider the incident to be abuse, because resident #9's skin was intact, and she did not seem to be offended. Staff #43 stated he informed his supervisor (the Social Service Manager/staff #8), who told him to inform the Director of Nursing (DON/staff #38) right away, which he did. Staff #43 stated he had been educated on the types of abuse and the steps of reporting abuse. He said that sexual abuse would be unwanted physical contact or innuendos, things like that. He said that looking back on the incident between resident #9 and resident #56, and based on his definition of sexual abuse, that incident would be considered sexual abuse. The facility was unable to provide any documentation that this incident was reported to law enforcement. Review of a policy titled, Resident Abuse Definitions and Reporting revealed that when a staff member suspects abuse of a resident, has received knowledge of a report or complaint from a resident of such treatment, or has actual knowledge a resident has been a victim of such treatment, he/she shall report it immediately to the Administrator. The Administrator will initiate an investigation and report it to the appropriate authorities in a timely manner. The report of abuse will be made to the State Survey Agency and may result in reports to law enforcement.",2020-09-01
216,PHOENIX MOUNTAIN POST ACUTE,35072,13232 NORTH TATUM BLVD,PHOENIX,AZ,85032,2018-11-09,609,E,1,1,66CG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews, facility documentation and policy and procedures, the facility failed to report allegations of abuse involving three residents (#9, #56 and #58) to Adult Protective Services (APS) and/or the State Agency within two hours after the allegation was made, failed to report an allegation of verbal abuse immediately to the Administrator and to the State Agency within two hours after the allegation was made for one resident (#204). Findings include: -Resident #56 was admitted to the facility on (MONTH) 20, 2012, with [DIAGNOSES REDACTED]. Review of the nursing monthly summaries dated (MONTH) 27, (MONTH) 24, and (MONTH) 11, (YEAR), revealed that resident #56 had moderate cognitive impairment, delusions, hallucinations, wanders in the facility, uses a wheelchair and displays sexual behaviors toward female staff. A nursing monthly summary dated (MONTH) 11, (YEAR) included that resident #56 had severe cognitive impairment, uses a wheelchair, continues to be sexually inappropriate and makes inappropriate comments to female staff and visitors. A nursing monthly summary dated (MONTH) 10, (YEAR) revealed that resident #56 has disorganized thinking and memory problems, uses a wheelchair, and is sexually inappropriate with female staff and is redirected. Review of a nursing monthly summary dated (MONTH) 10, (YEAR) revealed the resident had severe cognitive impairment, memory problems, uses a wheelchair, and that behavior monitoring is in process for sexually inappropriate behaviors at times. Review of an activity care plan dated (MONTH) 2, (YEAR) revealed that resident #56 was unable to complete simple program tasks and has little speech during activities, with the exception of episodes of inappropriate sexual remarks. Interventions included the following: quickly redirect at the first show of behaviors and be aware of the surroundings or seating of resident #56 related to the potential for inappropriate verbal behaviors with other residents. A care plan dated (MONTH) 3, (YEAR) included the resident has long and short term memory deficits, with poor cognitive decision making abilities related to Alzheimer's. The care plan included the resident makes sexually inappropriate gestures and comments towards female staff. Interventions were as follows: attempt to redirect the resident when sexually inappropriate gestures or comments are made towards staff by talking with him about his family, assign consistent caregivers whenever possible, and approach the resident in a calm manner. Review of a care plan dated (MONTH) 3, (YEAR) revealed the resident has a [DIAGNOSES REDACTED].e. grabbing genitals) and comments (advances for oral sex) toward female staff. Interventions listed included the following: Do not respond or react to inappropriate comments, instead distract to more appropriate conversation, if the behavior continues offer reminders of respectful talk or use sterile attention, reinforce with staff that firm and clear limits are healthy and required when the resident makes inappropriate gestures or statements, when resident #56 engages in inappropriate gestures (grabbing genitals) distract him and engage in an activity, offer a snack to occupy his hands, or escort him to his room if safe. Review of the resident assessment change of condition-alert charting dated (MONTH) 6, (YEAR), revealed documentation that the physician stated that resident #56 made sexual inappropriate comments to her, during her visit with him. A physician progress notes [REDACTED]. The physician questioned resident #56 regarding his behaviors in his room and in common areas to see if he knows right from wrong, but made sexually inappropriate comments to the female physician instead. The documentation included that the resident was alert, but was not appropriate in conversation or behaviors. -Resident #9 was admitted to the facility on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. An interview was conducted on (MONTH) 5, (YEAR) at 9:26 a.m. with resident #9 who stated that last week, either Thursday or Friday (November 1 or (MONTH) 2, (YEAR)), a man (resident #56) was sitting in his wheelchair in the hallway and held out his hand to her. Resident #9 stated she thought he was being friendly and went to shake his hand but he grabbed her hand and pulled her toward his chest and stated I'm going to F--- you. Resident #9 stated there was a nurse in the hall at that time (staff #115) and believes the nurse witnessed the incident. Resident #9 stated that resident #56 wanders that hall in his wheelchair and has wandered into her room on multiple occasions. She stated that she now uses her wheelchair and walker to build a fence around her bed at night to feel safe. Following the interview with resident #9, the allegation of abuse was reported immediately to the Administrator (staff #81). An interview was conducted on (MONTH) 5, (YEAR) at 10:20 a.m., with the Administrator (staff #81). Staff #81 stated that he became aware of the incident this morning when interviewing resident #9, and that resident #9 said she was fine. Staff #81 was informed that resident #9 felt that the incident was abuse. Another interview was conducted on (MONTH) 6, (YEAR) at 9:31 a.m. with resident #9, who stated that she began barricading herself in bed the night after the incident with resident #56, when he made the sexual comment to her. Resident #9 stated that the comment resident #56 said to her has now made her afraid of him, so sets up her wheelchair and walker by her bed to ensure he does not come near her bed, while she is sleeping. An interview was conducted on (MONTH) 9, (YEAR) at 11:36 a.m. with Social Services (staff #43). Staff #43 stated that resident #9 approached him Friday morning (November 2, (YEAR)) and wanted to talk with him. Staff #43 said the resident stated that when she was walking past resident #56, he reached out to shake her hand and then took her hand and pulled her close to him stating I want to f--- you. Staff #43 said that resident #9 originally said she was shocked about the incident, but said no when asked if she felt abused or assaulted. Staff #43 stated that he told her if she changed her mind, the facility will need to report it and call the police. Staff #43 stated that resident #9 replied Well that's just (resident #56) but if it happens again, she would file a police report. Staff #43 stated he was surprised that the incident occurred and the language used by resident #56, but did not think any more about it. Staff #43 stated that he did not consider the incident to be abuse, because resident #9's skin was intact and she did not seem to be offended. Staff #43 stated he informed his supervisor (the Social Service Manager/staff #8), who told him to inform the Director of Nursing (DON/staff #38) right away, which he did. Staff #43 stated he had been educated on the types of abuse and the steps of reporting abuse. He said that sexual abuse would be unwanted physical contact or innuendos, things like that. He said that looking back on the incident between resident #9 and resident #56, and based on his definition of sexual abuse, that incident would be considered sexual abuse. The facility was unable to provide any evidence that the allegation of abuse was reported to APS and the State Agency within two hours as required. The facility did not notify the State Agency until (MONTH) 5, (YEAR), which was three days after the incident. -Resident #58 was admitted to the facility (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. An interview was conducted on (MONTH) 5, (YEAR) at 3:29 p.m. with resident #58, who stated that there is a male resident (resident #56) who has been sexually inappropriate for a long time. Resident #58 stated that approximately three weeks ago, resident #56 was in the dining room during meal time, when he started to remove his shirt and started masturbating. Resident #58 stated that she had to get the attention of a staff member, who removed resident #56 from the dining room. She said that resident #56 has behaved like this for a long time and she tries not to look when he does it because it's not something she wants to see. An interview was conducted on (MONTH) 5, (YEAR), with the Director of Nursing (DON/staff #38). Staff #38 stated that she recently became aware that resident #56 had inappropriate behaviors, but did not investigate what the inappropriate behaviors consisted of. Another interview was conducted on (MONTH) 6, (YEAR) at 9:03 a.m. with resident #58, who stated that at the time of the incident approximately three weeks ago, there were multiple female residents who were present in the dining room, when he was masturbating. Resident #58 stated that she was the one who notified a staff member, because she thinks the other female residents have dementia and are not very with it and are unable to speak for themselves. Resident #58 stated that resident #56 displays this behavior often and wishes not to see it, so when it happens in a public area, she will take herself elsewhere. Resident #58 also recalled an incident when resident #56 was sitting close to the nurses station in his wheelchair masturbating. She could not recall the date, but stated that there were multiple staff members who saw resident #56 masturbating and they did not do anything about it, until she intervened and asked resident #56 to stop. Resident #58 stated it was only then that a staff member removed resident #56 from the nurses station area. Resident #58 stated that she feels like the staff do not care about his behavior in public, because they do not do anything to help or stop the behavior from happening. An interview was conducted on (MONTH) 7, (YEAR) at 8:17 a.m. with a CNA (staff #119), who stated that resident #56 has displayed sexually inappropriate behaviors mostly verbal, but will occasionally start to masturbate while in the dining room and at the nurses station. Staff #119 said that she will place a blanket on his lap with his hands outside of the blanket to try and prevent this behavior from occurring. A later interview was conducted on (MONTH) 7, (YEAR) at 9:51 a.m. with staff #119. She said there was an incident approximately three weeks ago where resident #56 was in the dining room and she was assisting him to eat. She said that resident #56 yelled out F--- me and suck my c---, then proceeded to remove his shirt and brief and pulled his private parts out. She said that she immediately covered resident #56 with a blanket and removed him from the dining room. Staff #119 stated that she reported this to the nurse (staff #115), but did not report the incident to anyone else. Staff #119 stated that resident #56 has had behaviors such as masturbating in public areas and has made inappropriate sexual comments for a long time. The facility was unable to provide any documentation that the allegations of abuse/incidents were reported to the State Agency within two hours. -Resident #204 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was discharged on [DATE] to Hospice. Review of the facility's investigative summary revealed that on 2/01/18 at approximately 9:30 a.m., three staff members (CNA/staff #132, CNA/staff #187 and housekeeper manager/staff #131) and a visitor, witnessed a Licensed Practical Nurse (LPN/staff #188) yell at resident #204 saying at least three times You can go to hell. According to the summary, staff #187 reported that she was taking the resident down the hall when he started cursing. Staff #187 reported that immediately staff #188 started yelling at the resident saying not to talk like that and that he is an educated man and should start to behave like one. The documentation included that the visitor who witnessed the incident reported that the nurse came up the hall saying, You don't treat people that way, I am not putting up with it and this if f------ BS. A statement by staff #131 included that staff #188 yelled at resident #204 saying, You go to hell, you go to hell. I thought you were more intelligent than that. A statement by staff #188 included that staff #187 was taking resident #204 down the hall, when he started using profanity and she replied, Please Mr. (resident's name) you are a fine educated gentleman, so please do not speak that way to me or my staff. She said that she repeated this three times and then the resident calmed down and stopped using profanity. Review of an e-mail dated 2/1/18 at 10:29 a.m. written by the Business office Administrator (staff #54) to the Director of Nursing (DON/staff #38) and Administrator (staff #81), revealed documentation that staff #131 came to her office on 2/1/18 around 10 a.m. to report that staff #187 was taking resident #204 by the station, and the resident told staff #187 to go to hell. Staff #188 followed them and then told resident #204 to go to hell, you are a more educated man than that. An interview was conducted on 11/07/18 at 8:44 a.m. with the DON, who stated that she was not notified immediately, but found out the next day (02/02/18) when she received an e-mail from staff #54. An interview was conducted on 11/07/18 at 8:46 a.m. with staff #54, who stated that staff #131 came to her office on 2/01/18 and said that staff #188 said to resident #204 to go to hell, you are a more educated man that that Staff #54 stated that she sent an e-mail to the DON and the Administrator, but the DON never had her e-mail set up to her phone and she had entered the Administrator's e-mail address incorrectly, so neither of them received the e-mail that day. An interview was conducted on (MONTH) 8, (YEAR) at 12:36 p.m. with the Administrator (Abuse Prohibition Officer/staff #81), who stated if a staff member witnessed or was informed of abuse, they should report it immediately. Staff #81 also stated that a report should be made to the State Agency. Per the facility's documentation, the incident occurred on 2/1/18 and the Director of Nursing was not notified until 2/02/18, and it was not reported to the State Agency until 2/02/18 at 8:06 a.m. The facility was unable to provide evidence that the staff to resident verbal abuse was reported immediately to the Administrator/designee and to the State Agency within two hours after the allegation was made. Review of the Resident Abuse Definitions and Report policy revealed the resident has the right to be free from mental, physical, sexual, and verbal abuse .and prohibits staff from engaging in any such conduct, as well as sets forth procedures for reporting complaints, concerns or incidents. The Procedure section included: when a staff member reasonably suspects Abuse, Neglect, misappropriation of property or exploitation of a resident, or has received a report or complaint from a resident of such treatment or has actual knowledge that a resident has been a victim of such treatment; he/she shall report it immediately to the Administrator .The Administrator will make a timely report to the appropriate authority. The policy included that allegations that involve Abuse will be made immediately, but not more than two (2) hours after the allegation is made. Failure to make any report required by this policy is a violation of facility policy and may result in disciplinary action up to, and including termination of employment.",2020-09-01
217,PHOENIX MOUNTAIN POST ACUTE,35072,13232 NORTH TATUM BLVD,PHOENIX,AZ,85032,2018-11-09,610,D,1,1,66CG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews, facility documentation and policy and procedures, the facility failed to ensure that allegations of abuse involving three residents (#56, #58 and #204) were thoroughly investigated. Findings include: -Resident #56 was admitted to the facility on (MONTH) 20, 2012, with [DIAGNOSES REDACTED]. Review of the nursing monthly summaries dated (MONTH) 27, (MONTH) 24, and (MONTH) 11, (YEAR), revealed that resident #56 had moderate cognitive impairment, delusions, hallucinations, wanders in the facility, uses a wheelchair and displays sexual behaviors toward female staff. A nursing monthly summary dated (MONTH) 11, (YEAR) included that resident #56 had severe cognitive impairment, uses a wheelchair, continues to be sexually inappropriate and makes inappropriate comments to female staff and visitors. A nursing monthly summary dated (MONTH) 10, (YEAR) revealed that resident #56 has disorganized thinking and memory problems, uses a wheelchair, and is sexually inappropriate with female staff and is redirected. Review of a nursing monthly summary dated (MONTH) 10, (YEAR) revealed the resident had severe cognitive impairment, memory problems, uses a wheelchair, and that behavior monitoring is in process for sexually inappropriate behaviors at times. Review of an activity care plan dated (MONTH) 2, (YEAR) revealed that resident #56 was unable to complete simple program tasks and has little speech during activities, with the exception of episodes of inappropriate sexual remarks. Interventions included the following: quickly redirect at the first show of behaviors and be aware of the surroundings or seating of resident #56 related to the potential for inappropriate verbal behaviors with other residents. A care plan dated (MONTH) 3, (YEAR) included the resident has long and short term memory deficits, with poor cognitive decision making abilities related to Alzheimer's. The care plan included the resident makes sexually inappropriate gestures and comments towards female staff. Interventions were as follows: attempt to redirect the resident when sexually inappropriate gestures or comments are made towards staff by talking with him about his family, assign consistent caregivers whenever possible, and approach the resident in a calm manner. Review of a care plan dated (MONTH) 3, (YEAR) revealed the resident has a [DIAGNOSES REDACTED].e. grabbing genitals) and comments (advances for oral sex) toward female staff. Interventions listed included the following: Do not respond or react to inappropriate comments, instead distract to more appropriate conversation, if the behavior continues offer reminders of respectful talk or use sterile attention, reinforce with staff that firm and clear limits are healthy and required when the resident makes inappropriate gestures or statements, when resident #56 engages in inappropriate gestures (grabbing genitals) distract him and engage in an activity, offer a snack to occupy his hands, or escort him to his room if safe. Review of the resident assessment change of condition-alert charting dated (MONTH) 6, (YEAR), revealed documentation that the physician stated that resident #56 made sexual inappropriate comments to her, during her visit with him. A physician progress notes [REDACTED]. The physician questioned resident #56 regarding his behaviors in his room and in common areas to see if he knows right from wrong, but made sexually inappropriate comments to the female physician instead. The documentation included that the resident was alert, but was not appropriate in conversation or behaviors. -Resident #58 was admitted to the facility (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. An interview was conducted on (MONTH) 5, (YEAR) at 3:29 p.m. with resident #58, who stated that there is a male resident (resident #56) who has been sexually inappropriate for a long time. Resident #58 stated that approximately three weeks ago, resident #56 was in the dining room during meal time, when he started to remove his shirt and started masturbating. Resident #58 stated that she had to get the attention of a staff member, who removed resident #56 from the dining room. She said that resident #56 has behaved like this for a long time and she tries not to look when he does it because it's not something she wants to see. An interview was conducted on (MONTH) 5, (YEAR), with the Director of Nursing (DON/staff #38). Staff #38 stated that she recently became aware that resident #56 had inappropriate behaviors, but did not investigate what the inappropriate behaviors consisted of. Another interview was conducted on (MONTH) 6, (YEAR) at 9:03 a.m. with resident #58, who stated that at the time of the incident approximately three weeks ago, there were multiple female residents who were present in the dining room, when he was masturbating. Resident #58 stated that she was the one who notified a staff member, because she thinks the other female residents have dementia and are not very with it and are unable to speak for themselves. Resident #58 stated that resident #56 displays this behavior often and wishes not to see it, so when it happens in a public area, she will take herself elsewhere. Resident #58 also recalled an incident when resident #56 was sitting close to the nurses station in his wheelchair masturbating. She could not recall the date, but stated that there were multiple staff members who saw resident #56 masturbating and they did not do anything about it, until she intervened and asked resident #56 to stop. Resident #58 stated it was only then that a staff member removed resident #56 from the nurses station area. Resident #58 stated that she feels like the staff do not care about his behavior in public, because they do not do anything to help or stop the behavior from happening. An interview was conducted on (MONTH) 7, (YEAR) at 8:17 a.m. with a CNA (staff #119), who stated that resident #56 has displayed sexually inappropriate behaviors mostly verbal, but will occasionally start to masturbate while in the dining room and at the nurses station. Staff #119 said that she will place a blanket on his lap with his hands outside of the blanket to try and prevent this behavior from occurring. A later interview was conducted on (MONTH) 7, (YEAR) at 9:51 a.m. with staff #119. She said there was an incident approximately three weeks ago where resident #56 was in the dining room and she was assisting him to eat. She said that resident #56 yelled out F--- me and suck my c---, then proceeded to remove his shirt and brief and pulled his private parts out. She said that she immediately covered resident #56 with a blanket and removed him from the dining room. Staff #119 stated that she reported this to the nurse (staff #115), but did not report the incident to anyone else. Staff #119 stated that resident #56 has had behaviors such as masturbating in public areas and has made inappropriate sexual comments for a long time. The facility was unable to provide any documentation that the allegations of abuse/incidents had been investigated. -Resident #204 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was discharged on [DATE] to Hospice. Review of the facility's investigative summary revealed that on 2/01/18 at approximately 9:30 a.m., three staff members (CNA/staff #132, CNA/staff #187 and housekeeper manager/staff #131) and a visitor, witnessed a Licensed Practical Nurse (LPN/staff #188) yell at resident #204 saying at least three times You can go to hell. According to the summary, staff #187 reported that she was taking the resident down the hall when he started cursing. Staff #187 reported that immediately staff #188 started yelling at the resident saying not to talk like that and that he is an educated man and should start to behave like one. The documentation included that the visitor who witnessed the incident reported that the nurse came up the hall saying, You don't treat people that way, I am not putting up with it and this if f------ BS. A statement by staff #131 included that staff #188 yelled at resident #204 saying, You go to hell, you go to hell. I thought you were more intelligent than that. A statement by staff #188 included that staff #187 was taking resident #204 down the hall, when he started using profanity and she replied, Please Mr. (resident's name) you are a fine educated gentleman, so please do not speak that way to me or my staff. She said that she repeated this three times and then the resident calmed down and stopped using profanity. Further review of the facility's investigative documentation revealed that it was not thorough, as it did not include any interviews with other residents who were in the area at the time of the incident, nor interviews with other residents who may have been cared for by staff #188. An interview was conducted on 11/07/18 at 8:44 a.m. with the DON (staff #38), who stated that she interviewed the staff which were present and the Social Worker interviewed residents. The DON stated that it is her policy to interview 5-10 residents, however, the Social Worker was terminated and there are no records of other resident interviews. An interview was conducted on (MONTH) 8, (YEAR) at 12:36 p.m. with the Administrator (Abuse Prohibition Officer/staff #81), who stated a thorough investigation included an interview with the resident involved, other residents in the vicinity or who had contact with or was provided care by the alleged perpetrator, and staff that worked with the alleged perpetrator. The Resident Abuse Definitions and Report policy revealed to promote a resident's right to be free from verbal, sexual, physical, and mental abuse by anyone, including facility staff and other residents. All allegations, observations, or suspected cases of Abuse will be thoroughly investigated by the facility. The Procedure section included that the Administrator will initiate an investigation of the report and maintain documentation of the investigation, including the date of the incident, a description of the incident, resident(s) involved, and the identity of the person(s) alleged to be responsible for the potential misconduct towards a resident. Review of the policy titled, Investigative Process revealed the facility will conduct a thorough investigation of incidents affecting resident care. The policy included that an investigation will be conducted for any allegation of abuse. The Procedure section of the policy included that each witness will be interviewed and that each person interviewed is asked to write a narrative statement describing the incident on a facility approved form. The policies did not address the need to interview other residents who are in the vicinity at the time of an incident, or of the need to interview other residents who may have been cared for by the staff member who is named in an allegation.",2020-09-01
218,PHOENIX MOUNTAIN POST ACUTE,35072,13232 NORTH TATUM BLVD,PHOENIX,AZ,85032,2018-11-09,756,D,0,1,66CG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and policy and procedure, the facility failed to ensure a Medication Regimen Review (MRR) was reviewed by a pharmacist within the required time frame of at least once a month for one resident (#79). Findings include: Resident #79 was admitted to the facility on (MONTH) 5, (YEAR), with [DIAGNOSES REDACTED]. Review of the physician's admission orders [REDACTED]. Review of the clinical record revealed no evidence that the resident's medication regimen had been reviewed by a pharmacist. An interview was conducted on (MONTH) 9, (YEAR) at 12:18 pm with the Director of Nursing (DON/staff #38). She stated that normally the pharmacist would review the resident's medication regimen right after the resident was admitted to the facility. Later that day, at 1:48 pm, the DON stated that she contacted the pharmacy and confirmed that a MRR had not been conducted for the resident from the date of admission to the facility until the current date. The facility's Medication Regimen Review policy stated that each resident's medication regimen would be reviewed at least monthly or more frequently depending upon the resident's condition. The policy included that the medication regimen would be reviewed by a pharmacist at times of transitions in care, such as from the hospital to the facility, for all residents with an expected stay of less than 30 days. The policy further included that medications would be reviewed by a pharmacist at the time of dispensing and with modifications in dosages.",2020-09-01
219,PHOENIX MOUNTAIN POST ACUTE,35072,13232 NORTH TATUM BLVD,PHOENIX,AZ,85032,2018-11-09,757,E,0,1,66CG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy, the facility failed to ensure one resident's (#55) drug regimen was free from unnecessary drugs, by failing to ensure there was adequately monitoring in place for an antidepressant medication. Findings include: Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. A laboratory (lab) result obtained on 09/15/18 included that the resident had a CrCl (creatinine clearance) of 22 ml/minute. The normal reference range for CrCl is greater than or equal to 61 for the laboratory used for the testing. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. The assessment also included the resident had no mood changes or behaviors. Review of the Mood State care plan for depression initiated on 09/25/18, revealed the following interventions: use Duloxetine and monitor for adverse side effects; educate resident on anger management techniques and the benefits and risks of refusal of care; monitor for refusal of care and document on the Behavior Monitoring Flow Sheet; [MEDICAL CONDITION] medications to be reviewed quarterly and as needed by the Interdisciplinary Team, Physician, and Pharmacist to evaluate for ongoing need and for potential gradual dose reduction. A lab result obtained on 10/06/18 included that the resident had a low CrCl of 17 ml/minute. A Pharmacist Medication Regimen Review (MRR) dated 10/09/18 included a manufacturer statement to avoid the use of Duloxetine with a CrCl of A lab result obtained on 10/10/18 included that the resident had a low CrCl of 18 ml/minute. A lab result obtained on 10/25/18 included that the resident had a low CrCl of 19 ml/minute. Review of the Behavior/Intervention Monthly Flow Record for (MONTH) (YEAR) revealed no identified behaviors of depression AEB refusing care and only one day shift with identified behaviors of depression AEB refusing care in (MONTH) (YEAR). A review of the Medication Administration Record [REDACTED]. No Behavior/Intervention Monthly Flow Record was initiated to monitor the resident's behavior for depression for the month of November. An interview was conducted on 11/08/18 at 9:31 AM with the Licensed Practical Nurse (LPN/staff #13), who stated that the resident was receiving the Duloxetine for depression and refusing care. The LPN stated that the resident should be monitored for those behaviors as well as adverse effects of the medication. Staff #13 stated that there was no behavior monitoring done for (MONTH) 1-7, (YEAR). The LPN stated that it is important to monitor the behaviors so that even a slight change in behavior would be captured. An interview was conducted on 11/08/18 at 09:49 AM with the Director of Nursing (DON/staff #38), who stated that when there is a new physician's orders [REDACTED]. The DON stated that a couple of days prior to a new month starting, the order recapitulation (recap) sheets are distributed to the Nurse Managers to review and verify. Staff #38 stated that if a resident is receiving a medication that requires monitoring, the Nurse Manager will prepare the appropriate monitoring sheet to include with the MARs. The DON stated that she receives the MRRs and distributes them to the Nurse Managers, who ensures the physician reviews and responds to any recommendations. She stated that if the Physician has agreed to the recommendation, the Nurse Manager will write the order for the recommendation. An interview was conducted on 11/08/18 at 10:04 AM with the Unit Manager (staff #23), who stated there should have been a behavior monitoring sheet included with the MAR for the month of November. Staff #23 further stated it is important to monitor residents receiving [MEDICAL CONDITION] medications because if the behaviors are decreasing, attempts can be made to decrease the medication or stop the medication. He stated that once he is given the MRR reports; he gives them to the physicians for review. He stated that once the physician has reviewed the MRR, he would write any needed orders. Staff #23 stated that his signature is on the MRR as having reviewed it and that the recommendation was missed. Review of the facility's policy titled Medication Regimen Review revealed It is the policy of this facility that each resident's medications will be reviewed at least monthly by the Consulting Pharmacist or more frequently depending on the resident's condition and the risks or adverse consequences related to the current medication(s) .the DON or designee will ensure all recommendations are reconciled. The policy included that the pharmacists identifies irregularities through a variety of sources including laboratory results and behavior monitoring. The policy included the Pharmacist will review medications for medical condition and response to drug therapy. The policy also included, The Director of Nursing will forward all findings to the respective nurse manager for timely follow-up/contact with the attending physician .The attending physician must address the issues identified .by accepting and ordering recommended alterations in medication regimen or by providing justification for the decision to not accept.",2020-09-01
220,PHOENIX MOUNTAIN POST ACUTE,35072,13232 NORTH TATUM BLVD,PHOENIX,AZ,85032,2018-11-09,758,D,0,1,66CG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, clinical record review, and policy review, the facility failed to ensure one resident (#79) had adequate indication for the use of an antipsychotic medication. Findings include: Resident #79 was admitted to the facility on (MONTH) 5, (YEAR), with [DIAGNOSES REDACTED]. Review of the physician's admission orders [REDACTED]. Review of the physician's admission History and Physical (H & P) dated (MONTH) 8, (YEAR), revealed the resident was alert with pleasant affect, and that the resident was oriented to month, year, general place, and room. The H & P stated that the resident had been taking [MEDICATION NAME] twice daily and [MEDICATION NAME] (antipsychotic) 0.5 mg at bedtime. The H & P stated [MEDICATION NAME] would be discontinued, and the resident would continue to take [MEDICATION NAME] twice daily. The H & P did not include the rationale for the continued use of [MEDICATION NAME]. A nursing note dated (MONTH) 9, (YEAR) revealed the resident has not exhibited any unsafe behaviors and appears to be adjusting to the facility well. The admission Minimum Data Set (MDS) assessment dated (MONTH) 14, (YEAR), revealed a Brief Interview for Mental Status (BIMS) score of 8 which indicated the resident had moderate cognitive impairment. In addition, the MDS assessment included the resident was assessed to have no symptoms of [MEDICAL CONDITION] such as hallucinations and/or delusions, and that she did not display behaviors of physical aggression, verbal aggression, or other behavioral symptoms. Review of the care plan initiated (MONTH) 18, (YEAR) regarding the resident's mood state revealed interventions that included administering [MEDICATION NAME] as ordered, observing for side effects, and monitoring for targeted behaviors including agitation, refusing medications, and dysphoria. The interventions also included that [MEDICAL CONDITION] medications would be reviewed quarterly to evaluate for ongoing need and for potential gradual dose reductions. The Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. From (MONTH) 6, (YEAR) through (MONTH) 9, (YEAR), the resident had zero documented episodes of dysphoria, one episode of refusing medications, and five episodes of agitation. Review of the Medication Regimen Review (MRR) conducted on (MONTH) 9, (YEAR), revealed the resident was receiving [MEDICATION NAME] for [MEDICAL CONDITION] with mood features as evidenced by agitation, refusing medications, [MEDICAL CONDITION], and dysphoria. The review included a request to clarify how the resident exhibited agitation. The review further included the resident's behaviors would be monitored and a Gradual Dose Reduction (GDR) would be considered at the next evaluation. Additional review of the clinical record revealed no adequate indication for the continued use of [MEDICATION NAME]. An observation of the resident was conducted on (MONTH) 9, (YEAR) at 9:51 am. The resident was observed seated in her wheelchair in her room. She appeared neatly groomed with a calm affect. She appeared to be engaging in conversation with her guest. An interview was conducted on (MONTH) 9, (YEAR) at 10:16 am with a Certified Nursing Assistant (CNA/staff #119). The CNA described the resident's only behaviors as acting grumpy, and insisting on trying to independently perform her own activities of daily living. The CNA stated that the resident would occasionally yell, Leave me alone, but that the resident would calm down if given a little time and space. During an interview conducted on (MONTH) 9, (YEAR) at 10:21 am with a Licensed Practical Nurse (LPN/staff #41), the LPN stated that the resident's only behaviors consisted of acting confused and stating that she wanted to go home. The LPN also stated he had not witnessed the resident yelling, striking out, or showing aggression. Review of the facility's policy regarding psychoactive medication administration revealed the following: -it is the policy of the facility to provide psychoactive medications for only those residents diagnosed or identified with conditions indicated. -Behaviors with physical symptoms will be monitored.",2020-09-01
221,PHOENIX MOUNTAIN POST ACUTE,35072,13232 NORTH TATUM BLVD,PHOENIX,AZ,85032,2018-11-09,842,B,0,1,66CG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a clinical record review, staff and resident interviews, and policies review, the facility failed to ensure the medical record for one resident #22 was accurately documented. Findings include: Resident #22 was admitted to the facility on (MONTH) 2, (YEAR) and readmitted on (MONTH) 12, (YEAR) with [DIAGNOSES REDACTED]. An advance directive form sign by the resident's representative on (MONTH) 11, (YEAR) revealed the resident was a full code indicating the resident's representative elected to have all emergency resuscitation efforts for the resident. Further review of the clinical record revealed a second advance directive form electing Do not resuscitate signed by the resident's representative on (MONTH) 28, (YEAR). Review of the recapitulation of physician orders [REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 19, (YEAR) revealed a Brief Interview for Mental Status score of 12 which indicated the resident had moderate cognitive impairment. An interview was conducted on (MONTH) 7, (YEAR) at 10:11 a.m. with a registered nurse (RN/staff #101). She stated that upon admission the nurse obtains a completed advance directive from the resident and/or the power of attorney. After reviewing the clinical record she stated that the resident has a full code order dated (MONTH) 11, (YEAR) and an advance directive for do not resuscitate dated (MONTH) 28, (YEAR). During an interview conducted on (MONTH) 7, (YEAR) at 10:18 a.m. with the MDS coordinator (staff #153), he stated that advance directives are obtained on admission by the nurse and that the unit manager will review the physician orders [REDACTED].#22 has a health care power of attorney that signed a do not resuscitate advance directive (MONTH) 28, (YEAR) and that the most recent advance directive order is for a full code status. He stated that advance directives should match the physician's orders [REDACTED].>An interview was conducted on (MONTH) 7, (YEAR) at 10:27 a.m. with the Director of Nursing (DON/staff #38). She stated that upon admission advance directives are explained to the resident and/or the resident's representative and that the form is completed and signed. She stated that the unit managers are to write clarification orders if the advance directives do not match physician's orders [REDACTED]. She stated that there is a full code order dated (MONTH) 11, 1018 and there is a do not resuscitate form signed (MONTH) 28, (YEAR). The DON further stated that there was no clarification order to change the advance directive order to a do not resuscitate in the chart. An interview was conducted on (MONTH) 7, (YEAR) at 10:41 a.m. with resident #22. He stated that on admission he was given an opportunity to elect advance directives and elected not to be resuscitated. The facility's policy titled Advance Directives revealed the facility is to determine on admission whether the resident has an advance directives and, if not, determine whether the resident wishes to formulate an advance directive. The policy included the facility must identify, clarify, and periodically review as a part of the compressive care planning process, the existing care instructions and whether the resident wishes to change or continue these instructions. Review of the facility's policy titled Medical Records revealed the facility is to maintain medical records on each resident that are in accordance with accepted professional standards and practices and that are complete and accurately documented.",2020-09-01
222,PHOENIX MOUNTAIN POST ACUTE,35072,13232 NORTH TATUM BLVD,PHOENIX,AZ,85032,2018-11-09,867,E,0,1,66CG11,"Based on concerns identified during the survey, staff interview, facility documentation and policy and procedures, the Quality Assessment and Assurance (QAA) committee failed to develop and implement an appropriate plan of action to correct concerns regarding abuse. Findings include: The facility's Abuse Prohibition Officer/Administrator (staff #81) and the Director of Nursing (DON/staff #38) were notified of a staff to resident verbal abuse incident on 02/02/18 that occurred on 02/01/18, which resulted in failure to protect residents, a delay in reporting, and an incomplete investigation. As a result, the facility initiated a Process Improvement plan (PIP) for correction on 02/09/18 regarding the two-hour reporting requirement for abuse. The action plan items included in-servicing nursing staff on the new rules and presenting the new rules during orientation. The responsible persons were the DON, Administrator, and the Nurse Managers. Review of the plan on 11/05/18 revealed the following documentation on the Follow-Up Date section: 1. 02/19/18, 02/21/18, then as needed and yearly; 2. On-going. The plan did not reflect any root cause analysis, scope of the problem or plan, and any documentation of follow-up actions, other than in-service sign-in sheets. The State Agency received multiple facility self-reports regarding allegations of abuse since the initiation of the PIP and none were reflected on the PIP as being reviewed for compliance. The PIP regarding abuse did not include the failure to protect residents as soon as a suspicion of abuse is identified and the lack of staff knowledge as to what constitutes abuse. The facility then provided a copy of the plan that now contained handwritten notes under the follow-up date section that included the following: -02/02/18 In-service -02/05/18 All staff meeting -April (YEAR) Annual in-service with test to all staff. See staff development -April 5 General staff In-service and Kahoot Quiz -April 27, (YEAR) In-service by Social Service -11/05/18-11/09/18. 11/06/18 Abuse In-service The supporting documentation for the above plan included: -An in-service sheet with no date, title/topic with one Registered Nurse Signature -A partial copy of the Kahoot Quiz that contained 10 questions, of which only 2 were related to abuse that asked when reporting should occur and the acceptable form of communication when reporting abuse to the Administrator or DON -A copy of the Resident Rights & Abuse Quiz used at the annual in-service in (MONTH) (YEAR) of which approximately half of the 14 questions were on abuse and 10 questions under the Elder Justice Act were regarding reporting a crime. -A copy of the one page document titled Social Service Orientation on Abuse/Neglect and Reporting with handwritten dates of (MONTH) 23 at 2:30 and (MONTH) 27 at 2:30 -A copy of the outdated federal regulations regarding abuse and resident rights (pre (MONTH) (YEAR)) -A copy of the Elder Justice Act Notice -Mandatory Meeting for (MONTH) (YEAR) that included 4 bullet points to report immediately and regarding the 2-hour time frame. -Staff in-service sign-in sheets from 02/17/18 (x 2) and 02/21/18 (x 2), and all staff that signed in are from the nursing area and no other departments in the facility. An interview was conducted on 11/09/18 at 12:50 PM with the Administrator (staff #81) and the DON (staff #38). The Administrator stated that the QAA Committee meets monthly and that if a concern is presented that requires monitoring and improvement, a Process Improvement Plan (PIP) is initiated. Staff #81 stated that the sub-committee working on the concern would identify the problem using root cause analysis (RCA) and the documentation would include identification of the problem, possible causes, responsible person, outcomes, on-going monitoring, and identification of changes to be expected. The administrator stated that the goal is to have a PIP completed in 3-6 months. Staff #81 stated that if something failed after the PIP was completed; the QAA Committee would open a new PIP. The facility's policy regarding Quality Assurance-Performance Policy revealed the following statement It is the policy of this facility to utilize the principles of Quality Assurance (QA) and Performance Improvement (PI) to create systems to provide care and achieve compliance with state and federal regulations; track, investigate, and try to prevent recurrence of adverse events . The policy also included The activities of QAPI involves members from all levels of the organization to: -identify opportunities for improvement; -address gaps in systems or processes; -develop and implement an improvement or corrective plan; -and continuously monitor effectiveness of interventions.",2020-09-01
223,SANTA RITA NURSING & REHABILITATION CENTER,35073,150 NORTH LA CANADA DRIVE,GREEN VALLEY,AZ,85614,2017-03-17,241,E,0,1,RY2C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based clinical record reviews, resident and staff interviews, and facility documentation, the facility failed care for six resident's (#'s 29, 336, 328, 343, 345, and 323) in a manner that promotes and maintains their quality of life, by failing to answer call lights in a timely manner. Findings include: -Resident #29 was admitted to the facility on (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 21, (YEAR), revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. During an interview conducted at 10:20 a.m. on (MONTH) 14, (YEAR), the resident was asked if she felt there was enough staff available to make sure she received the care and assistance she needed, without having to wait a long time. The resident stated No, they get busy sometimes and she has to wait. A review of the call light logs from (MONTH) 6 through (MONTH) 13, (YEAR), revealed it had taken 40- 43 minutes for staff to respond to the resident's call light on two occasions. -Resident #336 was admitted to the facility on (MONTH) 20, (YEAR), with [DIAGNOSES REDACTED]. A review of the MDS assessment dated (MONTH) 27, (YEAR), revealed the resident had a BIMS score of 9, which indicated the resident had moderate cognitive impairment. During an interview conducted at 10:17 a.m. on (MONTH) 14, (YEAR), the resident was asked if she felt there was enough staff available to make sure she received the care and assistance she needed without having to wait a long time. The resident stated that sometimes she has to wait a long time for help. A review of the call light logs from (MONTH) 6 through (MONTH) 13, (YEAR), revealed it had taken 59-73 minutes for staff to respond to the resident's call light on two occasions. -Resident #323 was readmitted to the facility on (MONTH) 22, (YEAR), with [DIAGNOSES REDACTED]. A review of the Nurses Notes dated (MONTH) 15, (YEAR) revealed the resident was alert and oriented x 2, with the ability of making her needs known occasionally. During an interview conducted at 8:38 a.m. on (MONTH) 14, (YEAR), the resident was asked if she felt there was enough staff available to make sure she received the care and assistance she needed without having to wait a long time. The resident stated No. The resident stated it takes a long time for help, like 30 minutes. The resident further stated that sometimes staff tell her that the light is not working. A review of the call light logs from (MONTH) 6 through (MONTH) 13, (YEAR), revealed it had taken 33- 42 minutes for staff to respond to the resident's call light on three occasions. -Resident #345 was admitted to the facility on (MONTH) 26, (YEAR), with [DIAGNOSES REDACTED]. A review of the admission MDS assessment dated (MONTH) 5, (YEAR), revealed the resident had a BIMS score of 15, which indicated the resident was cognitively intact. During an interview conducted at 9:56 a.m. on (MONTH) 14, (YEAR), the resident was asked if he felt there was enough staff available to make sure he received the care and assistance he needed without having to wait a long time. The resident stated No. The resident stated that sometimes he had to wait a long time. A review of the call light logs from (MONTH) 6 through (MONTH) 13, (YEAR), revealed it had taken 43 minutes for staff to respond to the resident's call light on one occasion. -Resident #328 was admitted to the facility on (MONTH) 26, (YEAR), with [DIAGNOSES REDACTED]. A review of the Nurses Notes dated (MONTH) 28, (YEAR) revealed Patient alert and oriented x 2-3, pleasant and cooperative with care, able to make needs known . During an interview conducted at 10:29 a.m. on (MONTH) 14, (YEAR), the resident was asked if he felt there was enough staff available to make sure he received the care and assistance he needed without having to wait a long time. The resident stated that he had to wait almost a half hour for someone to answer the call light. A review of the call light logs from (MONTH) 6 through (MONTH) 13, (YEAR), revealed it had taken 31- 87 minutes for staff to respond to the resident's call light on three occasions. -Resident #343 was admitted to the facility on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. A review of the admission MDS assessment dated (MONTH) 8, (YEAR), revealed the resident had a BIMS score of 11, which indicated the resident had moderate cognitive impairment. During an interview conducted at 1:41 p.m. on (MONTH) 13, (YEAR), the resident was asked if he felt there was enough staff available to make sure he received the care and assistance he needed without having to wait a long time. The resident stated it takes a while to get help and that staff's response to the call light is worse at night. A review of the call light logs from (MONTH) 6 through (MONTH) 13, (YEAR), revealed it had taken 37- 45 minutes for staff to respond to the resident's call light on three occasions. During an interview conducted at 3:05 p.m. on (MONTH) 15, (YEAR), the Administrator (staff #39) stated that 30 or more minutes was not acceptable wait times for having call lights answered. She also stated that the staff may not have turned off the call lights after providing care, or the resident may have had to wait for additional staff to be available to help them, because they required the assistance of two staff members. During an interview conducted at 9:25 a.m. on (MONTH) 15, (YEAR), the Assistant Director of Nursing stated call lights should be answered within 10 minutes. He stated that if a call light is not answered within so many minutes (he was unsure of the time frame) he is notified via pager and then checks to make sure a staff member has addressed the resident's needs. During an interview conducted at 9:45 a.m. on (MONTH) 15, (YEAR), a certified nursing assistant (CNA/staff #16) stated when a resident pushes the call light button in the resident's room or bathroom, the call light system pages the CNA and the resident's room number appears on the electronic display in the hallway. She also stated that if the resident requires the assistance of two staff, the call light is not turned off until two staff are available to provide the needed care. During an interview conducted at 10:00 a.m. on (MONTH) 15, (YEAR), a LPN (Licensed Practical Nurse/staff #2) stated when the call light is turned on, the system notifies the CNA via pager and also displays the room number on the electronic display in the hallways. She stated that after a call light has been on for 5 minutes, the call light system notifies the nurse working on the unit via pager, and if the call light remains on for 15 minutes the call light system notifies the Director of Nursing via a pager. A policy and procedure for the answering of call lights was requested and administrative staff stated the facility had no such policy and procedure.",2020-09-01
224,SANTA RITA NURSING & REHABILITATION CENTER,35073,150 NORTH LA CANADA DRIVE,GREEN VALLEY,AZ,85614,2017-03-17,247,E,0,1,RY2C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, resident and staff interviews, facility documentation and policy and procedures, the facility failed to provide four residents (#s 29, 345, 322 and 317) with written notice prior to roommate changes. Findings include: -Resident #29 was admitted to the facility on (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 21, (YEAR), revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Review of facility documentation revealed the resident received a new roommate on (MONTH) 22, (YEAR). However, review of the clinical record revealed no documented evidence the resident was provided with written or verbal notice prior to receiving a new roommate. -Resident #345 was admitted to the facility on (MONTH) 26, (YEAR), with [DIAGNOSES REDACTED]. A review of the admission MDS assessment dated (MONTH) 5, (YEAR), revealed the resident had a BIMS score of 15. A review of facility documentation revealed the resident received a new roommate on (MONTH) 7, (YEAR). During an interview conducted at 9:58 a.m. on (MONTH) 14, (YEAR), the resident stated that he was not provided any notice prior to receiving a new roommate. He said the staff just brought him into my room. A review of the clinical record revealed no documented evidence the resident was provided with written or verbal notice prior to receiving a new roommate. -Resident #322 was admitted to the facility on (MONTH) 22, (YEAR), with [DIAGNOSES REDACTED]. A review of the admission MDS assessment dated (MONTH) 1, (YEAR), revealed the resident had a BIMS score of 15. A review of facility documentation revealed the resident received a new roommate on (MONTH) 13, (YEAR). During an interview conducted at 9:32 a.m. on (MONTH) 14, (YEAR), the resident stated that she had received a new roommate, and was not provided any notice prior to receiving the new roommate. A review of the clinical record revealed no documented evidence the resident was provided with written or verbal notice prior to receiving a new roommate. -Resident #317 was admitted to the facility on (MONTH) 6, (YEAR), with [DIAGNOSES REDACTED]. A review of the Nurses Notes dated (MONTH) 7, (YEAR), revealed the resident was alert and oriented x 3 and able to make his needs known, but was forgetful at times. A review of facility documentation revealed the resident received a new roommate on (MONTH) 13, (YEAR). During an interview conducted at 9:16 a.m. on (MONTH) 14, (YEAR), the resident stated he had no notice, prior to receiving a new roommate. A review of the clinical record revealed no documented evidence the resident was provided with written or verbal notice prior to receiving a new roommate. During an interview conducted at 10:47 a.m. on (MONTH) 16, (YEAR), the Operations Director (staff #148) stated there were no notes in the clinical records to indicate the residents were notified of room or roommate changes. During a second interview conducted at 11:10 a.m., staff #148 stated the residents all received new roommates and that she was unable to find documented evidence they were provided notice, prior to the new roommates arrival. She stated the certified nursing assistants (CNA) prepare the room for the new admission and are responsible for notifying the resident in the room that they would be receiving a new roommate. During an interview conducted at 10:48 a.m. on (MONTH) 16, (YEAR), Social Services staff (staff #13) stated she has not been providing resident's notices of room or roommate changes. She stated that maybe the admissions coordinator or administrator were notifying the residents. During an interview conducted at 11:27 a.m. on (MONTH) 16, (YEAR), the Admissions Director (staff #128) stated a form is filled out by staff informing a resident when moving, and staff notify the resident who is receiving a new roommate. She stated that several different staff members are involved, such as nurses and CNAs. During an interview conducted at 11:51 a.m. on (MONTH) 16, (YEAR), a CNA (staff #16) stated that when she is told a new resident is going to be admitted , she prepares the room and lets the resident know they are getting a new roommate. She stated if the resident who resides in the room is not present when the room is prepped, she may tell the resident if she sees them in the hall, but she may leave before the resident returns. She further stated that she does not provide any written notice to the resident who is residing in the room, nor does she document if she informs the resident regarding the new roommate. A review of the Room/Roommate Change Notification policy and procedure revealed, The facility shall notify a resident and/or the resident's representative when there is a change in room or roommate. The policy also included For a resident who is receiving a new roommate, staff should give the resident as much notice and information about the new individual as possible, while maintaining confidentiality regarding medical information .and Documentation of a room/roommate change is recorded in the resident's clinical record either in Progress Notes or on the Room/Roommate Change Notification form.",2020-09-01
225,SANTA RITA NURSING & REHABILITATION CENTER,35073,150 NORTH LA CANADA DRIVE,GREEN VALLEY,AZ,85614,2017-03-17,278,D,0,1,RY2C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that one resident's (#11) Minimum Data Set (MDS) assessment was coded correctly regarding [MEDICAL TREATMENT]. Findings include: Resident #11 was admitted to the facility on (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. The admission nursing assessment dated (MONTH) 19, (YEAR) included documentation that the resident had a double lumen catheter for [MEDICAL TREATMENT]. Review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. However, review of the admission MDS assessment dated (MONTH) 26, (YEAR) revealed the resident was not coded as receiving [MEDICAL TREATMENT] in Section O: Special Treatments, Procedures, and Programs. An interview was conducted with an MDS coordinator (staff #33) at 10:05 a.m. on (MONTH) 16, (YEAR). She stated that when she is coding the MDS assessment for [MEDICAL TREATMENT], she looks in the clinical record to see if the resident is receiving [MEDICAL TREATMENT] services and if they are, she codes this in the MDS. She stated that this resident was receiving [MEDICAL TREATMENT] services at the time of the assessment and that it was missed and was coded incorrectly. In an interview with the operations director (staff #148) at 11:20 a.m. on (MONTH) 16, (YEAR), she stated that the facility does not have any policy in regards to MDS accuracy and instead they follow the RAI manual. Review of the RAI manual revealed that the importance of accurately completing and submitting the MDS cannot be overemphasized. The MDS is the basis for the development of an individualized care plan. Further, Federal regulations require that the assessment accurately reflects the resident's status. The RAI manual indicates that [MEDICAL TREATMENT] which occurs at the facility or another facility should be coded on the MDS assessment.",2020-09-01
226,SANTA RITA NURSING & REHABILITATION CENTER,35073,150 NORTH LA CANADA DRIVE,GREEN VALLEY,AZ,85614,2017-03-17,281,E,0,1,RY2C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, interviews and policy and procedures, the facility failed to ensure that an interim care plan was developed for one resident (#325) with an indwelling urinary catheter, failed to ensure a physician's order was followed for one resident (#399) regarding wound treatment, and failed to ensure one resident's (#341) pain medication was administered per the physician's order. Findings include: -Resident #325 was admitted to the facility on (MONTH) 7, (YEAR), with [DIAGNOSES REDACTED]. Review of the Admission Nursing Review dated from (MONTH) 7, (YEAR) revealed the resident was admitted with an indwelling urinary catheter. Review of the Bowel and Bladder Evaluation dated from (MONTH) 8, (YEAR) revealed the resident was alert and confused, required 1-2 person assistance with activities of daily living, and required total assistance with catheter care. A physician's order received on (MONTH) 13, (YEAR) included for catheter care to be performed every day and evening shift. However, upon admission there were no physician's order for the catheter or for the size of the catheter and there were no orders regarding how often to change the catheter. Review of the clinical record revealed an interim care plan with a section to document catheter size, justification and interventions, such as catheter care. However, this section of the interim care plan was left blank. An interview was conducted with a floor nurse (registered nurse/staff #144) on (MONTH) 17, (YEAR) at 8:28 a.m. She stated that this resident has a Foley catheter for obstructive [MEDICAL CONDITION] and if the resident has a catheter, it should be in their care plan. Review of the facility policy regarding care plan development revealed the interdisciplinary team shall develop a comprehensive, individualized plan of care for each resident that is in accordance with State and Federal regulations and professional standards for nursing care. The policy indicated that after completing the admission nursing assessment, nursing will use the information available to develop an interim care plan, within 24 hours of admission. -Resident #339 was admitted to the facility on (MONTH) 26, (YEAR), with [DIAGNOSES REDACTED]. A nursing progress note dated (MONTH) 26, (YEAR), revealed the resident was admitted to the facility for a left total hip arthroplasty. A physician's order was written on (MONTH) 26, (YEAR), which included to cleanse the left hip with wound cleanser and apply an island dressing daily in the morning for infection prevention. However, review of the resident's Treatment Administration Record (TAR) for (MONTH) (YEAR) showed no documentation that the resident received the wound treatment on (MONTH) 29. Review of the progress notes for this date also showed no documentation that the treatment had been administered. An interview was conducted on (MONTH) 15, (YEAR) at 3:14 p.m. with the Licensed Practical Nurse (LPN/staff #34), who was working with this resident on (MONTH) 29. She stated she remembered the resident and was aware of the daily dressing treatments, however, she did not know why the documentation for (MONTH) 29 was not completed. She further stated that if the dressing was not done for some reason, it should have been documented in the progress notes. In an interview with the Director of Nursing (DON/staff #70) on (MONTH) 15, (YEAR) at 1:28 p.m., she confirmed that the area on the TAR where the treatment should have been documented for (MONTH) 29 was blank. -Resident #341 was admitted to the facility on (MONTH) 21, (YEAR), with [DIAGNOSES REDACTED]. Review of an interim care plan dated (MONTH) 21, (YEAR), revealed a problem area of uncontrolled pain, related to disease process. One of the approaches included to medicate for pain. A physician's order dated (MONTH) 25, (YEAR) revealed for [MEDICATION NAME]-[MEDICATION NAME] 5-325 (narcotic pain medication) give 1 tablet by mouth every 4 hours as needed for mild to moderate pain (1-6) and give 2 tablets by mouth every 4 hours as needed for severe pain (7-10). According to the Medication Administration Record for (MONTH) (YEAR), the resident was administered [MEDICATION NAME]-[MEDICATION NAME] one tablet on (MONTH) 26 at 12:12 p.m. The area on the MAR for documenting the resident's pain level was not completed. However, the corresponding Nurses Notes documented that the resident was administered one tablet of [MEDICATION NAME]-[MEDICATION NAME] at 12:12 p.m. for a pain level of 8. A physician's note dated (MONTH) 28, (YEAR), included a late entry which stated .Currently patient is progressing but in much discomfort in the pelvic area still. Further review of the (MONTH) (YEAR) MAR revealed [MEDICATION NAME]-[MEDICATION NAME] one tablet was administered at 9:53 p.m. on (MONTH) 28, with no documentation of the resident's pain level prior to administering. Review of the corresponding Nurses Notes revealed that [MEDICATION NAME]-[MEDICATION NAME] one tablet was administered at 9:53 p.m. on (MONTH) 28, for a pain level of 7. The admission Minimum Data Set (MDS) assessment dated (MONTH) 28, (YEAR), included a Brief Interview for Mental Status score of 15, which indicated that the resident was cognitively intact. The MDS included the resident was receiving routine and as needed pain medications. The MDS further included the resident was interviewed and stated that the pain was almost constant, made it hard to sleep, and limited day to day activities. Per this assessment, the resident reported her worst pain was rated at 10, out of a 1-10 pain scale (with 10 being the worst pain possible). Continued review of the (MONTH) (YEAR) MAR revealed [MEDICATION NAME]-[MEDICATION NAME] one tablet was administered at 9:12 a.m. on (MONTH) 29, with no documentation that the resident's pain was assessed prior to administering. A review of the corresponding Nurses Notes revealed [MEDICATION NAME]-[MEDICATION NAME] one tablet was administered at 9:12 a.m. on (MONTH) 29, for a pain level of 7. The (MONTH) (YEAR) MAR further revealed that [MEDICATION NAME]-[MEDICATION NAME] one tablet was administered at 10:22 a.m. on (MONTH) 31, for a pain level of 7. Another physician's order dated (MONTH) 1, (YEAR) included for [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg, give one tablet by mouth every 4 hours as needed for mild to moderate pain of 1-6, and give two tablets by mouth every 4 hours as needed for severe pain of 7-10. The MAR for (MONTH) (YEAR) revealed [MEDICATION NAME]-[MEDICATION NAME] one tablet was administered as follows: (MONTH) 2 at 9:39 p.m. for a pain level of 8; (MONTH) 3 at 3:03 a.m. for pain level of 7 and on (MONTH) 5 at 9:31 p.m. for a pain level of 7. Further review of the clinical record revealed no documentation explaining why the resident was administered one tablet of [MEDICATION NAME]-[MEDICATION NAME] on multiple occasions, when the physician's order was for two tablets to be administered for a pain level between 7-10. According to the clinical record documentation, the resident was discharged home on (MONTH) 11, (YEAR). During a telephone interview conducted at 12:15 p.m. on (MONTH) 14, (YEAR), the former resident (resident #341) stated that her pain medication had not been administered per the physician's orders multiple times during her stay in the facility. During an interview conducted at 9:25 a.m. on (MONTH) 15, (YEAR), the Assistant Director of Nursing (staff #129) stated a nurse administering the medication outside of the physician ordered parameters, should document if the resident refused two tablets and requested only one tablet and should also call the physician to inform them of the resident's refusal to take the medication as ordered. During an interview conducted at 1:45 p.m. on (MONTH) 15, (YEAR), a licensed practical nurse (staff #34) stated if a nurse administers one [MEDICATION NAME]-[MEDICATION NAME] tablet for a pain level of 7-10 when the order for one tablet indicates it was to be given for a pain of 1-6 and two tablets for a pain level of 7-10, the nurse would need to document why, such as the resident was offered two tablets and refused one. The nurse also stated that a resident's pain is assessed on a scale of 1 to 10, with 1-6 being mild to moderate pain and 7-10 being severe pain. During an interview conducted at 1:55 p.m. on (MONTH) 15, (YEAR), the Director of Nursing (staff #70) stated that if one tablet of [MEDICATION NAME]-[MEDICATION NAME] was administered when the resident's pain assessment indicated that two tablets should be administered, the nurse would have to document the reason why the medication was not administered, per the physician's order. A review of the Medication Management policy and procedure revealed the Nurses shall follow the Five Rights of Medication Administration which includes the right dose. The policy also included A resident's refusal to take a prescribed medication shall be documented on the MAR by indicating refused at the scheduled time.",2020-09-01
227,SANTA RITA NURSING & REHABILITATION CENTER,35073,150 NORTH LA CANADA DRIVE,GREEN VALLEY,AZ,85614,2017-03-17,329,D,0,1,RY2C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews and policy review, the facility failed to ensure each resident's drug regimen was free of unnecessary drugs, by failing to ensure physician's orders [REDACTED].#339) and by failing to ensure one resident's (#341) pain level was assessed, prior to administering narcotic pain medication. Findings include: -Resident #339 was admitted to the facility on (MONTH) 26, (YEAR), with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. The documentation showed that on two occasions on (MONTH) 1, the resident was administered 2 tablets of [MEDICATION NAME] for a pain level of 7. In an interview with a Licensed Practical Nurse (LPN/staff #2) on (MONTH) 16, (YEAR) at 12:58 p.m., she stated that if a resident is reporting pain, a pain assessment is done and depending on what their level or severity of pain is, the corresponding PRN (as needed) pain medication will be administered. Staff #2 stated that if the resident requests a medication that is outside of the parameters set by the order, it is to be documented in the notes, and the physician should be notified. In an interview with the Director of Nursing (DON/staff #70) on (MONTH) 15, (YEAR) at 1:28 p.m., she stated that it is the expectation of the nurses to give the pain medications within the ordered parameters, unless the resident requests something different and then it would be documented. Review of a facility policy titled, Medication Management revealed that nurses should follow the Five Rights of Medication Administration, which include the right dose. -Resident #341 was admitted to the facility on (MONTH) 21, (YEAR), with [DIAGNOSES REDACTED]. Review of an interim care plan dated (MONTH) 21, (YEAR), revealed a problem area of uncontrolled pain, related to disease process. One of the approaches included to assess for signs and symptoms of pain. A physician's orders [REDACTED]. According to the Medication Administration Record [REDACTED] However, review of the clinical record including the MAR indicated [REDACTED]. The admission Minimum Data Set (MDS) assessment dated (MONTH) 28, (YEAR), included a Brief Interview for Mental Status score of 15, which indicated that the resident was cognitively intact. The MDS included the resident was receiving routine and as needed pain medications. The MDS further included the resident was interviewed and stated that the pain was almost constant, made it hard to sleep, and limited day to day activities. Per this assessment, the resident reported her worst pain was rated at 10, out of a 1-10 pain scale (with 10 being the worst pain possible). According to the clinical record documentation, the resident was discharged home on (MONTH) 11, (YEAR). During an interview conducted at 1:45 p.m. on (MONTH) 15, (YEAR), a licensed practical nurse (staff #34) stated that a resident's pain is to be assessed on a scale of 1 to 10, with 1-6 being mild to moderate pain and 7-10 being severe pain. Review of the Pain Management policy revealed when administering a PRN (as needed) pain medication, the resident's pain level (using the 0-10 pain scale) before the medication is given, is to be documented.",2020-09-01
228,SANTA RITA NURSING & REHABILITATION CENTER,35073,150 NORTH LA CANADA DRIVE,GREEN VALLEY,AZ,85614,2017-03-17,371,E,0,1,RY2C11,"Based on observations, staff interviews, and policy review, the facility failed to ensure that two juice dispenser nozzles were thoroughly cleaned on a regular basis. Findings include: The initial kitchen observation was conducted at 10:30 a.m. on (MONTH) 13, (YEAR). At this time, a dark, slimy substance was observed on the two juice machine nozzles. A follow-up kitchen observation was conducted at 9:00 a.m. on (MONTH) 15, (YEAR). The same juice dispensers were observed and the dark slimy substance was still present on the inside of both nozzles. An interview was conducted with the dietary manager (staff #114) at 9:15 a.m. on (MONTH) 15, (YEAR). She stated that the dispensers are cleaned every night and soaked in hot water. She stated that the nozzles were not able to be removed to clean the inside of the juice dispenser. A surveyor then demonstrated how to remove the nozzles from the juice dispensers. Staff #114 stated that she was unaware that these nozzles could be removed for cleaning. She stated there was a slimy substance stuck in the base of the nozzles and that it should be sanitized right away. Another interview was conducted with staff #114 on (MONTH) 15, (YEAR) at 11:45 a.m. She stated that there is a weekly cleaning schedule for the entire kitchen. She stated that she assigns someone to do certain tasks and then posts the schedule on the wall in the kitchen, so employees know what they are supposed to clean. She stated that once they complete the assigned tasks, each employee must sign and date the form on the wall, so she can see that the tasks have been done. She stated that cleaning the juice dispenser nozzles was not a task on the cleaning schedule. She stated the task of removing the nozzles and soaking the juice dispenser heads in hot water and sanitizer, will be added to the cleaning list once a week to ensure they get cleaned properly. An interview was conducted with corporate compliance (staff #148) on (MONTH) 16, (YEAR) at 9:33 a.m. She stated that the facility does not have a policy specific to cleaning the juice dispensers or nozzles, but that the milk dispenser policy contains the same procedure as what they would use to clean the juice machine. Review of the milk dispenser policy and procedure revealed that the dispensers should be cleaned at least once each week, and that the dispenser heads should be removed and dismantled, washed in a detergent solution, rinsed and let dry. The policy also revealed that the interior of the dispenser should be washed and rinsed during weekly cleaning.",2020-09-01
229,SANTA RITA NURSING & REHABILITATION CENTER,35073,150 NORTH LA CANADA DRIVE,GREEN VALLEY,AZ,85614,2018-05-11,609,D,0,1,ZHPK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policies and procedures, the facility failed to report allegations of neglect to the State Agency involving one resident (#369). Findings include: Resident #369 was admitted on (MONTH) 12, (YEAR), with [DIAGNOSES REDACTED]. Review of an admission MDS (Minimum Data Set) assessment dated (MONTH) 19, (YEAR), revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15, which indicated intact cognition. The MDS also assessed the resident with moderate depression and had no [MEDICAL CONDITION] or behavioral concerns. A Health Status note dated (MONTH) 22, (YEAR) included the county sheriff appeared at the facility in response to a call made by a family member of the resident. The family member alleged that the resident was being neglected and wanted the resident transported to the hospital. The family member alleged that the resident was found asleep in her wheelchair and was leaning on a table after a meal, and that was unacceptable. The family member was at the facility at the time the sheriff arrived and the resident was transported to the hospital and was not readmitted to the facility. A Health Status Note dated (MONTH) 24, (YEAR) revealed the facility had notified Adult Protective Services regarding the events that took place on (MONTH) 22, (YEAR). Administrative staff were unable to provide any documentation that the State Agency was notified of the allegation of neglect. An interview was conducted with the Administrator (staff #43) and the Director of Operations (staff #94) on (MONTH) 9, (YEAR) at 9:48 a.m. Staff #94 stated that Adult Protective Services had been called, as there was an open case involving the resident and the family member, but the facility did not call the State Agency to report the allegation of neglect made by the family member. Staff #43 and #94 stated that the State Agency should have been notified. A review of the facility policy regarding reporting allegations of abuse and neglect revealed it is the responsibility of all employees to immediately report any suspected or alleged violations of abuse, neglect, injuries of unknown source, exploitation and misappropriation of resident property. Such violations are also reported to State agencies in accordance with existing State Law. Per the policy, the facility investigates each alleged violation thoroughly and reports the results of the investigation to the State agencies as required by State and Federal law. The policy defined neglect as the failure of the facility, its' employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility will take appropriate steps to ensure that all suspected or alleged violations which involve mistreatment, neglect, abuse, injuries of unknown source, exploitations and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation is made, to the Administrator and to other officials including the State Survey Agency and Adult Protective Services.",2020-09-01
230,SANTA RITA NURSING & REHABILITATION CENTER,35073,150 NORTH LA CANADA DRIVE,GREEN VALLEY,AZ,85614,2018-05-11,637,E,0,1,ZHPK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, facility documentation and policy review and the RAI (Resident Assessment Instrument) manual, the facility failed to ensure a Significant Change in Status Assessment (SCSA) was completed for one resident (#8) within the required timeframe. Findings include: Resident #8 was admitted on (MONTH) 28, (YEAR) with [DIAGNOSES REDACTED]. The hospice care plan dated (MONTH) 3, (YEAR) revealed that resident was on hospice care related to [DIAGNOSES REDACTED]. A health status note dated (MONTH) 11, (YEAR) included that resident was discharged from skilled stay and will stay at the facility on hospice. The hospice physician order [REDACTED]. The hospice plan of care update report dated (MONTH) 11, (YEAR) included this date as the start date. The current care plan dated (MONTH) 13, (YEAR) included resident was with hospice services. Interventions included working cooperatively with hospice team. The hospice social worker note dated (MONTH) 13, (YEAR) included that the resident was admitted to hospice. However, continued review of the clinical record revealed that there was no SCSA MDS Assessment completed until (MONTH) 1, (YEAR). The SCSA assessment dated (MONTH) 1, (YEAR) revealed that under Section O - Special Treatments, hospice was coded. In an interview with the MDS (Minimum Data set) Coordinator (staff # 44) conducted on (MONTH) 11, (YEAR) at 9:35 a.m., she stated that a SCSA assessment is completed when the resident goes on hospice within 14 days of the order for hospice. She said that she follows the RAI manual in coding for the MDS. She stated the hospice order for resident #8 was missed and she does not know how and why the communication between staff related to the hospice order was not relayed. She further stated the SCIC assessment related to hospice order was only completed on (MONTH) 1, (YEAR). The RAI manual instructed that SCSA is required to be performed when resident enrolls in hospice program. Further, the RAI instructed that the ARD (Assessment Reference Date) must be within 14 days from the effective date of hospice election.",2020-09-01
231,SANTA RITA NURSING & REHABILITATION CENTER,35073,150 NORTH LA CANADA DRIVE,GREEN VALLEY,AZ,85614,2018-05-11,640,B,0,1,ZHPK11,"Based on clinical record review, review of MDS (Minimum Data Set) assessment transmission documentation, and staff interview, the facility failed to ensure that the discharge MDS assessments were transmitted within 14 days of completion for four residents (#2, #3 and #4). Findings include: Resident # 2 was admitted admitted on (MONTH) 1, (YEAR) and discharged on (MONTH) 11, (YEAR). A review of the MDS transmittal information revealed that the MDS discharge assessment was completed on (MONTH) 11, (YEAR), however, there was no documentation that it had been successfully submitted/transmitted. Resident #3 was admitted on (MONTH) 21, (YEAR). A review of the resident's clinical record revealed documentation that the resident expired in the facility on (MONTH) 21, (YEAR). A discharge MDS assessment dated (MONTH) 31, (YEAR), documented that the resident had expired in the facility and that the assessment was complete, however there was no documentation that it had been successfully submitted/transmitted. Resident #4 was admitted (MONTH) 16, (YEAR) and discharged on (MONTH) 23, (YEAR). A review of the MDS transmittal information revealed that the MDS discharge assessment was completed on (MONTH) 23, (YEAR), however there was no documentation that it had been successfully submitted/transmitted. An interview was conducted with the MDS coordinator/staff #44 on (MONTH) 10, (YEAR) at 10:23 a.m. Staff #44 reviewed the MDS transmittal data for residents #2, #3, and #4 and stated that the MDS's had not been transmitted within 14 days of completion, stating further that it must have been an over sight. Staff #44 stated that MDS assessments were to be submitted within 14 days of completion. A review of the the CMS (Center for Medicare/Medicaid Services) RAI (Resident Assessment Instrument) 3.0 manual revealed documentation of instructions regarding transmittal of the discharge assessment and death in the facility assessment. The assessments were to be transmitted within 14 days of completion.",2020-09-01
232,SANTA RITA NURSING & REHABILITATION CENTER,35073,150 NORTH LA CANADA DRIVE,GREEN VALLEY,AZ,85614,2018-05-11,686,G,0,1,ZHPK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, facility documentation, and policy review, the facility failed to provide the necessary treatment and services to promote healing for one resident (#6) with pressure ulcers. Findings include: Resident #6 was admitted on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. Regarding the coccyx (sacrum) pressure ulcer: Review of the admission nursing assessment dated (MONTH) 1, (YEAR) revealed the resident had an open ulcer to the coccyx. However, the documentation did not include any measurements, any description of the wound bed and surrounding skin, or if any drainage or odor was present. The assessment also did not include the stage of the ulcer, or if this wound was the unstageable pressure ulcer to the sacrum or a different wound. The admission nursing note dated (MONTH) 2, (YEAR) included that the coccyx area was red with an 8 x 10 cm area of open tissue. There is no documentation of an unstageable pressure ulcer to the sacrum. The skin care plan dated (MONTH) 2, (YEAR) included a potential for skin breakdown/pressure ulcers related to decreased mobility. The care plan included the resident had an unstageable pressure ulcer to the sacrum. Interventions included following the skin protocol, pressure reducing mattress and turning and repositioning as needed. An NP (nurse practitioner) note dated (MONTH) 2, (YEAR) included the resident had skin breakdown to the coccyx, secondary to friction spasms and pressure. The note included the resident had spastic [MEDICAL CONDITION]. The note did not include that the resident had an unstageable pressure ulcer to the sacrum, nor any description of the coccyx area. Review of the admission physician's orders [REDACTED]. A nursing progress note dated (MONTH) 4, (YEAR) revealed the resident had redness to the coccyx area. A physician's orders [REDACTED]. However, this order was not transcribed onto the TAR (Treatment Administration Record) for February, as a result there was no documentation that the treatment was done on (MONTH) 4, as ordered. Further review revealed that this order was discontinued on (MONTH) 5, (YEAR). A nursing progress note dated (MONTH) 5, (YEAR) revealed the resident had an unstageable decubitus ulcer to the coccyx, with interventions that included turning/repositioning and use of an alternating mattress. A physician's orders [REDACTED]. According to the Skin/Wound Note dated (MONTH) 5, (YEAR), the resident was admitted with an unstageable pressure injury to the sacrum, which measured 5 cm x 5 cm, and the wound bed had 80% slough with 20% pink tissue, and had blanchable redness in the periwound. This was the first documentation of a description of the wound bed and measurements. The note also included that the wound was cleansed with wound cleanser and that Puracol was applied. Review of the Weekly Skin and Pain Assessment note dated (MONTH) 6, (YEAR), revealed an unstageable ulcer to the coccyx and that treatment continued. The documentation did not include any measurements of the coccyx pressure ulcer, a description of the wound bed or surrounding skin, if there was any tunneling or undermining, or if there was any drainage or odor present. A nursing progress note dated (MONTH) 7, (YEAR) revealed an unstageable pressure ulcer to the coccyx, which had 75% slough. Per the note, an [MEDICATION NAME] dressing was in place and to continue treatment. An NP note dated (MONTH) 9, (YEAR) included that the coccyx was examined and the pressure ulcer was noted to be small. The Weekly Skin and Pain Assessment note dated (MONTH) 13, (YEAR) included there was blanchable redness to the coccyx. There was no mention of an unstageable pressure ulcer to the sacrum. The NP note dated (MONTH) 16, (YEAR) revealed skin breakdown to the coccyx. No further description was included. Per the Skin/Wound note dated (MONTH) 16, (YEAR), the resident had an unstageable pressure injury to the sacrum, which measured 5 x 4.8 cm, had 80% slough and 20% pink tissue to the wound bed, and blanchable redness to the peri-wound. Per the documentation, the wound was cleansed with wound cleanser and Puracol was applied. The note did not include if any tunneling, undermining, drainage or odor were present. This wound was measured 11 days after the previous assessment (on (MONTH) 5). A nursing progress note dated (MONTH) 19, (YEAR) revealed the treatment of [REDACTED]. The Weekly Skin and Pain Assessment note dated (MONTH) 20, (YEAR) revealed the coccyx wound had 80% yellow slough and treatments continued. The assessment did not include the stage of the pressure ulcer, any wound measurements, a description of the surrounding skin, or if any tunneling, undermining, drainage or odor were present. The nursing progress note dated (MONTH) 21, (YEAR) revealed the pressure ulcer to the coccyx continued to receive treatment of [REDACTED]. The Skin/Wound note dated (MONTH) 23, (YEAR) revealed the resident had an unstageable pressure injury to the sacrum which measured 4.6 cm x 4.5 cm, with 50% slough and 50% pink tissue, and blanchable redness to the peri-wound. Per the documentation, the wound was cleansed with wound cleanser and Puracol was applied. A nursing progress note dated (MONTH) 27, (YEAR) included redness to the coccyx area. Review of the Skin/Wound note dated (MONTH) 27, (YEAR) revealed the resident had a pressure ulcer to the coccyx, which was covered with slough and that a treatment was in place. The note did not include the stage of the pressure ulcer, any wound measurements, a description of the surrounding skin, or if any tunneling, undermining, drainage or odor were present. A nursing progress note dated (MONTH) 28, (YEAR) included the resident had a pressure ulcer to the coccyx and that treatments continued. Despite documentation that treatments with Puracol and [MEDICATION NAME] continued to the coccyx, the physician's orders [REDACTED]. Therefore, there was no consistent documentation that the physician ordered treatment was provided as ordered from (MONTH) 5 through 28, (YEAR). The Weekly Skin & Pain Assessment note dated (MONTH) 2, (YEAR) included an unstageable pressure ulcer to the sacrum, which measured 4.5 cm x 4.5 cm. A physician's orders [REDACTED]. This order was transcribed onto the TAR for (MONTH) (YEAR) and was first administered on (MONTH) 3. The Skin/Wound note dated (MONTH) 2, (YEAR) revealed the resident had an unstageable pressure injury to sacrum which measured 4.6 cm x 4.5 cm, with 50% slough and 50% pink tissue, and blanchable redness to the peri-wound. Per the documentation, the wound was cleansed with wound cleanser and applied with Puracol. A physician's orders [REDACTED]. A nursing progress note dated (MONTH) 9, (YEAR) included an unstageable pressure injury to the sacrum, which measured 4.2 cm x 4 cm, with 50% slough and 50% pink tissue on the wound bed, and blanchable redness to the peri-wound. However, the Weekly Skin & Pain Assessment note dated (MONTH) 9, (YEAR) revealed the resident had an unstageable pressure injury to the sacrum which measured 4.6 cm x 4.5 cm. The Weekly Skin and Pain Assessment note dated (MONTH) 10, (YEAR) included the resident had an open area to the coccyx. This assessment did not include the type of the wound, any measurement, description of the wound bed, surrounding skin, presence/absence of tunneling, drainage or odor. According to a NP note dated (MONTH) 16, (YEAR), the resident had a stage II pressure ulcer to the coccyx, which measured 2 cm x 2 cm. A physician's orders [REDACTED]. The Skin/Wound note dated (MONTH) 20, (YEAR) included an unstageable pressure injury to the sacrum which measured 3.5 cm x 3.5 cm, with 80% slough and 20% pink tissue on wound bed and blanchable redness to the peri-wound. A pressure ulcer care plan dated (MONTH) 22, (YEAR) included the resident had multiple pressure injuries and was at risk for further pressure injury development. Interventions included the following: -Administer treatments as ordered -Assess/record/monitor wound healing every week -Assess and document status of wound perimeter, wound bed, healing progress, and report improvements and declines to the physician -Weekly treatment documentation to include measurement of each area of skin breakdown to include the width, length, depth, type of tissue and exudate. The Weekly Skin & Pain Assessment note dated (MONTH) 24, (YEAR) revealed the sacrum as the site of the skin condition. However, the documentation also described the skin condition as an open area to the coccyx. The documentation did not include any measurements, description of the wound bed, surrounding skin, or the presence/absence of tunneling, drainage or odor. A physician's progress note dated (MONTH) 4, (YEAR) included no skin breakdown. However, the assessment documentation included a pressure ulcer to the sacral region with unspecified stage. The Skin/Wound note dated (MONTH) 5, (YEAR) included the resident had an unstageable pressure injury to the sacrum which measured 3.2 cm x 2.8 cm, with 80% slough and 20% pink tissue on the wound bed, and with blanchable redness to the peri-wound. Per the documentation, the wound was cleansed with wound cleanser and an alginate dressing. The Skin/Wound note dated (MONTH) 11, (YEAR) included the unstageable pressure injury to the sacrum had 100% slough, a pinpoint opening, and blanchable redness to the periwound. The note also included the slough was debrided by the wound physician and that the wound now measured 2 cm x 3 cm x 2 cm with 3 cm undermining from 10 o'clock to one o'clock. The wound was classified as a stage IV pressure injury. The note included the wound was cleansed with wound cleanser, [MEDICATION NAME] (antibiotic) was crushed and sprinkled onto the wound base, alginate was applied, and the wound was covered with [MEDICATION NAME]. A physician's note dated (MONTH) 11, (YEAR) revealed the resident had a stage IV pressure ulcer in the coccygeal lower spinal area and that the stage IV pressure ulcer to the sacrococcygeal area had non-viable tissue fat and deeper subcutaneous tissues, with lots of odor after removal of necrotic tissue. The note included the depth was 1 1/2 cm but did not include any other measurements. Review of a physician's orders [REDACTED]. The Weekly Skin and Pain assessment note dated (MONTH) 14, (YEAR), included the resident had wound injuries to the coccyx. The Weekly Skin and Pain assessment note dated (MONTH) 21, (YEAR), revealed the coccyx wound had a foul odor. The Weekly Skin and Pain assessment note dated (MONTH) 28, (YEAR), revealed the coccyx wound had tunneling and copious drainage. The Weekly Skin and Pain Assessment note dated (MONTH) 5, (YEAR), included the coccyx wound had tunneling and was under treatment. Further review of the Weekly Skin and Pain Assessment notes dated (MONTH) 14, 21, 28 and (MONTH) 5, (YEAR), revealed the notes did not include the wound type, any measurements, any description of the wound bed or surrounding skin, or if there was any tunneling, undermining, drainage or odor. Review of the TAR revealed the alginate dressing treatment to the coccyx was provided as ordered from (MONTH) 1, (YEAR) through (MONTH) 7, (YEAR). The Skin/Wound notes dated (MONTH) 19, 27 and (MONTH) 2, (YEAR), revealed the sacrum Stage IV pressure ulcer had undermining from 10 o'clock to one o'clock and that the treatment was provided as ordered. Regarding the right and left ischial tuberosity pressure ulcers: The Skin/Wound note dated (MONTH) 21, (YEAR), revealed the wound to the right ischial tuberosity was assessed by the wound physician as SDTI (suspected deep tissue injury) and measured 4.0 cm x 4.5 cm. The note also included interventions to replace the ischial step with the coccyx cutout pressure cushion with a roho wheelchair cushion. A physician's note dated (MONTH) 21, (YEAR), revealed the right ischial area was a deep tissue pressure injury and that the left ischium wound was blanchable. The note included that these 2 new wounds are not from lying down but are from the resident spending time in his wheelchair. Also included in the note was that the resident continued to be challenged nutritionally so a better turning schedule or weight redistribution must be put in place. The Weekly Skin & Pain Assessment note dated (MONTH) 24, (YEAR), did not include the right ischial tuberosity SDTI. Review of the Skin/Wound note dated (MONTH) 29, (YEAR), revealed the right ischial tuberosity SDTI measured 4.3 cm x 4.5 cm and had a dark purple wound bed. The note did not include the left ischial tuberosity wound. Review of the clinical record revealed no evidence that treatment was initiated and provided to these newly identified wounds from (MONTH) 21, (YEAR) through (MONTH) 4, (YEAR). A physician's note dated (MONTH) 4, (YEAR), revealed the resident continued to have issues with bilateral ischial pressure injuries. The Skin/Wound note dated (MONTH) 5, (YEAR), revealed the right ischial tuberosity wound was now classified as unstageable and measured 5 cm x 4.5 cm, with 80 % slough and dark purple edges. The note also included a deep tissue injury to the left ischial tuberosity which measured 4.0 cm x 3.0 cm, with dark purple wound bed and blanchable redness to the periwound. However, the note did not include whether the wounds had tunneling, drainage, or odor. A physician's orders [REDACTED]. Review of the TAR dated (MONTH) (YEAR), revealed the treatment was provided as ordered. A physician note dated (MONTH) 11, (YEAR), included the unstageable pressure ulcer to the left ischial area. The Weekly Skin & Pain Assessment note dated (MONTH) 14, (YEAR), included the wound injuries to the left and right ischial tuberosity areas, but did not include the wound classification, measurements, wound bed and surrounding skin descriptions, or whether there was tunneling, drainage, or odor. Review of the physician's note dated (MONTH) 25, (YEAR), revealed the unstageable pressure ulcer to the right and left ischial tuberosity were the same as the right and left buttocks pressure ulcers. This was the first documentation found in the clinical record that the wounds were the same. Regarding the buttocks wounds: The Weekly Skin & Pain assessment dated (MONTH) 7, (YEAR), revealed an opened area to the left buttock and the right gluteal fold. Review of the clinical record revealed no evidence these wounds were assessed, monitored or provided treatments from (MONTH) 7 through (MONTH) 24, (YEAR). The physician note dated (MONTH) 25, (YEAR), revealed the first documentation that the unstageable pressure ulcer to the right and left buttocks were the same as the right and left ischial tuberosity pressure ulcers. Regarding the left ankle: The Weekly Skin & Pain Assessment note dated (MONTH) 10, (YEAR), revealed an unstageable pressure sore to the left outer ankle. However, the note did not include measurements, a description of the wound bed and the surrounding skin, or whether there was drainage, tunneling, or odor. Review of the physician's note dated (MONTH) 16, (YEAR), did not include an unstageable pressure ulcer to the left ankle. Further review of the clinical record revealed no evidence that the physician was notified about the left ankle wound or that an order for [REDACTED].>Additional review of the clinical record revealed no evidence that the left ankle wound was assessed from (MONTH) 10, (YEAR) through (MONTH) 20, (YEAR). The Weekly Skin & Pain Assessment note dated (MONTH) 21, (YEAR), revealed the wound to the left inner ankle (which was different from what was previously identified) was red and nonblanchable. The note did not include measurements, a description of the wound bed and surrounding skin, or whether there was drainage, tunneling, or odor. The physician's note dated (MONTH) 25, (YEAR), included documentation regarding other wounds but did not include any documentation related to the left ankle wound. Review of the Weekly Skin & Pain Assessment note dated (MONTH) 27, (YEAR), revealed a discolored left inner ankle area (which was different from what was previously identified) with black eschar and red non-blanchable areas. The Skin/Wound note dated (MONTH) 2, (YEAR), did not include documentation regarding the left ankle wound. The physician's note dated (MONTH) 2, (YEAR), did not include documentation regarding the left ankle wound. A Weekly Skin & Pain Assessment note dated (MONTH) 5, (YEAR), revealed the left inner ankle area had black eschar and open areas and that treatment was being provided. However, there was no evidence found in the clinical record that treatment was provided to the left inner ankle wound from (MONTH) 10, (YEAR) through (MONTH) 7, (YEAR). Further review of the clinical record did not reveal any evidence that the physician was notified of the left inner ankle wound or that an order was obtained for treatment. Review of a physician's note dated (MONTH) 9, (YEAR), revealed documentation regarding vascular wounds but did not include documentation regarding the left ankle wound. During interviews conducted on (MONTH) 9, (YEAR) at 9:17 a.m. with a licensed practical nurse (LPN/staff #38), registered nurse (RN/wound nurse staff #72), and the wound specialist/physician (staff #164), staff #38 stated that the resident was admitted with some of the wounds and that the resident had been consistently non-compliant with positioning. Staff #164 stated the wounds on the left foot were vascular wounds and that the consulting vascular surgeon recommended amputation but the resident declined. Staff #164 further stated that the wounds to the left foot were identified as vascular because there was no blood supply to the areas and even though the areas could be pressure points, the wounds were not considered pressure ulcers. At this time, the wound nurse (staff #72) stated the wounds to the left foot had been documented as pressure ulcers. Staff #164 stated the wounds are vascular related and not pressure related due to the lack of blood flow and vascular problems. Staff #164 later stated the wound on the back side of the ischium is clearly a stage IV pressure ulcer and the wounds to the right and left ischium are unstageable pressure ulcers. During a wound observation conducted (MONTH) 9, (YEAR) at 10:05 a.m. with the wound nurse (staff #72) the following wounds were observed: -Back side of the ischium/sacrum - Staff #72 stated the resident was admitted with this wound. She stated it was a stage IV pressure ulcer measuring 2 cm x 2 cm x 1.5 cm with 3.3 cm undermining from 11 o'clock to 1 o'clock, no odor, clean wound bed, and blanchable periwound. -Left Ischial Area -Staff #72 stated that it was an unstageable pressure ulcer acquired at the facility maybe 2-3 months ago. She stated that the wound measurements were 2 cm x 2.8 cm, there was 100% slough, and the area around the periwound was blanchable with slight redness. -Right Ischial Area- Staff #72 stated that it was an unstageable pressure ulcer that measured 6 cm x 6 cm with tunneling at 2.1. She stated there was thick adhering slough to 90% of the wound and that the periwound was blanchable with slight odor. An interview was conducted with an RN (staff #130) on (MONTH) 10, (YEAR) at 2:19 p.m. She stated that for a resident admitted with a pressure ulcer she will document a description of the wound in the nursing progress notes including any drainage and measurements but that she cannot stage the wound. She stated that she would apply padded foam dressing if there is no treatment order and will notify the physician and the wound nurse and that they will assess the pressure ulcer right away or the next day. She stated that she would implement interventions like offloading, a mattress, and Prafo boot. She stated a weekly assessment is conducted and documented every week but will not include the measurement of the wound because the wound nurse does the measurements. Staff #130 also stated the wound nurse documents on a separate progress note and ensures that all pressure ulcers are identified and documented in the clinical record. During an interview conducted on (MONTH) 10, (YEAR) at 3:27 p.m. with the RN/wound nurse (staff #72) she stated the nurses report to her any wound that they have identified and that she will assess the wound the same day. She stated that she will document the wound including the stage and measurement in the progress note, initiate treatment, and notify the provider. She stated pressure injuries are measured weekly. She also stated the nurses can describe the wound and measure the wound but that they cannot stage the wound. The wound nurse stated that when there is a discrepancy regarding the location of a pressure ulcer wound, she will clarify the accurate location with the nurse. Staff #72 stated that resident #6 has the following pressure injuries: Stage IV pressure ulcer to the sacrum, unstageable pressure ulcer to the right ischial, and an unstageable pressure ulcer to the left ischial. She stated that the resident did not have any wounds on the buttocks but that the ischial areas can be identified as buttocks wound by the floor nurses because of the location. She further stated that she discovered the resident had a wound to the left ankle during the treatment observation on (MONTH) 8, (YEAR) and that the wound specialist has classified the wound as vascular. Another interview was conducted with staff #72 on (MONTH) 11, (YEAR) at 9:01 a.m. She stated that she documented a sacral wound and the NP documented a coccyx wound, and that could be why the nurses are documenting coccyx. The wound nurse stated the treatment to the unstageable right ischial pressure ulcer was not initiated until (MONTH) 5, (YEAR). She stated this was because the wound was an unopened SDTI when it was identified on (MONTH) 21, (YEAR). The wound nurse had no answer as to why treatment was initiated to an unopened SDTI to the left ischium on (MONTH) 5, (YEAR), the day that wound was identified. She also stated that the documentation indicated the treatment was provided to the coccyx but that there was no documentation that treatment was provided to the sacrum until (MONTH) 13, (YEAR). An interview was conducted with the Director of Nursing (DON/staff #139) on (MONTH) 11, (YEAR) at 10:39 a.m. He stated that when a certified nurse assistant (CNA) discovers an area on a resident's skin, the CNA is expected to notify the nurse who is expected to evaluate the area and initiate treatment to protect the wound. He stated the nurse is expected to notify the physician and the wound nurse. The DON stated the wound nurse will assess the wound, classify the wound, and initiate treatment in conjunction with the physician. He stated if there are discrepancies with the identification, location, or treatment of [REDACTED]. The DON stated the wound nurse provides him a weekly report of all the wounds in the facility. The facility's policy regarding Skin/Wound Care Protocol included that a skin care program will be maintained to assess all residents for their risk for skin breakdown and/or the development of pressure ulcers and to promote and/or maintain skin integrity. The goal is to maintain skin integrity and provide guidelines for skin care. It also included that pressure ulcers shall be staged in accordance with the National Pressure Ulcer Advisory Panel Pressure Ulcer Staging Definitions.",2020-09-01
233,SANTA RITA NURSING & REHABILITATION CENTER,35073,150 NORTH LA CANADA DRIVE,GREEN VALLEY,AZ,85614,2018-05-11,695,E,0,1,ZHPK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, clinical record review, facility documentation and policy review, the facility failed to ensure that respiratory care was provided to two residents (#8 and #46) in accordance professional standards of practice. Findings include: -Resident #8 admitted on (MONTH) 28, (YEAR) with [DIAGNOSES REDACTED]. The respiratory care plan dated (MONTH) 13, (YEAR) included resident has altered respiratory status related to effects of [MEDICAL CONDITION], poor oxygen saturations and dependence on supplemental oxygen. Interventions included administration of medications as ordered and to provide humidified oxygen via nasal cannula per order. Under Section O-Special treatment of [REDACTED]. Active [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set) assessment dated (MONTH) 1, (YEAR) revealed resident had an active [DIAGNOSES REDACTED]. The hospice physician narrative note dated (MONTH) 6, (YEAR) revealed resident had a [DIAGNOSES REDACTED]. The TAR (Treatment Administration Record) for (MONTH) and (MONTH) (YEAR) revealed a transcribed order for oxygen at 2 LPM (liters per minute) via nasal cannula to keep oxygen saturation above 90%. There was no physician order for [REDACTED]. Continued review of the clinical record revealed no evidence that oxygen care to include oxygen tubing/cannula/humidification change was conducted. During an observation conducted on (MONTH) 8, (YEAR) at 9:02 a.m., the resident had oxygen on via nasal cannula at 2 LPM (liters per minute). There was no date on the oxygen tubing and humidification/concentrator. In an interview with the Director of Nursing (DON/staff #139) conducted on (MONTH) 10, (YEAR) at 1:08 p.m., he stated the nurses assess the residents and ask the physician for oxygen orders based on the findings on assessment. he said that oxygen care is something that the nurses just do and this include checking the oxygen, tubing and oxygen flow frequently during the shift. He said that the CNAs (certified nurse assistant) also check and replace the water in the oxygen concentrator and if it needed to be change will inform the nurse. He said that the central supply staff conducts every 2 weeks sweep which includes changing oxygen tubing but the facility does not have a tracking mechanism for this. On a later interview with staff #139 at 1:20 p.m., he stated that the oxygen concentrator is cleaned weekly and tubing is changed weekly. He also provided a copy of the Concentrator Maintenance Log form and stated that the facility maintains this log. However, in an interview with the central supply (staff #71) conducted simultaneously with staff #139(was present the whole time during this interview), staff #71 stated that she does not have any logs to show that the oxygen concentrator filters were cleaned and oxygen tubing/cannulas and face masks were changed. She stated that she had disposed of them last month because nobody had ever asked for the log and she thought it was not important. In an interview with a registered nurse (RN/staff #130) conducted on (MONTH) 10, (YEAR) at 2:19 p.m., she stated oxygen care included checking that the oxygen concentrator is turned on, the humidifier water bottle is full and oxygen tubing is changed by the CNA every week. However, she said that oxygen care is not documented anywhere in the clinical record and the staff just do it. The policy on Oxygen Concentrator/ Equipment Cleaning & Disinfecting stated that In order to prevent infection, Oxygen Equipment and Concentrators will be cleaned and disinfected using the following guidelines: -Oxygen concentrator will be cleaned and disinfected weekly) -Oxygen tubing and cannulas/masks will be changed every two weeks per manufacturer's guidelines. When tubing is changed, it will be marked with the change date. -Central supply will maintain a log with cleaning and disinfecting schedules. The Concentrator Maintenance Log included that concentrator filters will be cleaned weekly; and tubing, cannulas, face mask and bubbler will be changed every two weeks. It further stated the date these items are changed will be noted . and these items will also be marked with the date -Resident #46 was admitted on (MONTH) 6, 2005 and has current [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment dated (MONTH) 11, (YEAR) included that the resident had Brief Interview of Mental Status (BIMS) score of 13, which indicated that the resident was cognitively intact. The MDS assessment also included that the resident received oxygen therapy. The last nursing progress note related to oxygen use dated (MONTH) 20, (YEAR) showed that the resident had an oxygen level of 97% on 2 liters via nasal cannula. A written care plan revised on (MONTH) 28, (YEAR) shows oxygen use is included. The goal for the resident was to be free from respiratory distress through next review. An intervention included to monitor for signs and symptoms of fluid excess (e.g. respiratory status for dyspnea (shortness of breath), moist cough or excessive secretions). Review of (MONTH) and (MONTH) (YEAR) physician orders revealed Oxygen via nasal cannula @ 2 liters for Pulse Ox equal or less than 90% as needed and to check readings every shift for a [DIAGNOSES REDACTED]. Review of the (MONTH) (YEAR) Treatment Administration Records (TAR) for resident #46, the original physician order for [REDACTED].>May (YEAR) nursing notes were reviewed regarding oxygen and show that resident was currently receiving oxygen, but there was no documentation showing the oxygen tubing and/or humidifier was changed. During a resident interview and observation on (MONTH) 7, (YEAR) at 2:39 p.m. resident was using oxygen via nasal cannula. The oxygen tubing and humidifier was not dated and the humidifier was not hooked up to the oxygen concentrator and cannula. Another observation on (MONTH) 10, (YEAR) at 11:30 a.m. showed that resident #46 continued to be on oxygen via nasal cannula and the tubing and humidifier again were not date labeled. An interview was conducted on (MONTH) 10, (YEAR) at 8:30 a.m. with Central Supply (staff #71). She stated she rounds on the entire building every two weeks to replace oxygen tubing, nebulizer masks, inspects concentrator filters (machine has an alarm that sounds when it is time to clean and replace them), and service or replace as necessary. An interview was conducted on (MONTH) 10, (YEAR) at 8:35 a.m. with a Certified Nursing Assistant (CNA/Staff #165). She stated she inspects the P[NAME] humidifier bottles on any resident who is using an oxygen concentrator when she is providing resident care. If the humidifier bottle is low on water, she will add sterile water as necessary. On (MONTH) 10, (YEAR) at 9:31 a.m., an interview was conducted with Licensed Practical Nurse (LPN/staff #85). She stated that staff #71 maintains the resident's oxygen tubing. She stated that she is unsure of the schedule to change the tubing but that the CNA has a responsibility to change tubing and humidifier when needed, such as when humidifier is almost gone or if they see the oxygen tubing is damaged or dirty. On (MONTH) 10, (YEAR) at 10:33 a.m., an interview was done with Licensed Practical Nurse (LPN/staff #2). She stated that resident #46 is using oxygen for comfort and gets confused sometimes. She has had pneumonia that flares up with only symptoms of increased confusion. Staff #2 stated that the CNAs take care of oxygen tubing and humidifiers as needed, but staff #71 changes the oxygen tubing on all concentrators and humidifiers every 2 weeks for the entire building. Another interview was conducted on (MONTH) 10, (YEAR) at 10:44 a.m. with staff #71. She stated she changes oxygen tubing and humidifiers every other week, says sometimes on a different scheduled day, but is always done within the every two weeks as required. She showed the documents that she uses when documenting the tubing changes throughout the facility. She stated that currently she throws away the monthly documentation of when the tubing and humidifiers are changed, and that there is no where else to look to see what day the tubing had been changed. She stated that she will be keeping the documentation starting this month and will learn to scan it in to Point Click Care so she will not have to keep the physical paper. Another interview was conducted on (MONTH) 10, (YEAR) at 11:56 a.m. with staff #2. She stated that staff #71 would be the person to talk to regarding the schedule of the tubing changes. She also stated that if the nurses needed to verify when the tubing had been changed, they would verbally ask staff #71. Staff #2 stated she was unaware of where the tubing changes would be documented. Another interview on (MONTH) 10, (YEAR) at 12:04 p.m. with Staff #71, she stated that Staff #94, who still works here, gave her the schedule for the tubing changes of every two weeks and is unaware of how the scheduled was determined or created. She stated that staff #94 is Director of Operations and to check with her. On (MONTH) 10, (YEAR) at 12:13 p.m., an interview was conducted with staff #94, Director of Operations. She stated that the current tubing change schedule was established by another employee who looked up the manufacturer guidelines of changing the tubing, and that it was established at least five years ago. She stated that on the facility policy states that the oxygen tubing is to be changed every two weeks per manufacturers guidelines and the change date written on the tubing. She stated that there is also a tracking sheet for central supply to write down the residents that this is done for. The Director of Nursing (DON/staff #139), was interviewed on (MONTH) 10 at 1:07 p.m. He stated that oxygen orders are given on an individual basis for each patient, usually requested by the facility for how many liters and titration up or down as needed. If oxygen is ordered and if resident needs a humidifier, as standard with concentrator, it gets checked each shift by the clinician going into the room; nurse or CNA, and they can replace humidifier if needed. Staff #139 stated central supply does a sweep of the facility every 2 weeks to replace all oxygen tubing, between the 2 weeks. Tubing changes are not tracked at this time because he does not want tasks that are redundant to be given to clinicians and take away time to provide patient care. He stated he does not oversee the central supply tasks, and there is no system that he is aware of to document tubing changes. He stated he is unaware of any literature stating a 2 week sweep has to be done, meaning all tubing is changed. He will check with central supply to see where she documents the tubing changes. On (MONTH) 10, (YEAR) at 1:20 p.m., staff # 139 stated he made a mistake and restated the tube changes were done weekly. With staff #139 present, staff #71 said she threw away the oxygen tubing changes tracking logs because nobody has asked for them and does not have a log showing the tubing was changed. At this point, the DON instructed her to keep a log from now on and that he would teach her how to scan it in to the records. Review of the facility's policy regarding oxygen titled Oxygen Concentrator/ Equipment Cleaning & Disinfecting included that Central Supply will change oxygen tubing and cannula or masks every two weeks per manufacturer guidelines. When tubing is changed, it will be marked with the change date. Disposable humidifiers will be changed every two weeks, with the change date written on the humidifier. Central Supply will maintain a log with cleaning and disinfecting schedules.",2020-09-01
234,SANTA RITA NURSING & REHABILITATION CENTER,35073,150 NORTH LA CANADA DRIVE,GREEN VALLEY,AZ,85614,2019-07-31,607,D,1,1,PYJ811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews and review of policies and procedures, the facility failed to implement their Abuse policy, by failing to thoroughly investigate an allegation of abuse for one sampled resident (#127). The deficient practice could result in inaccurate findings and possible abuse not being identified. Findings include: Resident #127 was admitted on (MONTH) 1, 2019, with [DIAGNOSES REDACTED]. An admission MDS (Minimum Data Set) dated (MONTH) 8, 2019 included the resident had severe cognitive impairment and required extensive assistance from one staff for personal hygiene and total assistance from two staff for bathing. A written plan of care initiated on (MONTH) 17, 2019 included that resident #127 had an ADL (Activities of Daily Living) deficit related to a stroke. The care plan included that resident #127 required extensive assistance of one to two staff, with bathing and showering. A nurse's note dated (MONTH) 21, 2019 at 4:37 p.m. included that staff had followed up on an allegation that multiple staff were taking videos of the resident's privates during multiple bathing episodes and displaying them on the TV screen in the resident's room. The resident was unable to describe any of the staff and the abuse allegation was unsubstantiated. A social services note dated (MONTH) 21, 2019 at 4:47 p.m. included that during a care conference, a family member mentioned the resident had stated people are taking pictures of my private area. The note included that when staff spoke to the resident he was unable to provide detailed information and would take extensive periods of time to answer a question, which resulted in a very brief answer with not much information. The note also included that the social worker had contacted the State Agency, the Sheriff's Department and APS, and that the alleged incident was being investigated. Review of a facility report regarding this incident dated (MONTH) 22, 2019, revealed that on (MONTH) 21, 2019 in the afternoon (no time specified), the resident stated to a family member that People are taking pictures of my private area. The report included the resident was interviewed by the Social Service Director and the DON (Director of Nursing) and stated that several people were recording him while bathing. Resident #127 was unable to identify or describe any specific staff, and that he pointed to a wall and then to a television. The report also included two staff members to provide care for resident at all times, due to resident unable to identify staff members. Further review of the report revealed no evidence that additional staff or other residents had been interviewed related to this investigation. An interview was conducted on (MONTH) 29, 2019 at 12:55 p.m. with the Director of Social Services (staff #92). Staff #92 stated that she had participated in the investigation for resident #127 on (MONTH) 21, 2019. Staff #92 stated that resident #127 was confused and was unable to name or describe any staff members who he said had photographed him. Staff #92 stated that because the resident could not identify or describe any specific staff, there were no other staff or resident interviews conducted for this investigation. An interview was conducted on (MONTH) 30, 2019 at 1:52 p.m. with the Director of Nursing (staff #43), who stated that when she or designated staff investigate alleged abuse, they are to interview the resident and any additional residents who may have been in the area, and interview staff who may have worked in the area at the time. Staff #43 said that interviews are documented and should be included with the investigation. Staff #43 stated that resident #127 was interviewed regarding the allegations and repeatedly changed details regarding the allegation. Staff #43 acknowledged that the resident did receive assistance from staff during showers and may have been referring to staff taking his picture while in the shower. Staff #43 further stated that additional residents and staff were not interviewed for the investigation, because the allegation was so absurd it was unbelievable. Review of a facility policy titled, Abuse Prevention revealed to take appropriate steps to prevent the occurrence of abuse and exploitation. The policy stated that staff are prohibited from taking or using photographs or recordings in any manner that would demean or humiliate a resident. The policy further included the facility investigates each alleged violation thoroughly and reports the results of all investigations to the Administrator or his/her designee, as well as to State agencies as required by State and Federal law. The investigation may include interviews of employees, visitors and/or residents who may have knowledge of the alleged incident as appropriate, and shall include the names of witnesses to the alleged or suspected violation.",2020-09-01
235,SANTA RITA NURSING & REHABILITATION CENTER,35073,150 NORTH LA CANADA DRIVE,GREEN VALLEY,AZ,85614,2019-07-31,610,D,1,1,PYJ811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews and review of policies and procedures, the facility failed to thoroughly investigate an allegation of abuse for one sampled resident (#127). The deficient practice could result in inaccurate findings and possible abuse not being identified. Findings include: Resident #127 was admitted on (MONTH) 1, 2019, with [DIAGNOSES REDACTED]. An admission MDS (Minimum Data Set) dated (MONTH) 8, 2019 included the resident had severe cognitive impairment and required extensive assistance from one staff for personal hygiene and total assistance from two staff for bathing. A written plan of care initiated on (MONTH) 17, 2019 included that resident #127 had an ADL (Activities of Daily Living) deficit related to a stroke. The care plan included that resident #127 required extensive assistance of one to two staff, with bathing and showering. A nurse's note dated (MONTH) 21, 2019 at 4:37 p.m. included that staff had followed up on an allegation that multiple staff were taking videos of the resident's privates during multiple bathing episodes and displaying them on the TV screen in the resident's room. The resident was unable to describe any of the staff and the abuse allegation was unsubstantiated. A social services note dated (MONTH) 21, 2019 at 4:47 p.m. included that during a care conference, a family member mentioned the resident had stated people are taking pictures of my private area. The note included that when staff spoke to the resident he was unable to provide detailed information and would take extensive periods of time to answer a question, which resulted in a very brief answer with not much information. The note also included that the social worker had contacted the State Agency, the Sheriff's Department and APS, and that the alleged incident was being investigated. Review of a facility report regarding this incident dated (MONTH) 22, 2019, revealed that on (MONTH) 21, 2019 in the afternoon (no time specified), the resident stated to a family member that People are taking pictures of my private area. The report included the resident was interviewed by the Social Service Director and the DON (Director of Nursing) and stated that several people were recording him while bathing. Resident #127 was unable to identify or describe any specific staff, and that he pointed to a wall and then to a television. The report also included two staff members to provide care for resident at all times, due to resident unable to identify staff members. Further review of the report revealed no evidence that additional staff or other residents had been interviewed related to this investigation. An interview was conducted on (MONTH) 29, 2019 at 12:55 p.m. with the Director of Social Services (staff #92). Staff #92 stated that she had participated in the investigation for resident #127 on (MONTH) 21, 2019. Staff #92 stated that resident #127 was confused and was unable to name or describe any staff members who he said had photographed him. Staff #92 stated that because the resident could not identify or describe any specific staff, there were no other staff or resident interviews conducted for this investigation. An interview was conducted on (MONTH) 30, 2019 at 1:52 p.m. with the Director of Nursing (staff #43), who stated that when she or designated staff investigate alleged abuse, they are to interview the resident and any additional residents who may have been in the area, and interview staff who may have worked in the area at the time. Staff #43 said that interviews are documented and should be included with the investigation. Staff #43 stated that resident #127 was interviewed regarding the allegations and repeatedly changed details regarding the allegation. Staff #43 acknowledged that the resident did receive assistance from staff during showers and may have been referring to staff taking his picture while in the shower. Staff #43 further stated that additional residents and staff were not interviewed for the investigation, because the allegation was so absurd it was unbelievable. Review of a facility policy titled, Abuse Prevention revealed to take appropriate steps to prevent the occurrence of abuse and exploitation. The policy stated that staff are prohibited from taking or using photographs or recordings in any manner that would demean or humiliate a resident. The policy further included the facility investigates each alleged violation thoroughly and reports the results of all investigations to the Administrator or his/her designee, as well as to State agencies as required by State and Federal law. The investigation may include interviews of employees, visitors and/or residents who may have knowledge of the alleged incident as appropriate, and shall include the names of witnesses to the alleged or suspected violation.",2020-09-01
236,SANTA RITA NURSING & REHABILITATION CENTER,35073,150 NORTH LA CANADA DRIVE,GREEN VALLEY,AZ,85614,2019-07-31,641,D,0,1,PYJ811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the discharge Minimum Data Set (MDS) assessment for 1 of 3 sampled residents (#78) was accurate. The deficient practice could result in inaccuracies within the resident's clinical record. Findings include: Resident #78 was admitted to the facility on April, 25, 2019, with a [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of the nursing discharge summary dated (MONTH) 14, 2019 revealed documentation that the resident was discharged to home. However, review of the MDS discharge assessment dated (MONTH) 14, 2019, revealed documentation that resident #78 was discharged to an acute hospital. An interview was conducted with the MDS Coordinator (staff#71) on (MONTH) 31, 2019 at 8:59 a.m. Staff #71 stated that resident #78 was discharged home. After reviewing the MDS discharge assessment, staff #71 stated the resident did not go to an acute hospital and that the coding was incorrect. Review of the RAI manual revealed to review the resident's clinical record for documentation of the discharge location. The RAI manual also included that it is required that the assessment accurately reflects the resident's status and that the importance of accurately completing and submitting the MDS assessment cannot be over emphasized.",2020-09-01
237,FRIENDSHIP VILLAGE OF TEMPE,35074,2525 EAST SOUTHERN AVENUE,TEMPE,AZ,85282,2019-01-31,640,E,0,1,ESGI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interview, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure MDS (Minimum Data Set) assessments were transmitted to the CMS (Centers for Medicare and Medicaid Services) QIES ASAP (Quality Improvement Evaluation System Assessment Submission and Processing) system for 4 residents (#s 2, 3, 4, and 5). Findings include: Review of the QIES ASAP system revealed the last submitted MDS assessments for the following residents were over 120 days old. -Resident #2 was readmitted on (MONTH) 3, 2014 with [DIAGNOSES REDACTED]. Review of the QIES ASAP system revealed the last MDS assessment submitted was a quarterly MDS assessment dated (MONTH) 22, (YEAR). -Resident #3 was admitted on (MONTH) 30, 2013 with [DIAGNOSES REDACTED]. Review of the QIES ASAP system revealed the last MDS assessment submitted was an annual MDS assessment dated (MONTH) 22, (YEAR). -Resident #4 was admitted on (MONTH) 19, (YEAR) with [DIAGNOSES REDACTED]. Review of the QIES ASAP system revealed the last MDS assessment submitted was a SNF PPS (Skilled Nursing Facility Prospective Payment System) Part A Discharge (End of Stay) assessment dated (MONTH) 11, (YEAR). -Resident #5 was admitted on (MONTH) 9, (YEAR) with [DIAGNOSES REDACTED]. Review of the QIES ASAP system revealed the last MDS assessment submitted was a SNF PPS Part A Discharge (End of Stay) assessment dated (MONTH) 26, (YEAR). An interview was conducted with the MDS coordinator (staff #122) on 01/31/19 at 11:02 AM. The MDS coordinator stated that assessments had been completed for the 4 residents but that they were not submitted to the QIES ASAP system. She stated that she would submit the assessments immediately. After reviewing the RAI manual, the MDS coordinator admitted MDS assessments have to be submitted for a resident whose Medicare Part A stay has ended and the resident remains in a Medicare certified bed. The RAI manual instructs a discharge assessment is required if the resident is transferred from a Medicare-certified bed to a noncertified bed and is required if the resident's Medicare Part A stay ends, but the resident remains in the facility. The manual included when a resident's Medicare Part A stay ends but he/she remains in the facility in a Medicare certified bed with another payer source, the facility must continue with the OBRA (Omnibus Budget Reconciliation Act) schedule from the resident's original date of admission and must also complete a Part A PPS discharge assessment. The manual also included if the end date of the most recent Medicare stay occurs on the day of or one day before the discharge date , the OBRA discharge assessment and Part A PPS discharge assessment are both required and may be combined. The manual instructs MDS assessments must be transmitted (submitted and accepted into the MDS database) electronically no later than 14 calendar days after the MDS assessment completion date.",2020-09-01
238,FRIENDSHIP VILLAGE OF TEMPE,35074,2525 EAST SOUTHERN AVENUE,TEMPE,AZ,85282,2019-01-31,684,D,1,1,ESGI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, and policy and procedures, the facility failed to ensure that one resident (#176) received diuretic medication as per a physician's recommendation. Findings include: Resident #176 was admitted to the facility on (MONTH) 20, (YEAR) with [DIAGNOSES REDACTED]. Per the resident's weight record documented on (MONTH) 21, (YEAR), the resident weighed 154 pounds. The admission MDS (Minimum Data Set) assessment dated (MONTH) 27, (YEAR) revealed the resident scored a 13 on the BIMS (Brief Interview for Mental Status), indicating he was cognitively intact. Nursing notes from (MONTH) 28 through (MONTH) 31, (YEAR) indicated that the resident had bruising and [MEDICAL CONDITION] to his right arm and had been encouraged to elevate it. Also noted, the resident had swelling of BLE (Bilateral Lower Extremities). There was no evidence that the physician was notified of the resident's [MEDICAL CONDITION]. A physician's progress note dated (MONTH) 31, (YEAR) revealed no comment regarding the resident's BLE [MEDICAL CONDITION]. The physician recommended that the resident's right arm be elevated while in bed. Per the resident's weight record documented on (MONTH) 31, (YEAR), the resident's weight was 160.8 pounds. This was a 6.8 pound increase in 10 days. Nursing notes from (MONTH) 1 through 5, (YEAR) continued to document that the resident had [MEDICAL CONDITION] of BLE and the right arm. On (MONTH) 5, the nursing notes documented that the resident's right foot did not fit into his brace that was used for foot drop because his foot was too swollen. The resident was noted to be scheduled for a nephrologist appointment on (MONTH) 6, (YEAR). Review of the progress note from the nephrology appointment dated (MONTH) 6, (YEAR) revealed the resident was seen for follow-up and evaluation for CKD. The note stated that the [MEDICAL CONDITION] of the resident's lower extremity was much worse. The instructions the nephrologist provided were to start treating the resident with [MEDICATION NAME] (a diuretic, also known as [MEDICATION NAME]). The medication list from the nephrologist included an order dated (MONTH) 6, (YEAR) for [MEDICATION NAME] 40 milligrams (mg) per day. The resident's physician at the facility signed his initials at the bottom of the page. Review of the physician orders [REDACTED]. A nursing progress note dated (MONTH) 8, (YEAR) stated the resident's foot brace did not fit because of foot swelling. Review of the MAR (Medication Administration Record) for (MONTH) 1 through 17, (YEAR) revealed that [MEDICATION NAME] was not administered. Review of the resident's care plan revealed no evidence that the resident's [MEDICAL CONDITION] had been addressed. Per the resident's weight record documented on (MONTH) 17, (YEAR), the resident's weight was 160.4 pounds, indicating that the resident's weight was 6.4 pounds higher than on admission. A nursing progress note dated (MONTH) 17, (YEAR) reported that the resident had [MEDICAL CONDITION] to BLE and also had a new order for [MEDICATION NAME]. A physician's orders [REDACTED]. Review of the (MONTH) MAR indicated [REDACTED]. The resident's weight documented on (MONTH) 21, (YEAR) was 149 pounds which is about 10 pounds of weight loss after the [MEDICATION NAME] was ordered. An interview was conducted on (MONTH) 30, 2019 at 08:32 a.m. with an RN (Registered Nurse/staff #165). She stated that when a resident goes to an appointment, the nurse will fill out a form that includes what time the resident left the facility, what time they return, who they went to see, and how they were transported. She said that when the resident returns, they usually have a progress note that they give to staff. She said that if the resident does not have any notes, either the unit clerk or a nurse will call the doctor's office in case there are new medication orders or other changes to the resident's care that need to be implemented. Staff #165 stated she wasn't working on the day of the appointment in question and that she wasn't familiar with the information concerning the [MEDICATION NAME]. An interview was conducted on (MONTH) 30, 2019 at 09:16 a.m. with an RN (staff #209). She stated that she usually checks for resident appointments on the computer first thing in the morning on the days she works. She said that when a resident returns to the facility from an appointment, she reviews the paperwork to see if there are any new medication orders or changes to medications. She said she would then follow-up with the physician to report these changes. She said that regarding a resident with BLE [MEDICAL CONDITION] or with a brace that wasn't fitting because of [MEDICAL CONDITION], she would check the resident's weight and notify the physician of these issues to determine if the physician wanted to implement interventions or reassess the resident. Staff #209 also stated she was not working on the day of the resident's appointment and did not know what happened with the recommendation for [MEDICATION NAME]. On (MONTH) 31, 2019 at 12:39 p.m. the DON (Director of Nursing/staff #10) was interviewed. She stated that when a resident has an outside appointment, her expectation is that the resident will return with paperwork from the appointment and that if they do not, there would be a phone call to the the physician's office so that any recommendations can be sent to the facility. She said that this information would then be shared with the resident's physician who would then be responsible to respond to the recommendation. In response to why the [MEDICATION NAME] was not given per the nephrologist's order, she said that it is up to the physician's discretion whether or not to implement any recommendations and write and sign any new orders. An interview was conducted with the resident's physician (staff #255) on (MONTH) 31, 2019 at 3:07 p.m. He stated that he did see the note from the nephrologist that was dated (MONTH) 7, (YEAR) and that he did sign his initials to the note on (MONTH) 8, (YEAR), but that he must have missed the information regarding the [MEDICATION NAME] order from the nephrologist. He stated that he remembered that the resident's arm sling was too tight, but that he believed the resident had come from the hospital with it that way. He stated that he does remember thinking about [MEDICATION NAME] use for this resident, but did not implement this at the time. The facility policy on transcription of physician orders [REDACTED]. Upon completion of a physician order [REDACTED]. This ensures all steps have been completed.",2020-09-01
239,OSBORN HEALTH AND REHABILITATION,35076,3333 NORTH CIVIC CENTER PLAZA,SCOTTSDALE,AZ,85251,2017-07-13,281,D,1,0,8G3D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interviews and reviews of clinical records, the facility failed to ensure two narcotic pain medications were clarified to include differing parameters for use for one resident (#6.) The sample size was one of three. Findings include: -Resident #6 was readmitted to the facility on (MONTH) 4, (YEAR), with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. Further review of the physician's orders [REDACTED]. A review of the Medication Administration Record [REDACTED]. A review of the quarterly Minimum Data Set assessment dated (MONTH) 16, (YEAR), revealed the resident's Brief Interview for Mental Status score was 15. A score of 15 indicates the resident was cognatively intact. During an interview conducted at 3:00 p.m. on (MONTH) 12, (YEAR), a licensed practical nurse (staff #104) stated she sometimes administers to the resident the medication he requests when there are two medications ordered for pain that have the same parameters. During an interview conducted at 9:10 a.m. on (MONTH) 13, (YEAR), a registered nurse (staff #74) stated that upon admission, when a physician's orders [REDACTED]. The nurse stated that it was necessary so that both narcotic medications could not be administered at the same time or within the same time period She further stated that if both medications were administered very close together, it could result in an adverse consequence. During an interview conducted on (MONTH) 13, (YEAR), the Director of Nursing (staff #83) stated that the admitting nurse should call and obtain parameters for use when more than one medication was ordered for pain.",2020-09-01
240,OSBORN HEALTH AND REHABILITATION,35076,3333 NORTH CIVIC CENTER PLAZA,SCOTTSDALE,AZ,85251,2017-07-13,329,E,1,0,8G3D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interviews and reviews of clinical records, the facility failed to ensure one resident (#6) was not administered two narcotic pain medications per the physician's orders [REDACTED]. Findings include: -Resident #6 was readmitted to the facility on (MONTH) 4, (YEAR), with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set assessment dated (MONTH) 16, (YEAR), revealed the resident's Brief Interview for Mental Status score was 15. A score of 15 indicates the resident was cognatively intact. A review of the physician's orders [REDACTED]. Both oxycondone HCI and [MEDICATION NAME] sulfate are narcotic medications used to treat moderate to severe pain. A review of the clinical record revealed that between (MONTH) 20 and (MONTH) 12, (YEAR), [MEDICATION NAME] sulfate was administered three time for pain of 6, and [MEDICATION NAME] was administered ten times for pain of 7 or 8. A review of the Has acute/chronic pain care plan initiated on (MONTH) 29, (YEAR), revealed an intervention of Follow pain scale to medicate as ordered. During an interview conducted at 3:00 p.m. on (MONTH) 12, (YEAR), a licensed practical nurse (staff #104) stated she sometimes administers to the resident the medication the resident requests when there are two medications ordered for pain. However, she also stated the [MEDICATION NAME] sulfate should not have been administered for a pain level of 6, because the physician's orders [REDACTED]. During an interview conducted at 9:10 a.m. on (MONTH) 13, (YEAR), a registered nurse (staff #74) stated narcotic pain medication should only be administered per the physician's orders [REDACTED]. During an interview conducted on (MONTH) 13, (YEAR), the Director of Nursing (staff #83) stated the nurses were responsible for administering the medications per the physician's orders [REDACTED]. [REDACTED]. Further, review of the medical record revealed no evidence the physician was contacted prior to the administrations of [MEDICATION NAME] and [MEDICATION NAME] sulfate outside the parameters for the use per the physician's orders [REDACTED]. A review of the Medication Administration policy and procedure revealed the nurse should always ensure the medication being administered was the right medication per the physician's orders [REDACTED].>",2020-09-01
241,OSBORN HEALTH AND REHABILITATION,35076,3333 NORTH CIVIC CENTER PLAZA,SCOTTSDALE,AZ,85251,2016-09-21,242,D,0,1,3XMR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, family and staff interviews, facility documentation and policy and procedures, the facility failed to ensure one resident (#251) was provided daily showers, as requested per their interest. Findings include: Resident #251 was admitted to the facility on (MONTH) 2, (YEAR), with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 9, (YEAR), revealed a Brief Interview for Mental Status score of 3, which indicated the resident has severe cognitive impairment. The MDS also included the resident required extensive assistance, with personal hygiene and bathing. During an interview conducted at 11:26 a.m. on (MONTH) 16, (YEAR), the resident's family member stated the resident had requested daily showers and that they had informed staff of the resident's request. The family member stated the resident was initially receiving daily showers, but was no longer receiving them daily. An interview was conducted at 1:15 p.m. on (MONTH) 19, (YEAR), with another family member who stated that the resident had requested a shower daily. On (MONTH) 19, (YEAR), the Shower Book located at the nurses station was reviewed and the resident was scheduled to receive a shower daily. However, review of the computerized Bathing Record from (MONTH) 10 through 19, (YEAR), revealed the resident did not receive a shower, full-body bath, or sponge bath on (MONTH) 10, 13, 14, 15, 16, or 18, (YEAR). Review of the Activities of Daily Living care plan revealed that it was revised on (MONTH) 19, (YEAR) to include the following approach: BATHING: Resident requires, assistance with bathing/showering two times a week and as necessary. During an interview conducted at 1:02 p.m. on (MONTH) 19, (YEAR), a certified nursing assistant (CNA/staff #105) was asked if the resident had received a shower this morning. The CNA said no. She stated only one room number was listed on the dry erase board at the nurses station. She explained that the dry erase board was a list of residents who were to be given a shower. During an interview conducted at 1:07 p.m. on (MONTH) 19, (YEAR), a registered nurse (staff #42) stated that since the resident's admission, the resident's family has requested the resident receive daily showers, in the mornings before breakfast. The nurse also stated that she believed the CNA was aware that the resident was suppose to receive a shower daily. During an interview conducted on (MONTH) 19, (YEAR), the Director of Nursing stated the resident would be provided with two showers a week, and would receive daily showers when possible. A review of the ADL, Services to Carry Out policy revealed If a resident is unable to carry out activities of daily living, the necessary services to maintain good nutrition, grooming, and personal oral hygiene will be provided by qualified staff. The policy also included that residents will be involved in decision making and given choices related to ADL activities as much as possible, and that bathing will be offered at least twice weekly and PRN (as needed) per resident request.",2020-09-01
242,OSBORN HEALTH AND REHABILITATION,35076,3333 NORTH CIVIC CENTER PLAZA,SCOTTSDALE,AZ,85251,2016-09-21,281,D,0,1,3XMR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the clinical record, staff interview, and policy review, the facility failed to ensure that an interim care plan was developed to address the use of an indwelling urinary catheter for one resident (#80). Findings include: Resident #80 was admitted on (MONTH) 13, (YEAR), for surgical aftercare. The resident's [DIAGNOSES REDACTED]. Review of the admission physician's orders [REDACTED]. However, review of the resident's care plans revealed that there was no interim care plan which had been developed upon admission to address the resident's needs related to urinary catheter use. An interview was conducted on (MONTH) 19, (YEAR) at 3:00 p.m., with the previous Director of Nursing (DON/staff #125) who was present in the facility to assist the current DON. She stated that she or the assistant director of nursing would have been responsible to develop the interim care plan. Following a review of the clinical record, she confirmed that an interim care plan had not been developed upon admission. Staff #125 stated that the interim care plan should have been developed within the first 24 hours or the next business day. At this time, she stated that she was unable to explain why the interim care plan had not been developed. A facility policy titled, Care Planning included the following: 2. The resident's care plan will be initiated within 24 hours of admission.",2020-09-01
243,OSBORN HEALTH AND REHABILITATION,35076,3333 NORTH CIVIC CENTER PLAZA,SCOTTSDALE,AZ,85251,2016-09-21,431,D,0,1,3XMR11,"Based on observation, staff interview and policy review, the facility failed to ensure that appropriate temperatures were maintained in a medication storage refrigerator. Findings include: A medication storage observation was conducted on (MONTH) 20, (YEAR) at 9:00 a.m., on the 100 nursing unit. The medication storage refrigerator temperature log was posted on the outside of the refrigerator. Instructions on the log included to maintain the temperature at less than 41 degrees F. (Fahrenheit), however, it did not include a recommendation for the lowest acceptable temperature. Further review of the log from (MONTH) 1 through 20 revealed that on 16 days, the refrigerator temperatures were documented between 20 and 35 degrees F. Although the temperature log included a comment column, there was no documentation of any corrective action that was implemented, due to the low temperatures. At this time, the thermometer which was located inside of the refrigerator, indicated that the current temperature was 22 degrees F. Located inside of the refrigerator were the following injectable medications, along with the manufacturer's instructions for the proper storage of the medications: [REDACTED] -One unopened vial of Novolin R insulin: the manufacturer's instructions included to store in the refrigerator between 36 and 46 degrees F. and do not freeze. -One vial of Tuberculin Purified Protein Derivative (Mantoux): the manufacturer's instructions included to store at 35 to 46 degrees F. and do not freeze. -One vial of Novolog insulin: the manufacturer's instructions included to store opened and unopened vials in the refrigerator at 36 to 46 degrees F. -One vial of Levemir Insulin: the manufacturer's instructions included to store in refrigerator between 36 and 46 degrees F. and do not freeze. -One vial of Humulin Insulin: the manufacturer's instructions included do not freeze. -One vial of Prevnar (a strain of the Pneumovax vaccine): the label instructions included do not freeze. -Two vials of Epogen (a medication to treat anemia): the manufacturer's instructions were not with the medication. However, per the pharmacy provider the medication should be stored in the refrigerator between 36 and 46 degrees F. An interview was immediately conducted with the previous Director of Nursing (DON/staff #125), who was present in the facility to assist the current DON. She stated the night shift licensed staff were responsible to check and record the medication refrigerator temperatures. Staff #125 stated that the medication refrigerator temperatures were suppose to be maintained above 32 degrees and below 41 degrees F. She stated that if the refrigerator temperature was out of range, licensed staff were suppose to notify maintaince staff, and document the action which was implemented on the refrigerator temperature log in the comment section. At this time, staff #125 further stated that all of the involved medications would be destroyed. A facility policy titled Drug Storage included, It is the policy of this facility to ensure the proper and safe storage of drugs and biologicals. The policy also included that following: 3. Proper temperature range should be maintained within acceptable guidelines. 3b. Medications requiring refrigeration or temperatures between 36 degrees F. and 46 degrees F. are kept in a refrigerator.",2020-09-01
244,OSBORN HEALTH AND REHABILITATION,35076,3333 NORTH CIVIC CENTER PLAZA,SCOTTSDALE,AZ,85251,2017-11-08,318,D,0,1,QBUG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy review, the facility failed to provide one resident (#56) with range of motion treatments as ordered by the physician. Findings include: Resident #56 was admitted to the facility on (MONTH) 17, (YEAR), with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 18, (YEAR) revealed a BIMS score of 14, which indicated the resident had no cognitive impairment. The MDS included the resident had impairment to the upper and lower extremities and required extensive assistance with activities of daily living (ADL). Review of the ADL care plan revealed the resident was at risk for self care performance deficits related to disease process, limited mobility, impaired balance, [MEDICAL CONDITION], status [REDACTED]. An intervention included for restorative nursing therapy three times a week to the upper and lower extremities. Physician orders for (MONTH) and (MONTH) (YEAR) included for restorative nursing three times per week for active assistive range of motion to bilateral upper and lower extremities for maintenance. Review of the restorative nursing task sheets revealed that for the week of (MONTH) 17 through (MONTH) 23, (YEAR), the resident only received two of the required three treatments. During the week of (MONTH) 15 through (MONTH) 21, (YEAR), again the resident only received two of the required three treatments. During the week of (MONTH) 29 through (MONTH) 4, (YEAR), the resident only received one of the required three treatments. During an interview conducted on (MONTH) 11, (YEAR) at 12:01 p.m., with a certified nursing assistant (staff #56), she stated that she functions as the restorative nursing aide. She stated that she performs range of motion therapy for the resident and documents the treatments in the computer. She stated that if she was busy with other tasks such as resident weights, then the treatments would not get done on that day. She further stated the other CNA's do not perform the range of motion therapy and they chart NA for that task. Staff #56 stated if the resident refused it would also be documented in the computer. During an interview on (MONTH) 11, (YEAR) at 12:29 p.m. with a CNA (staff #108), she stated that she does not perform range of motion therapy for the RNA program, as there is a CNA assigned as the restorative aide. She stated other than repositioning the resident for comfort or turning them in bed which she records in the computer, she marks NA for range of motion therapy, as it was not performed by her. She stated the resident is able to refuse the treatment, but to her knowledge rarely does so. During an interview on (MONTH) 11, (YEAR) at 12:36 p.m. with the Assistant Director of Nursing (staff #106), she stated that residents are provided restorative nursing assistance, as directed by the physician's orders. Staff #106 stated that any of the certified nursing assistants are able to perform range of motion, not just the ones designated as restorative nursing aides. She stated that the time and day are not specified for the treatments, but the number of treatments per week should be documented. She also stated that NA on the chart would indicate that the activity was not completed. Review of the facility policy regarding Restorative Care revealed that restorative care will be provided to each resident according to his/her individual needs and desires, as determined by assessment and interdisciplinary care planning. The policy included that documentation of RNA services is specific to the facility's documentation practices.",2020-09-01
245,OSBORN HEALTH AND REHABILITATION,35076,3333 NORTH CIVIC CENTER PLAZA,SCOTTSDALE,AZ,85251,2017-11-08,463,D,0,1,QBUG11,"Based on observations, staff interviews and policy review, the facility failed to ensure the call light system at the nurses station was functioning properly for multiple resident rooms. Findings include: During an observation conducted at 4:45 a.m. on (MONTH) 8, (YEAR), the call light outside of room #113 was on, however, the call light board at the nurses station was not lit, nor was it sounding. At 4:48 a.m., the call light at the nurses station turned on for room #113, then after a minute the light went out at the call light board, however, the hallway call light was on. A call light check was conducted on (MONTH) 8, (YEAR) at 9:20 a.m., with the Maintenance Director (staff #69) at 9:20 a.m. At this time, the call light in room #113 was turned on in the bathroom by the Maintenance Director, and the light over the door in the hallway lit up. However, an observation of the call light board at the station 1 nurses station revealed the call light board did not light up or sound for room #113. A check was then done for room #112 and when the call light was turned on in the room, the light in the hallway lit up, however, the light at the call light board at the nurses station did not light up. A check was done of room #114 and when the call light was turned on, the call light at the nurses station did not light up or sound. During the observations, staff #69 checked the light bulbs on the call light board at the nurses station and replaced the bulbs. The call light to room #114 lit up, however, the call lights for room #112 and #113 still did not light up. During the observations the Maintenance Director stated that the call lights on the hall where the call light system was not fully functioning was the oldest part of the call light system. An interview was conducted at 2:30 p.m. on (MONTH) 8, (YEAR) with staff #69, who stated that a repair man was brought in and discovered that the bulbs in the call light board had been replaced with 12 volt bulbs and the system requires 24 volt bulbs. He stated the use of the wrong bulbs resulted in the system not working properly. Review of the Call Light/[NAME] policy and procedure revealed It is the policy of this facility to provide the resident a means of communication with nursing staff. The policy also included .If the call light/bell is defective, immediately report this information to the unit supervisor.",2020-09-01
246,HERITAGE COURT POST ACUTE OF SCOTTSDALE,35083,3339 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2018-01-18,623,D,0,1,O9PW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to ensure a written notice of transfer/discharge was provided to the Office of the State Long Term Care Ombudsman regarding one resident's (#42) discharge. Findings include: Resident #42 was admitted on (MONTH) 30, (YEAR), with [DIAGNOSES REDACTED]. Review of the nursing notes dated (MONTH) 18, (YEAR) at 12:15 p.m., revealed the resident had increased agitation, was striking out, and was unable to be redirect. The psychiatric nurse practitioner was notified and an order was received to administer [MEDICATION NAME] (atypical antipsychotic) for increased behaviors. Review of the nursing notes dated (MONTH) 18, (YEAR) at 5:19 p.m., revealed the resident was walking in the hallways with an unsteady gait, was tearing things off the walls, and entering into other resident rooms. She was unable to be redirected by staff and kicked a staff member in the stomach. The psychiatric nurse practitioner was notified and an order was received to send the resident to the hospital for evaluation and treatment of [REDACTED]. The resident was discharged to the hospital on (MONTH) 18, (YEAR). Review of the clinical record revealed no evidence that the Ombudsman received written notification of the transfer/discharge to the hospital. An interview was conducted on (MONTH) 18, (YEAR) at 10:06 a.m. with the case manager (staff #19). Staff #19 stated the Ombudsman is notified of discharges and transfers on a monthly report. During an interview conducted with the Director of nursing (staff #83) on (MONTH) 18, (YEAR) at 12:25 p.m., staff #83 stated the medical records supervisor faxes a list of all facility initiated discharges to the Ombudsman on a monthly basis and that this process only started (MONTH) 27, (YEAR). An interview was conducted with the medical records supervisor (staff #16) on (MONTH) 18, (YEAR) at 12:35 p.m. Staff #16 stated she started faxing notification of facility initiated discharges to the Ombudsman in (MONTH) (YEAR), and that she faxed the (MONTH) and (MONTH) (YEAR) discharges on (MONTH) 9, (YEAR). She also stated resident #42 discharge notice was not faxed to the Ombudsman. An interview was conducted on (MONTH) 18, (YEAR) at 1:50 p.m. with the corporate nurse (staff #84). Staff #84 stated the facility does not have a policy regarding providing written notice of residents' discharges to the Office of the State Long Term Care Ombudsman.",2020-09-01
247,HERITAGE COURT POST ACUTE OF SCOTTSDALE,35083,3339 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2018-01-18,655,D,0,1,O9PW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based clinical record review and staff interviews, the facility failed to ensure that a baseline care plan was developed for the use of an indwelling urinary catheter for one resident (#404). Findings include: Resident #404 was admitted on (MONTH) 12, (YEAR), with a [DIAGNOSES REDACTED]. Review of the clinical record revealed an Initial Admission Record dated (MONTH) 12, (YEAR), that the resident had an indwelling urinary catheter in place for a [DIAGNOSES REDACTED]. Further review of the clinical record revealed Physician Admission Notes dated (MONTH) 13, (YEAR), that the resident's indwelling urinary catheter was inserted 7 days ago. Review of the Daily Skilled Note dated (MONTH) 13, (YEAR), revealed the urinary catheter was patent and draining by gravity and that urinary catheter care was provided as needed. However, review of the baseline care plan initiated (MONTH) 12, (YEAR), revealed no evidence that a care plan had been developed for the indwelling urinary catheter. During an interview conducted with the Minimum Data Set assessment Coordinator (staff #43) on (MONTH) 18, (YEAR) at 9:05 a.m., staff #43 stated that if a resident is admitted on a weekday, she develops the baseline care plan; and if the resident is admitted on the weekend, the floor nurses develops the baseline care plan. She stated the baseline care plan is developed from the hospital history and physical, physician orders, the resident, and the initial nursing admission assessment. She further stated if a resident is admitted with an indwelling urinary catheter, the urinary catheter should be included in the baseline care plan. An interview was conducted with a licensed practical nurse (staff #79) on (MONTH) 18, (YEAR) at 9:45 a.m. Staff #79 stated the admitting nurse initiates the baseline care plan based on the nursing comprehensive assessment. She stated that if a resident is admitted with an indwelling urinary catheter and there is a physician's orders [REDACTED]. During an interview conducted with the Director of Nursing (staff #83) and the Corporate Resource Nurse (staff #84) on (MONTH) 18, (YEAR) at 10:07 a.m., staff #83 stated when a resident is admitted with an indwelling urinary catheter, the admitting nurse is expected to include the indwelling urinary catheter in the resident's baseline care plan which is developed within 24 - 48 hours of the resident's admission. During another interview conducted (MONTH) 18, (YEAR) at 12:25 p.m. with staff #83, he stated there was no care plan developed for this resident's urinary catheter. An interview was conducted the Corporate Resource Nurse (staff #84) on (MONTH) 18, (YEAR) at 1:00 p.m. Staff #384 stated no care plan was found in the clinical record for the resident's indwelling urinary catheter.",2020-09-01
248,HERITAGE COURT POST ACUTE OF SCOTTSDALE,35083,3339 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2018-01-18,658,D,0,1,O9PW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policies, the facility failed to ensure the administration of a narcotic was documented on the Medication Administration Record (MAR) for one resident (#406). Findings include: Resident #406 was admitted on (MONTH) 22, (YEAR), with [DIAGNOSES REDACTED]. A physician order [REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 29, (YEAR), revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Continued review of physician orders [REDACTED]. Review of the resident's pain care plan revealed the following interventions: -Administer [MEDICATION NAME] medication as per orders; -Evaluate the effectiveness of pain interventions; -Follow pain scale to medicate as ordered; -Monitor for side effects of pain medication; -Monitor/record pain characteristics; and -Pain assessment every shift. Review of the Medication Administration Record for (MONTH) 6, (YEAR) revealed [MEDICATION NAME] (anticonvulsant) and [MEDICATION NAME] (muscle relaxant) were the only medications administered to the resident that could relieve pain. No other pain medications were documented as administered. The pain level was documented at a 7 out of 10 and no side effects of the pain medication were identified. Review of the Resident's Controlled Substance Record for [MEDICATION NAME] 15 mg tablets revealed an [MEDICATION NAME] 15 mg tablet was removed (MONTH) 6, (YEAR) at 4:30 a.m. and at 8:30 a.m. and documented as administered. This record does not provide documentation space to document the resident's pain level, pain characteristics, or effectiveness of the medication. An interview was conducted with a Licensed Practical Nurse (staff #15) on (MONTH) 17, (YEAR) at 10:50 a.m. Staff #15 stated before administering a narcotic, the resident should be assessed for pain level, location of pain, and administered the narcotic according to the physician's orders [REDACTED]. Staff #15 stated if a medication was documented on the narcotic sheet and not on the MAR, she would notify the physician, the charge nurse, and/or the Director of Nursing that there may be a discrepancy. Staff #15 further stated she would document a note in the clinical record and would speak with the nurse that signed out the narcotic to determine if it had been administered. During an interview conducted with the Director of Nursing (staff #83) on (MONTH) 17, (YEAR) at 12:49 p.m., staff #83 stated the expectation is that the nurses assess the resident using the pain scale and administer the pain medications according to the physician orders. Staff #83 also stated that when a nurse administers a narcotic pain medication, the narcotic pain medication should be documented on the narcotic sheet and on the MAR immediately so that the documentation is consistent. The policy Documentation and Charting included it is the facility's policy to have a complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care. The policy Pain Management the policy included medications received, refused, and response to medication will be documented on the MAR. The policy Medication Administration included that when as needed medications are administered to residents the nurse must document the reason the medication is being administered, the date, the time, and the signature and title of the person administering the medication.",2020-09-01
249,HERITAGE COURT POST ACUTE OF SCOTTSDALE,35083,3339 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2018-01-18,684,D,1,1,O9PW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, and facility policy, the facility failed to consistently provide wound care for one resident (#406). Findings include: Resident #406 was admitted on (MONTH) 22, (YEAR) with [DIAGNOSES REDACTED]. A review of physician's orders [REDACTED]. The order also included to cleanse the wound with normal saline, pat dry, and cover the wound with Xeroform and Kerlix. Continued review of physician's orders [REDACTED]. A wound care plan initiated on (MONTH) 25, (YEAR) included the intervention to follow the facility's protocols for treatment of [REDACTED]. Review of the Treatment Administration Record for (MONTH) (YEAR) revealed the wound care was provided on (MONTH) 25, (YEAR) per existing orders. Review of electronic Medication Administration Record [REDACTED]. Continued review of e-MAR documentation revealed an e-MAR note dated (MONTH) 28, (YEAR) that a call was placed to the surgeon to clarify pending orders to be faxed. Review of the Ambulatory Encounter Summary dated (MONTH) 24, (YEAR), but fax-stamped on (MONTH) 28, (YEAR) revealed the Registered Nurse was to daily dress the surgical incision with Xeroform, apply the splint, pad the heel with an ABD pad for comfort, and secure it with Kerlix and ace wrap. It also included that staff may wash the right leg/surgical incision with soap and water and pat dry and redress daily as needed. Further review of the clinical record revealed wound care was not provided to the surgical wound on (MONTH) 26, 27, and 30, (YEAR). An interview was conducted with a Licensed Practical Nurse/Wound Nurse (staff #15) on (MONTH) 17, (YEAR) at 10:50 a.m. Staff #15 stated when a resident is admitted with a surgical wound the clinical record and the hospital records are reviewed. Staff #15 stated if the orders are not clear, the surgeon would be contacted for clarification. Staff #15 also stated the wound care was not provided on (MONTH) 26 and 27, (YEAR) because the orders needed to be clarified. Staff #15 further stated there was no documentation that the wound care was provided on (MONTH) 30, (YEAR). During an interview conducted with the Director of Nursing (staff #83) on (MONTH) 17, (YEAR) at 12:49 p.m., staff #83 stated the staff documented the wound care was not provided on (MONTH) 24, (YEAR) after the resident seen the surgeon due to pending clarification of the orders. Staff #83 further stated a wound should not be without care for that many days or without the orders for wound care that many days. He also stated he had not been made aware that the orders had not been received. The policy Wound Management included that once a wound has been identified, assessed, and documented, nursing shall administer treatment to each affected area as per the physician's orders [REDACTED].",2020-09-01
250,HERITAGE COURT POST ACUTE OF SCOTTSDALE,35083,3339 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2018-01-18,690,G,0,1,O9PW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, staff and caregiver interviews, and policies, the facility failed to ensure that a physician's order was obtained and care and services were provided to one resident (#404) admitted with an indwelling urinary catheter. Findings include: Resident #404 was admitted on (MONTH) 12, (YEAR), with [DIAGNOSES REDACTED]. The Initial Admission Record dated (MONTH) 12, (YEAR) revealed the resident was alert and oriented to person but not to time and place. It also included the resident had an indwelling urinary catheter in place for a [DIAGNOSES REDACTED]. A Bowel and Bladder assessment dated (MONTH) 12, (YEAR) revealed that the resident was always incontinent of the bladder. It also included a score of 14 indicating that the resident was an unlikely candidate for bladder retraining. The initial care plan included that the resident had an indwelling urinary catheter; however, there were no interventions regarding the catheter care. The Physician's Admission Notes dated (MONTH) 13, (YEAR) revealed the resident had a past medical history of [REDACTED]. Review of a Daily Skilled Note dated (MONTH) 13, (YEAR) revealed the resident was alert and oriented x 2. The note also included that the indwelling urinary catheter was patent and draining to gravity and that catheter care was provided as needed. Review of the Physician's Order Summary dated (MONTH) (YEAR) revealed no evidence of a physician's order for the use of [REDACTED] Continued review of the clinical record revealed no evidence that the physician was notified to obtain an order for [REDACTED].>A nurse practitioner progress note dated (MONTH) 15, (YEAR) included the resident had a [DIAGNOSES REDACTED]. The plan included resident with Foley but more for facility ease of use. No Foley at home will discontinue and have facility follow for adequate output. Review of a nursing progress note dated (MONTH) 15, (YEAR) revealed the resident had penis swelling and pain to the area. A physician progress notes [REDACTED]. The progress note further revealed that upon examination there was bright red [DIAGNOSES REDACTED] at the head of the penis. The progress note also included the resident had a penile skin infection and [MEDICATION NAME] (antibiotic) would be ordered. A physician's order dated (MONTH) 15, (YEAR) included to discontinue the indwelling urinary catheter and to administer [MEDICATION NAME] 875/125 milligrams oral twice a day for 7 days for a skin infection. Review of the care plan updated on (MONTH) 16, (YEAR) revealed the resident had an infection of the penis and was being administered an antibiotic. However, it did not include that the indwelling urinary catheter was to have been discontinued. During an observation conducted on (MONTH) 16, (YEAR) at 9:50 a.m., the indwelling urinary catheter remained in place, despite the physician's order to discontinue the catheter on (MONTH) 15, (YEAR). A review of the Treatment Administration Record (TAR) dated (MONTH) (YEAR) revealed the indwelling urinary catheter was discontinued on (MONTH) 16, (YEAR) at 5:47 p.m. Further review of the clinical record including the TAR revealed no evidence that catheter care was consistently provided to the resident from (MONTH) 12 - 16, (YEAR). During an interview conducted on (MONTH) 18, (YEAR) at 9:45 a.m. with a licensed practical nurse (staff #79), staff #79 stated for new admissions, she conducts a comprehensive head to toe assessment and documents all her findings including an indwelling urinary catheter in the electronic record. Staff #79 also stated she will review the physician's orders to ensure there is an order for [REDACTED].#79 stated the order would also include the frequency for changing the catheter bag and catheter care and that the orders would be automatically transcribed onto the TAR. She also stated that catheter care is conducted by the certified nursing assistants and documented by the nurse in the electronic record (TAR). An interview was conducted on (MONTH) 18, (YEAR) at 10:07 a.m. with the Director of Nursing (staff #83) and the Corporate Resource Nurse (staff #84). Staff #83 stated that when a resident is admitted with an indwelling urinary catheter, the admitting nurse is expected to ensure there is an order for [REDACTED]. During an interview conducted on (MONTH) 18, (YEAR) at 11:48 a.m. with the resident's primary caregiver, she stated that the resident's indwelling urinary catheter was inserted at the hospital when the resident was too weak to get up and go to the bathroom. The caregiver further stated the indwelling urinary catheter was removed because the resident had an infection. In an interview with the Clinical Resource (staff #85) conducted on (MONTH) 18, (YEAR) at 11:57 a.m., staff #85 stated that per their policy, catheter care is conducted daily and as needed. During another interview conducted (MONTH) 18, (YEAR) at 12:25 p.m. with staff #83, he stated that it is his responsibility and the assistant director of nursing responsibility to review all orders and ensure there are orders for any indwelling urinary catheter and any treatment. He further stated there was no order for this resident's urinary catheter. Staff #83 also stated that orders are rarely missed because they utilize a New Admission Work Sheet and Chart Check form/checklist to ensure that there are orders to meet the resident's needs. The facility's policy Physician Orders included the facility will accurately implement orders in addition to medications orders, treatments, and procedures only upon the written order of a person duly licensed and authorized to do so in accordance with the resident's plan of care. The facility's policy Indwelling Catheter Care included that each resident with an indwelling catheter will receive catheter care daily and as needed.",2020-09-01
251,HERITAGE COURT POST ACUTE OF SCOTTSDALE,35083,3339 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2018-01-18,695,E,0,1,O9PW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, staff and resident interviews, and facility policy, the facility failed to ensure that an order was obtained for the use of oxygen for one resident (#295). Findings include: Resident #295 was admitted on (MONTH) 2, (YEAR), with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessment dated (MONTH) 9, (YEAR), revealed that the resident had a Brief Interview of Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact. Review of the nursing progress notes dated (MONTH) 14th and 15th, (YEAR), revealed the resident was receiving oxygen at 2 liters via nasal cannula. An observation of the resident was conducted on (MONTH) 16, (YEAR) at 8:16 a.m. and (MONTH) 17, (YEAR) at 8:54 a.m. Resident #295 was observed to have humidified oxygen being administered at 2 liters via nasal cannula. However, review of the physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. An interview was conducted on (MONTH) 17, (YEAR) at 8:54 a.m. with resident #295 who did not speak English. A Licensed Practical Nurse (staff #79) translated. The resident stated that last week she was having trouble breathing and that was when the oxygen was first administered. Resident #295 also stated she was not administered oxygen at home or in the hospital. An interview was conducted on (MONTH) 17, (YEAR) with the Assistant Director of Nursing (staff #76). She stated that a physician's orders [REDACTED]. Staff #76 also stated that if a resident was being administered oxygen without a physician's orders [REDACTED]. She stated that she observed oxygen being administered to resident #295 on (MONTH) 15 - 17, (YEAR) because she helped care for the resident. After reviewing the physician's orders [REDACTED]. During an interview conducted on (MONTH) 17, (YEAR) at 11:00 a.m. with the Director of Nursing (staff #83), staff #83 stated a physician's orders [REDACTED]. He further stated the expectation is that if a resident is being administered oxygen there would be a physician's orders [REDACTED]. The policy Oxygen Administration included that oxygen therapy is administered by a licensed nurse as ordered by the physician. The policy also included that the clinical record will include that oxygen is to be administered, when and how often the oxygen is to be administered, the type of oxygen device to use, and any special procedures or treatments to be administered.",2020-09-01
252,HERITAGE COURT POST ACUTE OF SCOTTSDALE,35083,3339 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2018-01-18,880,D,0,1,O9PW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, staff interviews, and facility policy, the facility failed to ensure isolation precautions were consistently implemented for one resident (#244). Findings include: Resident #244 was admitted on (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. Review of the recapitulation of physician's orders revealed an order dated (MONTH) 14, (YEAR), for [MEDICATION NAME] (antibiotic) 875 milligrams oral twice a day for [MEDICAL CONDITION]. A physician admission progress note dated (MONTH) 15, (YEAR), revealed the resident was previously diagnosed with [REDACTED]. The progress note included the resident had an acute left chest wall wound that was likely related to the shingles. The progress note also included the physician's skin examination that revealed the resident had [DIAGNOSES REDACTED], shingles, and a left chest wall and back wound. Continued review of the recapitulation of physician's orders revealed an order dated (MONTH) 15, (YEAR), that the resident was being administered [MEDICATION NAME] 875 milligrams oral twice a day for [MEDICAL CONDITION] to the chest wall and open [MEDICAL CONDITION] to the back. Review of the care plan initiated (MONTH) 15, (YEAR), revealed the resident was on antibiotic therapy for the [MEDICAL CONDITION] shingles rash and had acute pain related to the [MEDICAL CONDITION] simplex rash. The care plan also included that the resident had actual skin impairment related to the recent shingles rash and that the resident will have no complications related to the open [MEDICAL CONDITION]. An observation of resident #244 was conducted on (MONTH) 16, (YEAR) at 8:10 a.m. An isolation cart was observed outside the resident's room. No sign was observed on the door to instruct visitors and staff to see the nurse prior to entering the resident's room. The resident was observed lying in bed being assisted with eating by a visitor that had no gown or gloves donned. The visitor was standing on the right side of the bed with her legs in contact with the mattress and her arms over the resident's upper body. Review of the clinical record revealed no physician's order for isolation precautions. Further review of the clinical record revealed no care plan regarding isolation precautions for the resident, nor any documentation that the resident was on isolation precautions. During an interview conducted (MONTH) 16, (YEAR) at 8:14 a.m. with a Licensed Practical Nurse (LPN/staff #65), she stated that the resident was on contact isolation precautions for a shingles. Staff #65 also stated that to prevent transmission of disease everyone who enters the resident's room should put on gloves and a gown. Another observation of the resident was conducted on (MONTH) 16, (YEAR) at 8:18 a.m. The resident's visitor was still in the resident's room without wearing gloves and gown. The visitor was then observed exiting the resident's room, walk down the hall, and enter the Speech & Occupational therapy room. A few minutes later the visitor was observed returning to the resident's room. When the visitor entered the room, staff #65 who was wearing a gown and gloves inside the room instructed the visitor, who had entered the room without gown and gloves, to wear a gown and gloves prior to entering and while in the resident's room. Following this observation an interview was conducted with staff #65, who stated the resident and the visitor do not speak or understand English. Staff #65 further stated the resident's family was going to be contacted to translate that anyone who enters the resident's room need to wear gloves and a gown. Staff #65 also stated that she would attempt to give the gloves and a gown to the visitor in hopes that the visitor would wear them. During an interview conducted on (MONTH) 18, (YEAR) at 9:00 a.m. with a LPN (staff #71), staff #71 stated that the physician's admitting orders would have an order for [REDACTED].#71 also stated the nurses and Certified Nursing Assistants (CNAs) would be informed of the isolation precautions during the shift to shift report. An interview was conducted on (MONTH) 18, (YEAR) at 9:36 a.m. with a CNA (staff #2). Staff #2 stated the nurse would inform her if a resident that is being admitted requires isolation precautions and why the resident requires isolation precautions. She stated that she would then gather the isolation materials so that they are ready before the resident arrives. Staff #2 also stated a sign is placed on the door to alert staff and visitors to check with the nurse before entering the resident's room. An interview with the Director of Nursing (staff #83) was conducted on (MONTH) 18, (YEAR) at 10:06 a.m. Staff #83 stated that the hospital transfer orders will have an order for [REDACTED]. to notify everyone that the resident is on isolation precautions. Staff #83 stated the nurses, CNAs, and therapy staff are informed of the isolation precautions through a verbal and written shift report. He also stated the family is educated about the risks/benefits of wearing a gown and gloves and that family members who visit the resident are expected to gown and glove before entering the resident's room. Staff #83 further stated the facility will asks the family members who do not want to wear gloves and gowns to use hand sanitization and to wash their hands when visiting the resident. The policy Transmission Based Precautions and Isolation included putting on gloves prior to resident contact and a gown prior to entering the resident's room and to remove the gloves after contact and the gown prior to leaving the room and wash your hands. The policy also included that handwashing before and after resident contact, and after removing the gloves is the single most effective infection control measure known to reduce the potential for transmission of microorganism.",2020-09-01
253,HERITAGE COURT POST ACUTE OF SCOTTSDALE,35083,3339 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2019-03-22,552,D,0,1,Y7PT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy and procedure, the facility failed to ensure one of five sampled residents (#2) was informed of the risks and benefits of a psychoactive medication, prior to administration. The deficient practice can result in the resident not being aware of the benefits and the potential adverse side effects of taking psychoactive medications. Findings include: Resident #2 was admitted to the facility on (MONTH) 30, (YEAR) and readmitted on (MONTH) 9, 2019, with [DIAGNOSES REDACTED]. The admission Minimum Data Set assessment dated (MONTH) 7, (YEAR) revealed a Brief Interview for Mental Status score of 13, which indicated the resident had intact cognition. Review of the clinical record revealed a physician order [REDACTED]. Review of the Medication Administration Record [REDACTED]. Continued reviewed of the physician's orders [REDACTED]. Review of the MAR for (MONTH) 2019 revealed the resident was administered [MEDICATION NAME] on (MONTH) 4, 5, and 15, 2019 Additional review of the clinical record revealed a physician order [REDACTED]. Review of the MAR for (MONTH) 2019 revealed the resident was administered [MEDICATION NAME] on (MONTH) 17, 2019. However, further review of the clinical record did not reveal evidence that the resident had been informed of the risks and benefits of [MEDICATION NAME]. An interview was conducted with a Registered Nurse (RN/staff #14) on (MONTH) 22, 2109 at 10:56 a.m. The RN stated that informed consent has to be obtained before a resident is administered a [MEDICAL CONDITION] medication. She stated that the informed consent form is completed which includes the medication name, the reason the medications is ordered, and the risk and benefits of the medication. She also stated that the resident would have to sign the form indicating that they agree or disagree to take the medication. During an interview conducted with the Director of Nursing (DON/staff #72) on (MONTH) 22, 2019 at 1:47 p.m., the DON stated that her expectation is that staff obtains informed consent prior to the administration of a [MEDICAL CONDITION] medication. Later that day at 1:56 p.m., the DON stated that she was unable to find documentation that informed consent had been obtain for [MEDICATION NAME]. Review of the facility's policy on psychoactive medication revealed the use of psychoactive medication must first be explained to the resident. The policy included the potential risk and benefits must be explained to the resident and consent has to be obtained from the resident. The policy also included the person obtaining the consent is to sign the consent once obtained.",2020-09-01
254,HERITAGE COURT POST ACUTE OF SCOTTSDALE,35083,3339 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2019-03-22,578,D,0,1,Y7PT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to ensure advanced directives were consistent in the clinical record for one of twelve sampled residents (#2). The census was 43. The deficient practice could result in residents receiving services which are not in accordance with their wishes. Findings include: Resident #2 was admitted on (MONTH) 30, (YEAR) and readmitted (MONTH) 9, 2019 with [DIAGNOSES REDACTED]. Review of the clinical record revealed an Advanced Directive/Medical Treatment Decisions form that the resident's choice was DNR (Do Not Resuscitate). The form revealed documentation that a verbal consent was obtained from the resident's Power of Attorney (POA) on (MONTH) 30, (YEAR) and that the POA signed the form on (MONTH) 1, (YEAR). An orange DNR form dated (MONTH) 2, (YEAR) was noted in the Health Records/Advanced Directive book at the nurses' station as well as the Advanced Directive form that the resident was a DNR. The admission Minimum Data Set assessment dated (MONTH) 7, (YEAR) revealed a Brief Interview for Mental Status score of 13, which indicated the resident had intact cognition. Review of a social service note dated (MONTH) 7, (YEAR) revealed the resident's advance directives choice was DNR. Continued review of the clinical record revealed a physician order [REDACTED]. A physician's orders [REDACTED]. Review of a social service note dated (MONTH) 16, 2019 revealed the resident's code status was CPR. A Nursing Home to Hospital Transfer form dated (MONTH) 24, 2019 revealed the resident code status was CPR/Full Code. However, further review of the clinical record did not reveal documentation that the resident or the resident's representative had changed the Advanced Directives to CPR/Full Code. On (MONTH) 22, 2019 at 10:47 a.m., the medical records supervisor (staff # ) stated that the resident's advanced directives are kept in the resident's Health Records/Advanced Directives book at the nurses' station and that she updates the book daily. During an interview conducted with a Certified Nursing Assistant (CNA/staff #55) on (MONTH) 22, 2019 at 10:50 a.m., the CNA reviewed the Health Records/Advanced Directive book at the nurses' station and stated that the resident is a DNR and that she would not resuscitate the resident. An interview was conducted with a Registered Nurse (RN/staff #14) on (MONTH) 22, 2019 at 10:56 a.m. The RN stated that if a resident stopped breathing, she would have to ask someone to check to see if the resident was a DNR or a Full Code. She stated that she would know from the electronic record information bar at the top of the resident's page, but that they always double check the Health Records/Advanced Directives book at the nurses' station before proceeding. The RN reviewed the resident's status in the electronic record and stated the resident was a a full code. After reviewing the advanced directive form, she stated that the resident should be a DNR. The RN stated that there was a risk that if the nurse went off of what the electronic record stated, the nurse would do CPR which is not the resident's choice. Another interview was conducted with medical records supervisor on (MONTH) 22, 2019 at 12:26 p.m. She stated that resident #2 is a full code per the electronic record. She stated that the nurse would look at the electronic record and the Health Records/Advanced Directives book at the nurse's station to find out the resident's code status. She stated that the order in the electronic record should match the decision on the advanced directive form. After reviewing the resident's Advanced Directive Form stating the resident was a DNR, she stated that there was a very bad risk of the resident's wishes not being followed if the order did not match the Advanced Directive form. An interview was conducted with the Director of Nursing (DON/staff #72) (MONTH) 22, 2019 at 12:29 p.m. The DON stated that advance directives information is obtained from residents upon admission. She stated that if a resident or their representative wished to changed their advance directives, another advanced directives form would be completed and a physician's orders [REDACTED].",2020-09-01
255,HERITAGE COURT POST ACUTE OF SCOTTSDALE,35083,3339 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2019-03-22,641,D,0,1,Y7PT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, the Resident Assessment Instrument (RAI) manual and policy review, the facility failed to ensure Minimum Data Set (MDS) assessments for 2 of 12 sampled residents (#4 and #6) were accurate. This deficient practice could result in care plans not accurately reflecting the residents' status and could affect residents' continuity of care. Findings include: -Resident #4 was admitted to the facility on (MONTH) 16, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed physician's orders [REDACTED]. sterile gauze to wound bed and to cover with dry dressing every shift for wound care; and to cleanse the left heel with wound cleanser, pat dry, apply [MEDICATION NAME], and cover with foam dressing on day shift every third day. The nursing progress notes dated (MONTH) 16, (YEAR), revealed the resident had a chronic indwelling urinary catheter in place. Review of the Treatment Administration Record (TAR) dated (MONTH) (YEAR) revealed treatments were provided to the resident's sacral pressure ulcer and left heel wound and that indwelling urinary catheter care was provided. A physician's admission progress note dated (MONTH) 17, (YEAR) revealed the resident was hard of hearing and that the resident had a chronic indwelling urinary catheter. A case manager progress note dated (MONTH) 18, (YEAR) revealed the resident required headphones with a hearing device in order to hear clearly. However, review of the admission MDS assessment dated (MONTH) 23, (YEAR) revealed the resident was occasionally incontinent, had an ostomy, was not provided pressure ulcer care, and did not use hearing appliances. Further review of the clinical record did not reveal documentation that the resident had an ostomy. Additionally, review of the 14 day Prospective Payment System (PPS) MDS assessment dated (MONTH) 30, (YEAR) revealed the resident was always incontinent and did not have a pressure ulcer. Review of the TAR for (MONTH) 2019 revealed the resident continued to have the indwelling urinary catheter and was receiving pressure ulcer care. However, review of the discharge MDS assessment dated (MONTH) 18, 2019 revealed the resident was occasionally incontinent and did not receive pressure ulcer care. An interview was conducted with a Certified Nursing Assistant (CNA/staff #21) on (MONTH) 21, 2019 at 9:33 a.m. He stated that the resident had an indwelling urinary catheter and that the CNA documentation of incontinent episodes was not accurate as the resident should have been documented as not rated for urinary incontinence. He stated that to his knowledge the resident has never had an ostomy. An interview was conducted with the MDS Licensed Practical Nurse (staff #10) on (MONTH) 21, 2019 at 9:51 a.m. He stated that the expectation is that the MDS assessments be 100% accurate. He stated that he uses the RAI manual to code the assessments. Staff #10 stated that at times resident #4 does not understand him but that he thought her hearing was adequate at the time of the admission assessment. He stated that the ostomy was coded in error on the admission MDS assessment. Staff #10 also stated that urinary incontinence should not have been coded on the MDS assessments and that the pressure ulcer care should have been coded on the MDS assessments. During an interview conducted with the Director of Nursing (DON/staff #72) on (MONTH) 21, 2019 at 12:45 p.m., she stated that her expectation is that the MDS assessments be accurate. The RAI manual instructs to review the clinical record, including skin care flow sheets or other skin tracking forms, speak with direct care staff and the treatment nurse, and to examine the resident to determine whether any pressure ulcers are present. The manual also instructs to review the clinical record, including treatment records and health care provider orders for documented skin treatments during the past 7 days. The RAI manual also included speaking with direct care staff and the treatment nurse to confirm conclusions from the clinical record review and to code the care provided. Further review of the RAI manual revealed the resident should be examined for the presence of any ostomies and to review the clinical record for documentation of ostomies. The manual also included that urinary continence should be coded not rated for residents that have an indwelling bladder catheter during the 7 day look-back period. The RAI manual instructs that prior to beginning the hearing assessment, determine if the resident uses a hearing aid or other hearing appliances by asking the resident, checking the clinical record, and asking staff and significant others. Ensure the resident is using his or her normal hearing appliance and that the hearing appliance is operational. The manual included some residents by choice may use hearing amplifiers or a microphone and headphones as an alternative to hearing aids. The manual also instructs to code yes if the resident did use a hearing aid or other hearing appliance for the hearing assessment. -Resident #6 was admitted to the facility on (MONTH) 26, (YEAR) with [DIAGNOSES REDACTED]. Review of a daily skilled nursing note dated (MONTH) 22, (YEAR), revealed the resident was alert and oriented to person, place, and time. Review of a social services assessment dated (MONTH) 1, 2019 revealed the resident was alert and oriented to person, place, time and is able to make needs known. However, review of the quarterly MDS assessment dated (MONTH) 3, 2019, revealed a Brief Interview for Mental Status (BIMS) was not conducted. An interview was conducted with social services (staff #38) on (MONTH) 21, 2019 at 9:53 a.m. She stated that she is responsible for completing the cognitive patterns which includes the BIMS of the MDS assessment. After reviewing the quarterly MDS assessment for resident #6, she stated the BIMS was not conducted. During an interview conducted with the MDS coordinator (staff #10) on (MONTH) 21, 2019 at 10:13 a.m., the MDS coordinator stated that social services completes the cognitive patterns portion of the MDS assessment which includes the BIMS. He stated that he will review the completed MDS assessment before it is transmitted. After reviewing the quarterly MDS assessment for resident #6, he stated that the BIMS portion of the assessment was not conducted and that it was an error. The facility's policy dated (MONTH) (YEAR) for Accuracy of Resident Assessment revealed it is the facility's policy to ensure that the assessment accurately reflects the resident's status. The policy included that the purpose is to assure that each resident receives an accurate assessment by staff that are qualified to assess relevant care areas and knowledgeable about the resident's status, needs, strengths, and areas of decline. The RAI manual revealed a structured cognitive test is more accurate and reliable than observation alone for observing cognitive performance. The manual included that without an attempted structured cognitive interview, a resident might be mislabeled based on his or her appearance or assumed diagnosis. The manual also included structured interviews will efficiently provide insight into the resident's current condition that will enhance good care and will assist in identifying needed supports. The manual instructs to attempt to conduct the interview with all residents. Additional review of the RAI manual for the MDS revealed the importance of accurately completing and submitting the MDS assessment cannot be over emphasized. The MDS assessment is the basis for the development of an individualized care plan.",2020-09-01
256,HERITAGE COURT POST ACUTE OF SCOTTSDALE,35083,3339 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2019-03-22,658,D,0,1,Y7PT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to meet professional standards of quality, by failing to ensure one of five sampled residents (#2) was administered a medication as ordered by the physician. The deficient practice could result in a decrease in blood pressure. Findings include: Resident #2 was readmitted on (MONTH) 9, 2019, with [DIAGNOSES REDACTED]. Review of the clinical record revealed a physician's orders [REDACTED]. Review of the MAR for (MONTH) 2019 revealed [MEDICATION NAME] was not administered 4 times for systolic blood pressures less than 120. An interview was conducted with the LPN (staff #59) on (MONTH) 22, 2019 at 1:45 p.m. The LPN stated that medications are to be administered according to the parameters ordered by the physician. During an interview conducted with the DON (staff #72) on (MONTH) 22, 2019 at 1:47 a.m., the DON stated that her expectation is that the nurses administer medications according to the parameters ordered by the physician. After reviewing resident #2's clinical record, the DON stated that [MEDICATION NAME] was not administered according to the physician's orders [REDACTED].>The facility's policy regarding administration of drugs revealed medications must be administered in accordance with the written orders of the attending physician.",2020-09-01
257,HERITAGE COURT POST ACUTE OF SCOTTSDALE,35083,3339 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2019-03-22,686,G,0,1,Y7PT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record reviews, staff interviews, facility documentation and policy and procedures, the facility failed to ensure that care and treatments were provided to 1 of 3 sampled residents (#4) who developed an unstageable pressure ulcer, and by failing to provide care and treatments for two additional pressure ulcers which were present upon admission. There were five residents in the facility who were identified as having pressure ulcers. The deficient practice could result in delayed wound healing and/or deterioration of wounds. Findings include: Resident #4 admitted to the facility on (MONTH) 16, (YEAR) and readmitted to the facility on (MONTH) 29, 2019, with [DIAGNOSES REDACTED]. A nursing progress note dated (MONTH) 16, (YEAR) included the resident was admitted with a large stage 4 sacral ulcer and had a chronic indwelling urinary catheter in place. Regarding the right thigh pressure ulcers: Physician orders dated (MONTH) 16, (YEAR) included for an indwelling urinary catheter for a [DIAGNOSES REDACTED]. Review of the clinical record revealed no documentation that the resident was admitted with any pressure ulcers to the right thigh. An admission Minimum Data Set (MDS) assessment dated (MONTH) 23, (YEAR) revealed the resident had a Brief Interview for Mental Status (BIMS) score of 6, which indicated severe cognitive impairment. Per the MDS, the resident required extensive assistance with bed mobility, transfers and toileting, was always incontinent of bowel and had an indwelling urinary catheter. Review of the (MONTH) (YEAR) Treatment Administration Record (TAR) revealed that catheter care was not completed on the night shift on (MONTH) 17 and 25. Review of the clinical record revealed there was no weekly skin evaluation which was completed the week of (MONTH) 23-29, (YEAR). Another physician's order dated (MONTH) 6, 2019 included for an indwelling urinary catheter for [MEDICAL CONDITION]. The (MONTH) 2019 TAR revealed the order for catheter care, however, there was no documentation that catheter care was provided on (MONTH) 1, 8 or 13 (on the night shift) or (MONTH) 15 (on the day and night shift). Further review of the clinical record revealed no documentation that a weekly skin evaluation was completed from (MONTH) 13-18, 2019. The clinical record documentation showed that the resident was admitted to the hospital on (MONTH) 18, 2019 for altered mental status and readmitted on (MONTH) 29, 2019. Review of the re-admission physician's orders dated (MONTH) 29, 2019, revealed for an indwelling catheter for [MEDICAL CONDITION]/urine retention, a bariatric low air loss mattress for decubitus precautions and for weekly skin checks. Upon re-admission, there was no clinical record documentation that the resident had any pressure ulcers to the right thigh. A provider's progress note dated (MONTH) 5, 2019 included the resident had an indwelling urinary catheter for compromised skin condition. A weekly skin assessment dated (MONTH) 5, 2019 revealed there were no skin issues to the right thigh. A care plan initiated on (MONTH) 6, 2019 included the resident was at risk for further pressure ulcer development related to immobility, incontinence, diabetes mellitus and [MEDICAL CONDITION]. The care plan included for an indwelling catheter to promote wound healing with a goal that the resident will remain free from catheter related trauma. An intervention included to provide catheter care every shift and as needed. Further review of the pressure ulcer care plan revealed it was revised on (MONTH) 9, 2019 to include that the resident had a right inner thigh pressure ulcer, due to the indwelling urinary catheter. The care plan included the resident was at risk of her condition worsening due to non-adherence with plan of care, as the resident does not like pillows or other assistive devices separating her legs. The goal included there will be signs of improved healing through the next review date. Interventions included the following: administer treatments as ordered and monitor for effectiveness; assess/record/monitor wound healing; measure length, width and depth where possible; assess and document status of wound perimeter, wound bed and healing progress; report improvements and declines to the medical doctor; catheter tubing re-routed to avoid inner thigh area; continue to educate and encourage resident on keeping padding in place to inner thighs; needs monitoring/reminding/assistance to turn/reposition; padding applied between legs to decrease pressure to the area; and weekly head to toe skin at risk assessment. Although the care plan identified that the resident was non compliant with keeping pillows or other assistive devices to keep her legs separated, there was no clinical record documentation of the resident's non compliance prior to (MONTH) 9. In addition, there was no clinical record documentation that a treatment order was obtained on (MONTH) 9 or 10, or that a thorough assessment of the right inner thigh pressure ulcer was conducted on (MONTH) 9, 10 or 11, 2019, which included any measurements, description of the wound bed and surrounding skin, staging of the pressure ulcer and if any drainage was present. A physician's progress noted dated (MONTH) 11, 2019 included the resident had new groin wounds, however, there was no description of the wounds. A physician's order for wound treatment was obtained on (MONTH) 11, 2019, two days after the pressure ulcer to the right thigh was identified. The order included to cleanse the right medial thigh pressure ulcer with normal saline, apply xeroform and cover with a dry sterile dressing every 24 hours. Review of the physician's progress note (MONTH) 12, 2019, revealed the resident had an ulceration on the right medial inner thigh (upper lid caused by the Foley catheter). There is mild thinning slough with scant serous drainage. No peri-wound inflammation. The note further included that the resident has a medical device associated ulceration to the right medial inner thigh. This note did not include any measurements. Review of a weekly pressure ulcer assessment dated (MONTH) 13, 2019 revealed the resident had a lower right inner thigh wound, with an onset date of (MONTH) 9. The wound was described as an unstageable pressure ulcer that measured 15.5 cm length by 1 cm, and the wound bed had slough with undefined wound edges with a small amount of serous exudate. This was the first documentation of any measurements to the right thigh pressure ulcer, since it was identified on (MONTH) 9. This same weekly pressure ulcer assessment dated (MONTH) 13, 2019 also included documentation that the resident now had a second pressure ulcer to the upper right inner thigh, which was a stage 2. The wound measured 18.5 cm length by 1 cm width with a pink wound bed and undefined edges and had a small amount of serous exudate. There was no physician ordered treatment for [REDACTED]. A wound care nurse practitioner progress note dated (MONTH) 21, 2019 revealed the resident had two ulcerations on the right medial inner thighs. The superior ulceration had minimal slough and the inferior ulceration had mild slough, with minimal granulation. No measurements were documented. The note indicated the wounds were medical device associated ulcerations. The note also included that a curette was used to remove slough from the right thigh. Review of the weekly pressure ulcer assessment dated (MONTH) 24, 2019 revealed the resident had an unstageable pressure ulcer to the right medial inner thigh, which measured 13.5 cm length by 1 cm width. The wound had a small amount of serous exudate and slough in the wound bed, with undefined wound edges. The note further included that the stage 2 pressure ulcer had healed. A nurse practitioner wound care note dated (MONTH) 26, 2019 revealed the medical device ulceration on the right medial inner thigh was improving and the superior ulceration has 100% re-[MEDICATION NAME] and the inferior ulceration has mild thin slough and mild granulation. A physician's order dated (MONTH) 27, 2019 included to cleanse the right medial thigh with wound cleanser, pat dry, apply [MEDICATION NAME], then apply a thin strip of xeroform and cover with a dry dressing for moisture associated skin damage. Review of the CNA documentation regarding assistance provided to the resident with bed mobility and turning and repositioning revealed no documentation of any assistance that was provided on (MONTH) 2, 6, 9, 18, 20, 23, 26, and 28, 2019 on the night shift. Regarding toileting assistance revealed no documentation that assistance was provided on (MONTH) 2, 9, 18, 20, 23, and 26, 2019 on the night shift. Regarding pressure ulcer devices in place revealed no documentation of any devices on (MONTH) 2, 6, 9, 18, 20, 23, 26 and 28, 2019 on the night shift. A physician's wound care progress note dated (MONTH) 5, 2019 revealed the right medial thigh ulceration was improving, with [MEDICATION NAME] of the edges and thin slough on the wound bed. Review of the weekly pressure ulcer assessment dated (MONTH) 6, 2019 revealed the resident had an unstageable pressure ulcer to the right medial thigh with an onset date of (MONTH) 9, 2019 which measured 13.2 length and width and 1 cm depth. The wound had a small amount of serosanguinous exudate with slough in the wound bed and defined edges. Only one thigh wound was documented. Review of the weekly pressure ulcer assessment dated (MONTH) 13, 2019 revealed the resident had an unstageable pressure ulcer to the right medial thigh, with an onset date of (MONTH) 9, 2019. The wound measured 9.5 cm length by 0.5 cm width by 0.2 cm depth with slough in the wound bed and undefined edges, and had a scant amount of serous exudate. Another physician's order dated (MONTH) 15, 2019 included for an indwelling catheter for wound management. Review of the CNA documentation regarding assistance provided to the resident with bed mobility revealed no documentation of any assistance that was provided on (MONTH) 2, 4, 9, 10, 13, 17, 19, 2019 on the night shift. Regarding assistance provided with turning and repositioning revealed no assistance was provided on (MONTH) 2, 4, 9, 10, 13, 17, 20, 2019 on the night shift. Regarding assistance with toilet use revealed no documentation of assistance provided on (MONTH) 2, 4, 9, 10, 13, 17, 19, 2019 on the night shift. Regarding documentation of pressure ulcer devices in place revealed no documentation on (MONTH) 2, 9, 10, 13, 17, 20, 2019 on the night shift. A Nurse Practitioner wound progress note dated (MONTH) 19, 2019 revealed the right thigh ulceration had resolved. A wound care observation of the resident was performed on (MONTH) 20, 2019 at 9:21 a.m., with the wound care certified Licensed Practical Nurse (LPN/staff #19). The resident was observed to be lying on her back in bed. There was a long thin strip of lightened skin noted to the inner right medial thigh, which was identified by the wound nurse as the newly healed pressure area that had been caused by the catheter tubing. The resident was not observed to have any open wounds to the right thigh. An interview was conducted with staff #19 on (MONTH) 20, 2019 at 10:06 a.m. He stated that the catheter caused the thigh wounds. He stated they assess residents for any items that could cause pressure injury, and that the catheter related wounds to the thigh could have been prevented by staff. Regarding the stage 4 sacral pressure ulcer: A nursing progress note dated (MONTH) 16, (YEAR) documented the resident was admitted with a large stage 4 sacral ulcer. Review of the Braden Scale for Predicting Pressure Sore Risk dated (MONTH) 16, (YEAR), revealed the resident was at low risk, despite having a stage 4 pressure ulcer. A physician's order dated (MONTH) 16, (YEAR) included to cleanse the sacral pressure ulcer with wound cleanser, pat dry, apply 1/4 strength Dakin's soaked sterile gauze to the wound bed and cover with a dry dressing. Further review of the clinical record revealed no documentation that the stage 4 pressure ulcer was thoroughly assessed on (MONTH) 16 or 17, (YEAR), which included any measurements, a description of the wound bed and surrounding skin and if any drainage was present. Review of the (MONTH) (YEAR) TAR revealed no documentation that the physician ordered treatment was provided to the sacral wound on (MONTH) 17 (night shift). A physician's progress note dated (MONTH) 17, (YEAR) included the resident had a chronic indwelling urinary catheter for a stage 4 sacral wound. A weekly pressure ulcer assessment was completed on (MONTH) 18, (YEAR) and revealed that the resident had a very large stage 4 sacral pressure ulceration, which was present on admit. The wound was described as having exposed necrotic bone and heavy necrotic soft eschar to the wound bed, with slough and no significant granulation. The wound had heavy serous to brownish drainage with moderate odor on dressing removal and no peri-wound inflammation was present. The was the first assessment of the stage 4 sacral pressure ulcer, which was done two days after admission. The assessment also did not include any wound measurements. A physician's wound progress note dated (MONTH) 18, (YEAR) included the resident has a very large sacral ulceration, with exposed necrotic bone on the wound bed. There is heavy necrotic soft eschar on the wound bed with slough. No significant granulation. Heavy serous to brownish drainage with moderate odor on dressing removal. No periwound inflammation. The plan included to turn the resident per facility protocol, continue dressing the sacral ulceration and a nutrition consultation. No measurements were included. A care plan dated (MONTH) 18, (YEAR) identified a problem of actual impairment to skin integrity related to pressure injury to the sacrum. A goal was that the resident would be free of injury though the next review date. Approaches included to educate resident/family/caregivers on causative factors and measures to prevent skin injury; follow facility protocols for treatment of [REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 23, (YEAR), revealed the resident was always incontinent of bowel and had an indwelling catheter. The MDS also included that the resident had a stage 4 pressure ulcer, which was present on admission. Review of the (MONTH) (YEAR) TAR revealed no documentation that the physician ordered treatment was provided to the sacral wound on (MONTH) 24 and 25 (day and night shifts) and on (MONTH) 29 (day shift). Review of the Braden Scale for Predicting Pressure Sore Risk dated (MONTH) 31, (YEAR) revealed the resident was at moderate risk. Review of the CNA documentation regarding assistance provided to the resident with bed mobility and toileting revealed no documentation of assistance provided on (MONTH) 20, 28, 29 or 31, (YEAR) on the night shift or on (MONTH) 30 on the day shift. Regarding assistance provided with turning and repositioning revealed no documentation of assistance provided on (MONTH) 16, 20, 28, 29 or 31, (YEAR) on the night shift or on (MONTH) 30 on the day shift. Regarding pressure ulcer devices in place revealed no documentation on (MONTH) 20, 28, 29 or 31, (YEAR) on the night shift and (MONTH) 30 on the day shift. Review of the (MONTH) 2019 TAR revealed no documentation that the physician ordered treatment to the sacral pressure ulcer was provided on the night shift on (MONTH) 1, 6 and 8. The next assessment of the sacral pressure ulcer was conducted nineteen days after the last assessment (which was done on (MONTH) 18). Per the weekly pressure ulcer assessment dated (MONTH) 7, 2019, the resident had a stage 4 pressure ulcer to the sacrum. The measurements were unclear as they were written as follows: 5.3.5 length and width, with a depth of 2.5 cm. The wound bed was described as beefy red, with attached wound edges and no exudate. This was the first documentation of any measurements of the stage 4 sacral pressure ulcer. A physician's order dated (MONTH) 9, 2019 included to cleanse the sacrum every day shift with wound cleanser, pat dry, apply Santyl ointment 250 units per gram to wound bed, apply [MEDICATION NAME] and cover with an island dressing. Physician orders dated (MONTH) 11, 2019 revealed to cleanse the sacrum with wound cleanser, pat dry, use skin prep to peri-wound, drape with tape, apply black foam to wound bed, apply wound vac at 125 millimeters of mercury (mmHg) continuous. Physician orders dated (MONTH) 12, 2019 included to discontinue the Santyl dressing once the wound vac was available. A weekly pressure ulcer assessment dated (MONTH) 14, 2019 revealed the resident had a very large sacral pressure ulcer stage 4, with exposed necrotic bone and heavy necrotic soft eschar on the wound bed with slough and no significant granulation. The assessment further noted heavy serous to brownish drainage with moderate odor on dressing removal and no peri-wound inflammation. The assessment did not include any wound measurements. A physician's order dated (MONTH) 15, 2019 revealed to cleanse the sacrum with wound cleanser, gently pack Dakin's 0.25% soaked Kerlix into wound bed and cover with an island dressing. Another treatment order dated (MONTH) 15, 2019 regarding the wound vac included to cleanse the sacrum with wound cleanser, pat dry, use skin prep to peri-wound, drape with tape, apply black foam to wound bed and apply wound vac at 125 millimeters of mercury (mmHg) continuous. Review of the (MONTH) 2019 TAR revealed no documentation that the sacral wound care was provided on (MONTH) 15. Review of the CNA documentation regarding assistance provided to the resident with bed mobility, toilet use and turning and repositioning revealed no documentation of assistance provided on (MONTH) 4, 5, 9, 12, 14, 2019 on the night shift and (MONTH) 17 on the day shift. Regarding pressure ulcer devices in place revealed no documentation on (MONTH) 4, 5, 9,12,14, 2019 on the night shift and (MONTH) 17 on the day shift. The clinical record documentation showed that the resident was admitted to the hospital on (MONTH) 18, and readmitted to the facility on (MONTH) 29, 2019. Review of the weekly pressure ulcer assessment dated (MONTH) 29, 2019 revealed the resident had a stage 4 pressure ulcer to the sacrum that was a deep beefy red full thickness wound and measured 9.5 cm in length by 11 cm in width by 5 cm in depth. The wound was described as now having 3 cm of undermining, moderate serosanguinous exudate with no odor and defined edges. This is the first documentation of clear measurements of the stage 4 sacral pressure ulcer. The physician orders dated (MONTH) 29, 2019 included to cleanse the sacral wound with wound cleanser or normal saline, apply wet to moist dressing with Dakin's and secure with tape every 12 hours until wound vac can be placed. A physician's order dated (MONTH) 29, 2019 included to cleanse the sacrum with wound cleanser, pat dry, apply no sting barrier skin prep to peri-wound skin, window frame wound with drape, apply black foam to sacral wounds, secure with additional drape, suction at continuous 125 mmHg. The order also included to change wound vac on Tuesday, Thursday, and Saturday, and as needed for malfunction or dislodgement and to monitor wound vac every shift for functioning and placement. Review of the provider's progress note dated (MONTH) 30, 2019 included the resident was admitted to the facility for rehabilitation and for wound care for a stage 4 decubitus ulcer of the sacral region and sacral osteo[DIAGNOSES REDACTED]. The note included that the sacral ulcer measured 7 cm by 6 cm by 5 cm and contained eschar/necrosis through to the muscle, tendon or bone. The note indicated to continue current dressing orders for wound care. Physician orders dated (MONTH) 2, 2019 included to cleanse the sacral wound with wound cleanser or normal saline, apply wet to moist dressing with Dakin's and secure with tape every 12 hours until wound vac can be placed started which was discontinued (MONTH) 6, 2019. A weekly pressure ulcer assessment dated (MONTH) 4, 2019 revealed the stage 4 pressure ulcer to the sacrum measured 9.5 cm length by 11 cm width, by 5 cm depth and 3 cm undermining. The wound bed was described as beefy red with no slough or eschar and has a moderate amount of serosanguinous exudate that now has a foul odor. A provider progress note dated (MONTH) 5, 2019 included the sacral ulcer measured 6 cm by 12.5 cm by 2.7 cm and contained eschar/necrosis through to the muscle, tendon or bone, and to continue current dressing orders. A care plan was initiated on (MONTH) 6, 2019 to reflect that the resident has a pressure ulcer to the sacrum and is at risk for further pressure ulcer development related to immobility, incontinence, diabetes mellitus and [MEDICAL CONDITION]. A goal included that the pressure ulcer will show signs of healing and remain free from infection. Interventions were as follows: administer treatments as ordered and monitor for effectiveness; assess/record/monitor wound healing, measure length, width and depth where possible; assess and document status of wound perimeter, wound bed and healing progress; report improvements and declines to the medical doctor; weekly head to toe skin at risk assessments and needs monitoring/reminding/assistance to turn and reposition. Review of the (MONTH) 2019 TAR revealed no documentation that wound vac monitoring was provided on (MONTH) 10. A physician's order dated (MONTH) 11, 2019 included to cleanse the sacrum wound with wound cleanser or normal saline, apply Dakin's 0.25% wet to moist dressing, cover with dressing and secure with tape every 12 hours. The next weekly pressure assessment was dated (MONTH) 13, 2019, which was nine day after the previous assessment (done on (MONTH) 4). The documentation revealed the stage 4 sacral pressure ulcer measured 7 cm length by 12 cm width by 4.5 cm depth, with 2.8 cm undermining. The wound bed was described as beefy red with a moderate amount of serosanguinous drainage, with no odor. The weekly pressure ulcer assessment dated (MONTH) 24, 2019 revealed the stage 4 sacral pressure ulcer measured 10 cm length by 7 cm width by 3.5 cm depth, with no undermining. The wound bed was described as beefy red with a moderate amount of serosanguinous drainage, with no odor. The next weekly pressure ulcer assessment was dated (MONTH) 6, 2019, which was 10 days after the previous assessment. The stage 4 sacral pressure ulcer measured 10 cm length by 6.8 cm width by 3.4 cm depth, with tunneling of 2.8 cm. The wound bed was described as having slough with a small amount of serosanguinous drainage, with no odor. Review of the weekly pressure ulcer assessment dated (MONTH) 13, 2019 revealed the stage 4 sacral pressure ulcer measured 9.2 cm length by 5.3 cm width by 3 cm depth and tunneling of 2.8 cm. The wound bed was described as beefy red with a moderate amount of serosanguinous drainage, with no odor and the wound edges are now rolling under. A wound observation of the resident was performed on (MONTH) 20, 2019 at 9:21 a.m. with a LPN/staff #19. The resident was observed lying on her back in bed. There was an intact dressing to the sacral area,with yellow, pinkish drainage to the dressing. Upon removal of the old dressing and packing, an odor was identified. The resident was observed to have a large deep oval pressure ulcer to the sacrum. The wound bed had a deep pink base with rolled edges and undermining was present. Staff #19 measured the wound and was 8.5 cm length 5.3 cm width by 2.5 cm deep, with tunneling of 2.3 cm between 10 to 1. The wound was identified by staff #19, as a stage 4 pressure wound which was present on admit. The weekly pressure ulcer assessment dated (MONTH) 20, 2019 revealed the stage 4 sacral pressure ulcer measured 8.5 cm length by 5.3 cm width by 2.5 cm depth and tunneling of 2.3 cm. The wound bed was described as normal for skin and had a moderate amount of serosanguinous drainage, with no odor and the wound edges are now undefined. Review of the CNA documentation regarding assistance provided to the resident with bed mobility revealed no documentation of assist provided on (MONTH) 2, 4, 9, 10, 13, 17, 19, 2019 on the night shift. Regarding assistance with turning and repositioning revealed no documentation of assistance provided on (MONTH) 2, 4, 9, 10, 13, 17, 20, 2019 on the night shift. Regarding assistance with toilet use revealed no documentation of assistance provided on (MONTH) 2, 4, 9, 10, 13, 17, 19, 2019 on the night shift. Regarding pressure ulcer devices in place revealed no documentation on (MONTH) 2, 9, 10, 13, 17, 20, 2019 on the night shift. Regarding the left heel deep tissue injury: According to the initial admission record dated (MONTH) 16, (YEAR), the resident was identified to have a superficial deep tissue injury (DTI) to the left heel. A physician's order dated (MONTH) 16, (YEAR) included to float heels as tolerated. Review of the (MONTH) (YEAR) TAR revealed no documentation that the heels were floated on (MONTH) 17, on the night shift. A physician's order was obtained on (MONTH) 17, (YEAR) to cleanse the left heel with wound cleanser, pat dry, apply [MEDICATION NAME], and cover with foam dressing. A care plan dated (MONTH) 18, (YEAR) identified a problem of actual impairment to skin integrity related to pressure injuries to the left and right heel. A goal included the resident would be free of injury though the review date. Approaches included to educate resident/family/caregivers on causative factors and measures to prevent skin injury; follow facility protocols for treatment of [REDACTED]. Review of the (MONTH) (YEAR) TAR revealed no documentation that the heel wound treatment was provided on (MONTH) 29. Review of the clinical record revealed no documentation that a weekly skin assessment was completed during the week of (MONTH) 23-29, (YEAR). A weekly skin evaluation dated (MONTH) 31, (YEAR) revealed the resident's bilateral heels were non blanchable. According to the (MONTH) 2019 TAR, there was no documentation that the resident's heels were floated on (MONTH) 1, 8 and 13 on the night shift and on (MONTH) 15 (day and night shift). A weekly skin evaluation dated (MONTH) 7, 2019 included the bilateral heels had healed. A wound care observation was performed on (MONTH) 20, 2019 at 9:21 a.m. The resident was not observed to have any wounds to the heels. An interview was conducted with a Certified Nursing Assistant (staff #42) on (MONTH) 20, 2019 at 1:59 p.m. She stated that residents would be at risk for pressure ulcers if staff were not cleansing residents well after incontinence, if left in a wet brief, and if a resident stayed in the same position too long. She stated that residents are repositioned every two hours and receive indwelling catheter care at least one time each eight hour shift by the CNA's. She stated that catheter tubing could cause pressure and staff could place a towel between the skin and catheter tubing and to make sure there is slack in the tubing between the stat Lock (indwelling urinary catheter stabilization device) and the insertion site. She stated that during catheter care, staff should lift the tubing when cleaning and visualize the skin beneath the tubing, and if she noticed any skin changes she would tell the nurse right away to come and assess the area. She stated that a resident should not develop a pressure ulcer under the indwelling urinary catheter tubing. Staff #42 said that she received in-services regarding residents with indwelling catheters and that staff were told to ensure that the skin was intact beneath the indwelling catheter tubing. She stated that during the training the wounds on resident #4's thighs were presented to the CNA's as pressure ulcers and were avoidable. An interview was conducted with a CNA (staff #3) on (MONTH) 20, 2019 at 2:23 p.m. She stated that pressure injuries could result from not positioning a resident often enough and improper placement of the catheter tubing. She stated the catheter tubing should be placed under the stat lock unless the resident refuses. She said that she would immediately report any changes to the skin to the nurse. She stated that resident #4 developed wounds from the indwelling catheter tubing, because the tubing was between her legs and her legs were pressing together which created pressure. She stated the CNA does catheter care every time the brief is changed. She stated that for staff to complete good catheter/peri-care, the resident would need to spread her legs, so staff can lift the catheter tubing to clean it and to look at the skin. She stated that she was told the wounds were pressure ulcers and were caused by the catheter tubing and the wounds should not have occurred. She also stated that residents receive repositioning every two hours. An interview was conducted with a CNA (staff #21) on (MONTH) 21, 2019 at 9:33 a.m. He stated that staff are expected to have 100% of their documentation completed by the end of the shift, and are to document after the care has been completed. He stated that there should not be any blanks in the documentation and if the care is not documented, then there is no proof that they did the care. He stated this resident is pretty compliant with her care. An interview was conducted with a LPN (staff #59) on (MONTH) 21, 2019 at 10:21 a.m. She stated that a resident is at risk for skin breakdown, if they are not repositioned often enough, if anything is sitting on the skin too long, if the resident does not have what they need for pressure relief and outside devices. She stated that an indwelling urinary catheter could cause a pressure injury, if the tubing is improperly placed (example: between areas of skin that are touching) or if a stat lock is improperly located. She stated that staff were told to be careful of the placement of the catheter tubing, and to be sure the stat lock position was being alternated. She stated that pressure wounds from medical devices/indwelling catheters would not be unavoidable. She stated that indwelling catheter care is completed each shift and that good care would include separating the resident's legs, lifting the tube and visualizing the peri area and under the tubing, as well as around the stat lock. She stated that any changes should be reported to the nurse as soon as the care is completed. She stated that she was aware of the pressure ulcer formation from the indwelling catheter tubing on resident #4 and that it was included in the shift to shift report. She stated the CNA's were made aware that the wounds were caused by pressure and were avoidable, and that the wounds could have been prevented with appropriate care and moving of the indwelling catheter tubing. She also stated there should not be blanks in the MARs/TARs and that a blank spot would mean the care was not given. She stated the risk of not doing wound care would be the wound could get worse or not show improvement. Staff #59 said if a resident's heels were not floated, the resident could get pressure ulcers in that area. At this time, she reviewed the holes in the TARs for resident #4 and stated that staff did not follow the expectation of the facility. Another interview was conducted with staff #19 on (MONTH) 21, 2019 at 12:05 p.m. He stated that the procedure followed by the facility for a new resident included assessing the resident's skin integrity. He stated the nurse does a skin assessment during the admission process to identify any skin integrity issues, including wounds. He",2020-09-01
258,HERITAGE COURT POST ACUTE OF SCOTTSDALE,35083,3339 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2019-03-22,689,G,0,1,Y7PT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, resident and staff interviews, facility documentation and policy review, the facility failed to ensure that safety measures and adequate supervision were provided to one resident (#2) who sustained a fall with injuries. The number of residents with falls was 6. The deficient practice could result in further falls with injuries. Findings include: Resident #2 was admitted to the facility on (MONTH) 30, (YEAR) and readmitted (MONTH) 9, 2019, with [DIAGNOSES REDACTED]. Review of a fall risk evaluation dated (MONTH) 30, (YEAR) revealed a fall risk score of 8, which indicated the resident was at medium risk for falls. The initial care plan with an effective date of (MONTH) 30, (YEAR) revealed the resident was at risk for falls. Interventions included keeping the bed in the lowest position and having a floor mat at the bedside. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 7, (YEAR) revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The assessment included the resident had [MEDICAL CONDITION] and required extensive assistance of two, with bed mobility and toilet use. The MDS also included the resident had no falls within the last 6 months or since admission. The comprehensive care plan dated (MONTH) 11, (YEAR) revealed the resident was at risk for falls with a goal to decrease the likelihood of falls. Interventions included keeping the bed in the lowest position and a floor mat at the bedside. The care plan also included the resident had ADL (activities of daily living) self care deficits related to [MEDICAL CONDITION]. Interventions included keeping the air activated call light within reach and that the resident required total assistance with transfers. Review of a fall risk evaluation dated (MONTH) 9, (YEAR) revealed a fall risk score of 9, which indicated the resident was at medium risk for falls. Review of a nursing progress note dated (MONTH) 24, 2019 at 7:17 a.m., revealed Heard a loud sound at the nursing station minutes after leaving resident's room/after repositioning lower legs back onto the resident lowered bed and medicating him. Resident found lying face down on the floor of his room in a pool of blood at his head . The note included the resident was assessed and observed to have a one and a half inch laceration under the left zygomatic arch, a half inch laceration to the left upper forehead and a slight amount of fresh blood from the left side of his mouth. Neurological assessments were initiated per their protocol. The note also included meticulous perineal care was given to the resident due to having a large formed bowel movement. The note did not include if a floor mat was in place at the time of the fall. The fall risk evaluation dated (MONTH) 24, (YEAR) revealed a fall risk score of 8. A nursing progress note dated (MONTH) 24, 2019 at 8:18 a.m. revealed 4 steri-strips were applied to the left zygomatic arch laceration and was reinforced with a heavy tight compression bandage, due to active bleeding. The note included the resident was transported to the hospital via ambulance. Review of the Nursing Home to Hospital Transfer form dated (MONTH) 24, 2019 revealed the resident was transported to the hospital, due to a fall and that the resident was having facial pain. Review of the hospital After Visit Summary dated (MONTH) 24, 2019, revealed the resident had a closed head injury and facial lacerations. The summary included a CT scan of the head/brain which revealed no evidence of an acute intracranial abnormality. The summary also included sutures were applied to the lacerations. A nursing progress note dated (MONTH) 24, 2019 at 11:45 a.m. revealed the resident returned to the facility via stretcher by medical transport. The note included the resident was observed to have an abrasion to the right shoulder and sutures to the left cheek bone. Review of the fall investigation report dated (MONTH) 24, 2019 revealed the fall occurred in the resident's room and that the resident stated that he moved his legs off the edge of the bed and fell . The report included the physician was notified and that orders were received to apply steri-strips to the left zygomatic arch and transfer the resident to the hospital. The report did not include documentation if the floor mat was in place at the time of the fall. Review of the Certified Nursing Assistant task documentation for fall prevention devices dated (MONTH) 2019 revealed documentation of a low bed, but did not include documentation that mats were to be on the floor, until after the resident fell . An interdisciplinary team fall committee progress note dated (MONTH) 25, 2019 revealed the fall was reviewed. The note included implementing a low bed with a floor mat to prevent further fall related injuries and that the resident agreed. During an interview conducted with residents on (MONTH) 20, 2019 at 10:13 a.m., they stated that the facility is understaffed and that residents are constantly crying out for help. One of the residents stated that they heard resident #2 calling for help and that he fell out of bed, and the next time they saw him he had stitches all over his face. An observation was conducted of the resident on (MONTH) 22, 2019 at 10:37 a.m. The resident was observed sleeping in the bed with a mat on the floor by the bed. An interview was conducted with resident #2 on (MONTH) 22, 2019 at 12:00 p.m. He stated that he woke up on the edge of the bed and that his call tube (air activated call light) was not next to him so he yelled for about 20 minutes and ended up falling off the edge of the bed. The resident stated that he hit a rolling table as he fell . He also stated that he received two wounds from the fall that required sutures. He stated that only two people were working the floor that day. The resident stated that there was never a mat on the floor beside his bed before he fell . During an interview conducted with a Certified Nursing Assistant (CNA/staff #55) on (MONTH) 22, 2019 at 10:40 a.m., the CNA stated that residents who are fall risks have their beds in the lowest position with the call light in reach, and with mats on the floor. She stated that resident #2 is a fall risk and now has a larger bed, with mats on the floor. An interview was conducted with a Registered Nurse (RN/staff #14) on (MONTH) 22, 2019 at 10:56 a.m. The RN stated that all residents are assessed for fall risk when they are admitted . She stated that for residents who are a fall risk, staff will ensure there is no clutter in the room, the call light is within reach, the bed is in the lowest position, and/or a floor mat is beside the bed. She stated that if the resident is care planned for a floor mat beside the bed, an order should be obtained and it should be on the Treatment Administration Record. The RN stated that resident #2 is at risk for falls and has had a fall. She stated if a floor mat is on his care plan, then there should have been a floor mat beside his bed. The RN also stated a resident's risk for injury is increased when fall interventions are not implemented, and if a floor mat was not in place the resident could hit their head on the floor. An interview was conducted with the Director of Nursing (DON/staff #72) on (MONTH) 22, 2019 at 12:29 p.m. The DON stated residents are assessed for fall risk on admission, quarterly, and as needed after a fall. She stated a fall care plan is initiated with interventions for residents that are assessed at risk for falls. The DON stated if the interventions included a low bed and a floor mat, her expectation is that staff implement the interventions. She also stated that if a floor mat is on the care plan, a physician's order should be obtained. Review of the facility policy titled, Fall Management System revealed each resident is provided with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. The policy included care plan interventions will be developed to prevent falls and will consider the particular elements of the assessment that put the resident at risk. The policy also included each resident is assisted in maintaining their highest practicable level of function, by providing the resident adequate supervision to prevent accidents.",2020-09-01
259,HERITAGE COURT POST ACUTE OF SCOTTSDALE,35083,3339 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2019-03-22,692,E,0,1,Y7PT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to obtain weights for 1 of 3 sampled residents (#29) who was identified to have severe malnutrition, and failed to modify the plan of care to include additional interventions to address the resident's non compliance. The deficient practice places residents at risk for the potential for nutritional decline. Findings include: Resident #29 was admitted on (MONTH) 20, (YEAR), with [DIAGNOSES REDACTED]. The nursing admission note dated (MONTH) 20, (YEAR) included the resident was admitted at the facility following an 83 day hospitalization stay for a septic open wound. The note included the resident was alert and oriented x 4 and was able to make needs known. A Braden Scale dated (MONTH) 20, (YEAR) included the resident's nutrition was very poor. Clinical record documentation included the resident had a PEG (percutaneous endoscopic gastrostomy) tube in place. Admission physician's orders [REDACTED]. -Regular diet, regular texture and thin liquids -Weekly weights x 4 every day shift for 4 weeks. -Vitamin A (supplement) 1000 units 1 capsule by mouth daily -Vitamin C (supplement) 500 mg (milligrams) 1 tablet by mouth daily -[MEDICATION NAME] (supplement) 325 mg 1 tablet daily -Flush tube feeding with 30 ml water before and after medication administration and after disconnecting tube feeding. A daily skilled note dated (MONTH) 21, (YEAR) included the resident was receiving and tolerating enteral feedings and was receiving pleasure feedings for oral gratification. Review of the clinical record revealed there was no documentation that the resident's weight was obtained on (MONTH) 20 or 21, (YEAR). There was no documentation that the resident refused to be weighed at this time. Review of the dietary admission evaluation dated (MONTH) 21, (YEAR) revealed the resident was on a regular diet, thin liquid consistency and enteral nutrition. The resident's height was 65 inches. Under weight history, it was documented that the resident's weight was 166.54 lbs per a History and Physical (from (MONTH) 8, (YEAR)). This weight was approximately six weeks prior to admission, when the resident was in the hospital. Per the evaluation, the resident had increased protein needs related to nutrient loss as evidenced by wound healing, and that the tube feeding was likely indicated for supplemental nutrition to promote wound healing. Recommendations included for [MEDICATION NAME] (enteral feeding/nutritional supplement) and to continue to monitor oral intake and weight change. A nutritional care plan dated (MONTH) 21, (YEAR) included the resident had a nutritional problem related to increased nutrient needs, due to nutrient loss. Interventions included for medications, supplements, tube feeding, weights as ordered, and to monitor and document intake and report to the physician any signs and symptoms of decreased appetite and unexpected weight loss. According to the meal intake percentages, the resident refused lunch and dinner on (MONTH) 21, (YEAR). A physician's admission note dated (MONTH) 21, (YEAR) included the resident was alert and oriented to person, place and time. Physical examination included the resident was alert and weak appearing and had an extensive sacral open wound with graft. Under assessments, the note included the following Diagnoses: [REDACTED]. Physician orders [REDACTED]. -[MEDICATION NAME] 1.5 (enteral feeding) at 75 ml (milliliters)/hour or until 1500 ml is infused with 30 ml/hour for 20 hours per PEG tube. -Prostat (liquid protein supplement) 30 ml mixed with 60 ml water via tube feeding twice daily or 30 ml by mouth twice daily and may mix with 4 ounces fluid of choice. These orders were transcribed onto the (MONTH) (YEAR) MAR (Medication Administration Record) and revealed the resident refused the [MEDICATION NAME] on (MONTH) 22 for the morning feeding and on (MONTH) 23 for the morning and afternoon feeding. A daily skilled note dated (MONTH) 22, (YEAR) included the resident refused the feeding and the physician was notified. The meal intake percentages included documentation that the resident refused breakfast, lunch and dinner on (MONTH) 22. A physician's note dated (MONTH) 23, (YEAR) included the resident was feeling nauseous on tube feeds. Physical examination included the resident was alert and weak appearing and had protein energy malnutrition, severe malnutrition and was on tube feeding, with oral intake as tolerated. The daily skilled note dated (MONTH) 24, (YEAR) included the resident was alert and oriented x 2, was anorexic and had refused enteral feeding or any food. Per the note, the resident drank a lot of soda. Another nursing note dated (MONTH) 24, (YEAR) revealed the resident refused to take any vitamins/minerals. The meal intake percentages also included the resident refused breakfast and lunch on (MONTH) 24, (YEAR). There was no clinical record documentation that the physician was notified that the resident had refused feedings/meals on (MONTH) 24. A daily skilled note dated (MONTH) 25, (YEAR) included the resident refused to eat anything/tube feeding and the physician was notified. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. The documentation included that a weight was due on (MONTH) 25, however, the area to document the weight was blank. Further review of the (MONTH) (YEAR) MAR indicated [REDACTED]. A physician's progress note dated (MONTH) 26, (YEAR) included the resident had low oral intake. Physical examination included the resident was alert and weak appearing and had [MEDICAL CONDITION] of chronic disease, chronic non healing abdominal wound, protein energy malnutrition and severe malnutrition. The note included the resident was refusing tube feeding, with oral intake as tolerated. Continued review of the clinical record revealed there was no documentation that the resident was weighed from admission through (MONTH) 26, (YEAR), despite the resident frequently refusing tube feedings/meals, Prostat and vitamins/minerals. There was also no documentation that the resident refused to be weighed during this time frame. In addition, there was no evidence that the resident was informed of the risks associated with refusing tube feedings/meals, Prostat and vitamins/minerals, nor was there documentation that the resident was offered any alternatives or that additional interventions were implemented to address the resident's non compliance. An admission MDS (Minimum Data Set) assessment dated (MONTH) 27, (YEAR) included a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. The MDS also identified that the resident was on tube feeding, had no swallowing problems and received 51% or more total calories via tube feeding. There was no weight entered in the MDS assessment. A nursing note dated (MONTH) 27, (YEAR) included the tube feeding resumed per the resident's request. A physician's progress note dated (MONTH) 28, (YEAR) revealed the resident was restarted on tube feeding after prolonged discussion with the resident. Physical examination included the resident was alert and weak appearing and had [MEDICAL CONDITION] of chronic disease, chronic non healing abdominal wound, protein energy malnutrition and severe malnutrition. The meal intake percentages included the resident refused lunch on (MONTH) 28. A daily skilled note dated (MONTH) 29, (YEAR) included the resident refused feedings. A physician's orders [REDACTED]. This order was transcribed onto the MAR. Per the MAR, the entry was coded as 1 indicating the resident refused. Further review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Continued review of the meal intake percentage records for (MONTH) (YEAR) revealed the resident was mostly coded as 0 indicating the resident consumed 2-25% of his meal and 0% of meal alternates. Review of the resident's care plans revealed that none of the care plans addressed the resident's refusal of tube feedings/meals, supplements and weight. A daily skilled note dated (MONTH) 2, (YEAR) included the resident continued to refuse all vitamins and minerals. physician progress notes [REDACTED]. A nursing note dated (MONTH) 9, (YEAR) included the resident refused to get weighed after 3 unsuccessful attempts and the nurse was informed. However, the documentation did not include that the physician was notified. A physician's note dated (MONTH) 10, (YEAR) included the resident's wound was positive for Pseudomonas. The note also documented the resident refused tube feedings. A physician's note dated (MONTH) 12, (YEAR) included the resident refused tube feedings, but was tolerating oral intake and tube feeding. Daily skilled notes dated (MONTH) 12 and 13, (YEAR) included the resident was tolerating enteral feedings and was receiving pleasure feedings for oral gratification. A change in condition note dated (MONTH) 14, (YEAR) included the resident declined his feeding. A physician's progress note dated (MONTH) 14, (YEAR) revealed the resident was refusing tube feedings, but was tolerating oral intake and tube feeding. A physician's orders [REDACTED]. On (MONTH) 24, (YEAR), a physician's progress note documented the resident was scheduled for 1 unit of PRBC (packed red blood cell) transfusion for [DIAGNOSES REDACTED]. The CNA (certified nursing assistant) documentation for (MONTH) (YEAR) included the resident refused to be weighed on (MONTH) 3, 9, 16, 23 and 30, (YEAR). However, there was no evidence found in the clinical record that the physician was notified of the resident's refusal to be weighed as ordered. In addition, there was no clinical record documentation that the resident's dietary needs were re-assessed since the last dietary assessment on 11/21/18 through 12/25/18, despite the resident's ongoing refusal of tube feedings/meals, supplements and weight. There was also no documentation that additional interventions were attempted or implemented to address the resident's refusals; such as offering other types of protein supplements, fortified foods and food choices based on the resident's preferences. A Nutrition Interdisciplinary Team Update note dated (MONTH) 26, (YEAR) revealed to continue the plan of care, which included tube feedings and supplements. Per the note, laboratory results were reviewed and the resident's current body weight was requested. The resident continued with varied oral intake with average meal percent intake of 50%. The note did not address the resident's refusals of meals, tube feedings, the Prostat and vitamins/minerals. There were also no new interventions which were recommended at this time. A physician's note dated (MONTH) 28, (YEAR) included the resident was refusing tube feeding and was tolerating oral intake well, and that it was okay to wean off of tube feeding. However, the meal intake percentages for (MONTH) (YEAR) revealed the resident refused meals on multiple dates. The meal percentages were coded with a 0 indicating 0-25% intake and 1 indicating 26%-50% majority of the time. A nursing note dated (MONTH) 5, 2019 included the resident was transferred to the hospital because of increased drainage from the wound site. A Change in Condition note dated (MONTH) 6, 2019 included the resident returned from the hospital. Review of the CNA documentation from (MONTH) 1 through 6, 2019 revealed the resident refused to be weighed on (MONTH) 6. According to the (MONTH) 2019 MAR, the resident refused tube feedings, Prostat, vitamin C, vitamin A and [MEDICATION NAME] sulfate multiple times from (MONTH) 1-16. A physician's note dated (MONTH) 14, 2019 included the resident had an episode of emesis with nausea and a low grade fever. It included to monitor hemoglobin and if trending down, transfusion will be arranged. Review of the Nutrition Interdisciplinary Team Update note dated (MONTH) 16, 2019, revealed the resident continued with varied oral intake and was likely not meeting needs to promote healing. The note included that per nursing, the resident self-directs weights. It also included the resident received Prostat, vitamin A, vitamin C and [MEDICATION NAME] sulfate. The plan was to continue the plan of care. There was no current body weight listed. There was also no documentation that addressed the resident's frequent refusal of tube feedings, meals, Prostat, vitamin A, vitamin C and [MEDICATION NAME] sulfate. and there were no new interventions which were recommended. A physician's note dated (MONTH) 21, 2019 included the resident had a low grade fever and wounds were improving slowly. The note also included for increased free water via tube for dehydration. The physician note dated (MONTH) 23, 2019 included the resident had a fever related to UTI (urinary tract infection), had received 2 liters of IVF (intravenous fluid) and was started on antibiotic for 7 days. A physician's note dated (MONTH) 28, 2019 included the resident continued to be on antibiotic for UTI. It also included slow improvement to the wound and the resident had a low hemoglobin and that a transfusion will be arranged. The CNA documentation from (MONTH) 7 through 31, 2019 revealed the resident refused to be weighed on (MONTH) 27. The MAR from (MONTH) 17 through 31, 2019 included the resident continued to refuse tube feeding, meals, Prostat, vitamin A, vitamin C and [MEDICATION NAME] sulfate. The meal intake percentages for (MONTH) 2019 revealed the resident refused meals on multiple dates and the intake amount was coded as 0 indicating 0-25% and 1 indicating 26%-50% majority of the time. Despite documentation of the resident's ongoing refusals of tube feedings, meals, supplements and weights in (MONTH) 2019, there was no evidence in the clinical record that additional interventions were attempted or implemented to address the resident's refusals; such as offering foods in accordance with the resident's likes and preferences, offering fortified foods (ingredients added to food which adds calories) or other types of oral protein supplements. There was also no documentation that the risks associated with continued refusals of feedings, supplements and weights were explained to the resident. A dietary note dated (MONTH) 1, 2019 included the resident was refusing tube feedings, so the dietician recommended to discontinue the tube feedings and add 100 ml free water twice daily for tube patency. Per the note, the resident self directs food and fluid intake, has outside food available and had refused all attempts to obtain a weight. The plan was to continue to monitor and proceed with the plan of care. Other than discontinuing the tube feedings, there were no additional interventions recommended. The physician note dated (MONTH) 1, 2019 included the resident had a low grade fever and to wean the resident off tube feedings per dietary and that the resident was tolerating oral intake. The nutritional care plan was revised on (MONTH) 1, 2019 to include that the tube feedings were discontinued related to the resident's refusal. A physician's orders [REDACTED]. A care plan was initiated on (MONTH) 3, 2019, which identified that the resident was resistive to care, as evidenced by refusal of tube feeding and refusal to be weighed. The care plan also included the resident self-directs care. An intervention included educating the resident of the possible outcome of not complying with treatment or care. This care plan was developed more than two months after the resident was identified to frequently refuse tube feedings, meals, supplements and weights. Review of the CNA documentation revealed the resident refused breakfast on 2/4/19 and lunch on 2/6/19. The physician note dated (MONTH) 8, 2019 included the resident's hemoglobin was low and will direct admit to the hospital for 2 units of PRBC (packed red blood cells) transfusion for chronic blood loss. A physician's note dated (MONTH) 11, 2019 included the resident was off tube feeds. The quarterly dietary evaluation dated (MONTH) 15, 2019 included the resident consumed 85% of Prostat and had oral meal intakes of 70% and that the resident's oral intake has improved. The resident continues to self direct weights, food and fluid intakes. According to the CNA documentation for (MONTH) 2019, the resident refused breakfast on 2/16, lunch on/2/17 and breakfast on 2/18. Review of the CNA documentation for (MONTH) 2019 revealed the resident refused to be weighed on (MONTH) 3, 9 and 17. A physician's note dated (MONTH) 18, 2019 included the resident had the transfusion and had complex medical issues. The nutrition IDT note dated (MONTH) 19, 2019 included the resident continued with varied oral intakes mostly 75% of meals and 100% of 30 ml Prostat. Per the note, the resident receives vitamin A, vitamin C and [MEDICATION NAME] sulfate. The resident continues to self direct weights and nutrition as evidenced by refusing tube feeding. Tube feeding was previously changed to 100 ml water twice daily related to refusing feeds. The IDT recommendation was to continue plan of care. The CNA documentation showed that on 2/20, the resident refused breakfast and dinner, and on 2/21 2/22, 2/25 and 2/26 refused breakfast and lunch. A nutrition IDT note dated (MONTH) 26, 2019 included the dietician was notified that if resident has poor meal intake, the physician requested to re-initiate tube feeding orders. Per the note, the resident declined to speak with the dietician. The documentation included the resident had a history of [REDACTED]. A physician's orders [REDACTED]. A physician's note dated (MONTH) 27, 2019 included the resident had an upper respiratory infection likely due to flu and had a positive urinalysis and was started on Bactrim (antibiotic). Review of the MAR for (MONTH) 2019 revealed the resident continued to refuse the Prostat, vitamin A, vitamin C and [MEDICATION NAME] sulfate on numerous occasions. An interview with a CNA (certified nursing assistant/staff #55) was conducted on (MONTH) 19, 2019 at 12:58 p.m. She stated the CNA's complete daily weights and weekly weights. She said if weight loss is identified, it is reported immediately to the DON (Director of Nursing) and/or the nurse. She stated if a resident is not eating, the resident is encouraged to eat and offered alternate foods. An interview with the dietary manager (staff #7) was conducted on (MONTH) 21, 2019 at 11:30 a.m. She stated weights are done weekly and that any issues related to weight will be addressed by the registered dietician (staff #75) and the dietary technician (staff #77). She stated that residents with weight issues are discussed during the NAR (Nutrition at Risk) weekly meetings and if there are any interventions related to food modifications, she will ensure they are implemented. She stated the nursing department ensures that supplements are administered as ordered. An interview with the dietary technician (staff #77) was conducted on (MONTH) 21, 2019 at 12:45 p.m. She stated that she is responsible for conducting the initial assessment of a resident upon admission, and the quarterly assessments. Staff #77 said if there is no height and/or weight available for the initial assessment, she will use the information from the History and Physical (from the hospital). She said the succeeding assessments such as the quarterly assessments, will be based on information and weights recorded in the electronic record. During an interview with the registered dietician (staff #75) conducted on (MONTH) 22, 2019 at 10:14 a.m., she stated the dietary technician writes weekly weight notes if there is a 2% weight gain or loss, and this will be discussed in the weekly weight meetings, and that recommendations are made to address the identified concerns. She stated that she does not review recommendations because she is not involved with the weekly weight meetings, unless they have asked her to assess and evaluate a specific resident whom the facility identified as having difficulty in weight management. She stated that she is responsible for assessing the nutritional needs of high risk residents, which included residents with wounds, on tube feedings or on [MEDICAL TREATMENT]. She stated for these high risk residents, she will write monthly notes. Regarding resident #29, staff #75 stated the resident refused to have his weight taken, because for the most part he self-directs a lot of his care. She stated that she attempted to talk with the resident, but he refused to talk to her. She said she informed the provider regarding the resident's refusal to measure his weight. She said when she completed her assessment of resident #29, she used the data from the laboratories, her knowledge that the resident orders outside food, and that the resident was receiving Prostat. She stated Prostat is a protein supplement which provides the resident 100 calories and 15 grams of protein per ounce. She stated the facility does have another way to measure a resident's weight by using the chair scale, but the resident also refused this. She said that she has not tried any other means to measure the resident's weight. During an interview with a registered nurse (RN/staff #14) conducted on (MONTH) 22, 2019 at 11:43 a.m., she stated the resident is alert and oriented, can verbalize his wants and needs, refuses a lot of care, and has a huge wound on his bottom which is bad. Staff #14 stated the resident once had his tube feeding removed because he refused, but the resident started to not eat so it was put back in. She also stated the resident refused to be weighed and she does not know why, but figured it was because of his wounds, tube feeding and a lot of things going on. Another interview with staff #77 was conducted on (MONTH) 22, 2019 at 12:04 p.m. She stated that when she conducts her assessment of a resident's nutritional needs, she uses the following data from the clinical record: diagnoses, height, weight, skin condition, appetite, BMI (body mass index), medications and laboratory results. She said if and when any of this data is missing such as height and weight, she will send a tiger text message (a message in the resident's computerized electronic record) to the DON and MDS coordinator. She stated that depending on when the assessment is due, if the DON and the MDS coordinator do not respond to her right away, she will use the data from the History and Physical and will document it in her assessment where the data came from. She said that residents with weight loss, pressure ulcers, wounds and residents who refuse weights are discussed during the weekly dietary meetings. She stated she does not know why resident #29 refused to be weighed. She stated the resident has snacks inside his room and has outside food delivered. Staff #77 stated that if resident #29 would allow her, she could measure arm circumference, but it is not a reliable way in determining weight loss or weight gain, but it is an alternate method. When asked how she ensures that resident #29 is meeting his nutritional needs, staff #77 stated I know what you mean but did not elaborate further. Review of the Weight policy revealed, It is the policy of this facility to obtain an accurate weight as part of the resident's assessment upon admission and at least monthly thereafter. A policy titled, Nutrition included to ensure that all residents maintain acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible. The policy further stated to provide care and services including .defining and implementing interventions for maintaining or improving nutritional status that are consistent with resident needs, goals, and recognized standards of practice, or explaining adequately in the medical record why the facility could not or should not do so; and monitoring and evaluating the resident's response or lack of response to the interventions; and revising or discontinuing the approaches as appropriate, or justifying the continuation of current approaches.",2020-09-01
260,HERITAGE COURT POST ACUTE OF SCOTTSDALE,35083,3339 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2019-03-22,755,D,0,1,Y7PT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interviews, and policy review, the facility failed to ensure the account of narcotics for two sampled residents (#240 and #33) were accurate. This deficient practice could result in misappropriation of residents' narcotic medications. Findings include: -Resident #240 was admitted to the facility on (MONTH) 4, 2019 with [DIAGNOSES REDACTED]. Review of the clinical record revealed a physician order [REDACTED]. Review of the Medication Administration Record [REDACTED]. An observation was conducted on (MONTH) 20, 2019 at 7:15 a.m. of staff #15 and a Licensed Practical Nurse (LPN/staff #9) reconciling narcotics at shift change. Review of the narcotic sheet for resident #240 dated (MONTH) 2019 revealed there were 22 [MEDICATION NAME] pills available. However, review of the blister package containing the [MEDICATION NAME] pills revealed there were 23 pills available. -Resident #33 was admitted to the facility on (MONTH) 1, 2019 with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of the MAR indicated [REDACTED]. During the same observation conducted of the RN and LPN reconciling narcotics on (MONTH) 20, 2019, review of resident #33 narcotic sheet for [MEDICATION NAME] revealed there should be 26 [MEDICATION NAME] pills available. However, review of the blister package containing the [MEDICATION NAME] pills revealed there were 25 [MEDICATION NAME] pills available. An interview was conducted with staff #15 immediately following the observation. Staff #15 stated that during the early morning hours of (MONTH) 20, 2019 she mistakenly removed a [MEDICATION NAME] 5-325 mg from the blister package for resident #33 and administered it to resident #240. Staff #15 stated that one resident's medication cannot be administered to another resident. The RN stated that this discrepancy needed to be reported immediately to the Director of Nursing and the physician. An interview was conducted with the corporate RN (staff #68) on (MONTH) 20, 2019 at 7:25 a.m. Staff #68 stated that the administration of medication designated for one resident being administered to a different resident is a medication error. Staff #68 further stated the expectation is that there are no discrepancies in the reconciliation of narcotic medications. The facility's policy regarding pharmacy services and narcotic count included the following: It is the policy of this facility to justify amount of narcotics remaining when control of supply is released to the nurse coming on duty. Procedures: One RN going off duty and one LPN coming on duty must count and justify narcotics supply for each individual resident at the exchange of each shift. If the count is not correct the nurse going off duty is not to leave until the count is correct. Every effort is made to reconcile the count and notify the DON of any discrepancy immediately.",2020-09-01
261,HERITAGE COURT POST ACUTE OF SCOTTSDALE,35083,3339 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2019-03-22,756,D,0,1,Y7PT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy review, the facility failed to ensure the pharmacist identified irregularities during the medication regimen review (MRR) for 1 of 5 sampled residents (#7) receiving [MEDICAL CONDITION] medications. This deficient practice could result in the administration of unnecessary medications. Findings include: Resident #7 was admitted on (MONTH) 5, (YEAR) with [DIAGNOSES REDACTED]. Review of the clinical record revealed physician's orders [REDACTED]. The Medication Administration Records (MAR) for (MONTH) through (MONTH) (YEAR) and (MONTH) through (MONTH) 2019 revealed [MEDICATION NAME] and [MEDICATION NAME] were administered as ordered. Review of the behavior monitoring on the MARs for (MONTH) through (MONTH) 2019 revealed the resident displayed no anxiety or depression behaviors except for (MONTH) 1, 2019. On (MONTH) 1, 2019 on the night shift there was documentation that the resident had 2 episodes of anxiety. Review of the MRR for (MONTH) through (MONTH) 2019 did not reveal a recommendation or a contraindication for a gradual dose reduction of [MEDICATION NAME] and [MEDICATION NAME]. The MRRs revealed documentation that the resident's medication regimen contained no new irregularities. An interview was conducted on (MONTH) 22, 2019 at 10:33 a.m. with the Director of Nursing (DON/staff #72) and the Administrator (staff #71). The DON stated that she and the pharmacist review all [MEDICAL CONDITION] medications monthly and discuss gradual dose reductions. She stated the pharmacist is responsible for tracking and scheduling the required gradual dose reductions. The DON stated that if the required dose reduction is contraindicated, the pharmacist will document the recommendation and the contraindication will be added to the physician's orders [REDACTED]. During an interview conducted with the consulting pharmacist (staff #80) on (MONTH) 22, 2019, the pharmacist stated that the [MEDICATION NAME] and [MEDICATION NAME] were not appropriate for gradual dose reductions. The pharmacist stated that they do not do GDRs on antianxiety medications and that they only recommend annual GDRs for antidepressants. The facility's policy titled Medication Regimen Review (MRR), Revised 8/2017, revealed the pharmacist reviews each resident's medication regimen at least once a month in order to identify irregularities. The policy also included that in performing the drug regimen review, the Pharmacist utilizes federally mandated standards of care. Review of the facility's policy titled Psychoactive Medication, Revised 5/2007, reviewed 11/17, revealed the facility should attempt to taper psychoactive medications per recommended guidelines. The policy included that tapering may be indicated when the resident's clinical condition has improved or stabilized, the underlying causes of the original target symptoms have resolved, or other interventions have been effective in reducing the symptoms. The policy also included the physician will document in the clinical record any contraindications to gradual dose reduction or rationale for why subsequent dose reductions should not be attempted.",2020-09-01
262,HERITAGE COURT POST ACUTE OF SCOTTSDALE,35083,3339 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2019-03-22,757,E,0,1,Y7PT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews and policy review, the facility failed to ensure 2 of 5 sampled residents (#6 and #2) were free from unnecessary drugs. The potential outcome includes receiving medications which may not be necessary. Findings include: -Resident #6 was admitted to the facility on (MONTH) 26, (YEAR) with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. -Tylenol 325 milligrams (mg) two tablets by mouth every 4 hours as needed for pain levels of 1-3 out of 10 dated (MONTH) 26, (YEAR). -[MEDICATION NAME] (narcotic) 10 mg by mouth every 4 hours as needed for pain levels of 4-10 dated (MONTH) 30, (YEAR). The quarterly Minimum Data Set (MDS) assessment dated (MONTH) 3, (YEAR) revealed a score of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident had intact cognition. The MDS assessment also included the resident experienced pain at a level of 6 on a daily basis. Review of the Medication Administration Record [REDACTED]. The physician's orders [REDACTED]. The order also included [MEDICATION NAME] 5 mg by mouth every 24 hours as needed for pain levels of 4-6. Review of the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Review of the MAR for (MONTH) (YEAR) revealed the resident was administered [MEDICATION NAME] 10 mg more than 45 times for pain levels less than 7. The MAR indicated [REDACTED]. The order for [MEDICATION NAME] 10 mg was changed on (MONTH) 1, 2019 to [MEDICATION NAME] 10 mg by mouth every 4 hours as needed for pain levels of 4-10. Review of the MAR indicated [REDACTED]. Further review of the MARs for October, November, and (MONTH) (YEAR) and (MONTH) 2019 revealed the resident was not administered Tylenol for pain. During an interview conducted with a Certified Nursing Assistant on (MONTH) 19, 2019 at 10:43 AM, the CNA stated that if a resident states they have unrelieved pain, he would notify the nurse. On (MONTH) 21, 2019 at 11:59 AM, an interview was conducted with a Licensed Practical Nurse (LPN/staff #59). The LPN stated that she would ask a resident that was having pain to rate their pain on a scale of 1-10. She stated that she would then administer pain medications according to the ordered parameters. The LPN stated that if the resident's pain was not relieved, she would notify the physician. She also stated that she would obtain a physician's orders [REDACTED]. An interview was conducted with the Director of Nursing (DON/staff # 72) on (MONTH) 21, 2019 at 12:13 PM. The DON stated that her expectation is that nurses administer pain medications to residents according to the physician's orders [REDACTED]. -Resident #2 was readmitted on (MONTH) 9, 2019, with [DIAGNOSES REDACTED]. Review of the clinical record revealed a physician's orders [REDACTED]. Review of the MAR for (MONTH) 2019 revealed [MEDICATION NAME] was administered 7 times for systolic blood pressures more than 120. Review of the MAR indicated [REDACTED]. An interview was conducted with the LPN (staff #59) on (MONTH) 22, 2019 at 1:45 p.m. The LPN stated that medications are to be administered according to the parameters ordered by the physician. She stated that the physician should be notified before administering a medication outside the ordered parameters. The LPN also stated that administering medications outside of the ordered parameters could result in unwanted side effects or harm to the resident. During an interview conducted with the DON (staff #72) on (MONTH) 22, 2019 at 1:47 a.m., the DON stated that her expectation is that the nurses administer medications according to the parameters ordered by the physician. After reviewing resident #2's clinical record, the DON stated that [MEDICATION NAME] was not administered according to the physician's orders [REDACTED].>The facility's policy regarding administration of drugs revealed medications must be administered in accordance with the written orders of the attending physician.",2020-09-01
263,HERITAGE COURT POST ACUTE OF SCOTTSDALE,35083,3339 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2019-03-22,758,D,0,1,Y7PT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy review, the facility failed to ensure that GDR (Gradual Dose Reductions) were attempted within the required timeframe or that there was clinical rationale documentation by the physician why GDRs were contraindicated for 1 of 5 sampled residents (#7) receiving [MEDICAL CONDITION] medications. This deficient practice could result in residents receiving unnecessary [MEDICAL CONDITION] medications. Findings include: Resident #7 was admitted on (MONTH) 5, (YEAR) with [DIAGNOSES REDACTED]. Review of the clinical record revealed physician's orders [REDACTED]. The Medication Administration Records (MAR) for (MONTH) through (MONTH) (YEAR) and (MONTH) through (MONTH) 2019 revealed [MEDICATION NAME] and [MEDICATION NAME] were administered as ordered. Review of the behavior monitoring documented on the MARs for (MONTH) through (MONTH) 2019 revealed the resident displayed no anxiety or depression behaviors except for (MONTH) 1, 2019. On (MONTH) 1, 2019 on the night shift there was documentation that the resident had 2 episodes of anxiety. Review of the Medication Regimen Review (MRR) for (MONTH) through (MONTH) 2019 did not reveal a recommendation or a contraindication for a GDR of [MEDICATION NAME] and [MEDICATION NAME]. The MRRs revealed documentation that the resident's medication regimen contained no new irregularities. Further review of the clinical record did not reveal documentation by the physician regarding GDRs attempts or why GDRs were contraindicated. During an interview conducted with a Registered Nurse (RN/staff #14) on (MONTH) 22, 2019 at 10:25 a.m., the RN stated that per the resident's request, a GDR had been attempted with the resident's pain medication, but that she was unaware of any GDR for the resident's [MEDICAL CONDITION] medications. An interview was conducted with the Director of Nursing and the Administrator (staff #71) on (MONTH) 22, 2019 at 10:33 a.m. The DON stated that prior to admission, she makes sure there are appropriate [DIAGNOSES REDACTED]. The DON stated that the nurses monitor for target behaviors and side effects of [MEDICAL CONDITION] medications. She stated that she and the pharmacist review all [MEDICAL CONDITION] medications monthly and discuss gradual dose reductions. The DON stated gradual dose reductions of [MEDICAL CONDITION] medications would be considered for reduced episodes of target behaviors and inappropriate diagnoses. She stated the pharmacist is responsible for tracking and scheduling the required gradual dose reductions. The DON stated that if the required dose reduction is contraindicated, the pharmacist will document the recommendation and the contraindication will be added to the physician's orders [REDACTED]. During an interview conducted with the consulting pharmacist (staff #80) on (MONTH) 22, 2019, the pharmacist stated that [MEDICATION NAME] is in a class unique to itself and is not technically a [MEDICAL CONDITION] medication. He stated that because [MEDICATION NAME] has much lower side effects than other antianxiety medications, residents are likely to experience rebound anxiety if the medication is discontinued. The pharmacist stated that he does not recommend gradual dose reductions for antianxiety medications. The pharmacist further stated that he does not recommend gradual dose reductions for antidepressants until a resident has been receiving the medication for a year because the resident may suffer rebound depression. He stated that a gradual dose reduction will be attempted in (MONTH) 2019 for [MEDICATION NAME]. Review of the facility's policy titled Psychoactive Medication, Revised 5/2007, reviewed 11/17, revealed the facility should attempt to taper psychoactive medications per recommended guidelines. The policy included that tapering may be indicated when the resident's clinical condition has improved or stabilized, the underlying causes of the original target symptoms have resolved, or other interventions have been effective in reducing the symptoms. The policy also included the physician will document in the clinical record any contraindications to gradual dose reduction or rationale for why subsequent dose reductions should not be attempted.",2020-09-01
264,HERITAGE COURT POST ACUTE OF SCOTTSDALE,35083,3339 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2019-03-22,770,E,1,1,Y7PT11,"> Based on facility documentation, staff interviews and policy review, the facility failed to ensure that quality control solution testing was consistently completed on the glucometers. The deficient practice could result in not being aware of glucometers that were not functioning properly and therefore; providing inaccurate glucose level results for residents with diabetes. Findings include: Review of the blood glucometer daily quality control record dated (MONTH) (YEAR) revealed sections for staff to complete the date, nursing station A or B, operator initials, test strip lot number, expiration date, low control result, high control result and any corrective action taken, due to out of range results. However, there were nine days in (MONTH) (YEAR) with no documentation that the daily glucometer control testing for accuracy was completed. Review of the blood glucometer daily quality control record dated (MONTH) (YEAR) revealed a total of 24 days that were blank, with no documentation to indicate that the glucometers had been tested for accuracy. Review of the blood glucometer daily quality control record dated (MONTH) (YEAR) revealed a total of 30 days which were blank, indicating the glucometers had not been tested for accuracy. An interview was conducted on (MONTH) 21, 2019 at 1:13 p.m. with a Licensed Practical Nurse (LPN/staff #59). Staff #59 stated the night shift are responsible for the daily glucometer control records. After staff #59 reviewed the glucometer testing logs for October, (MONTH) and (MONTH) (YEAR), she stated the night shift should have noticed all of the missing dates and taken the problem to the Director of Nursing (DON). An interview was conducted with the DON (staff #72) on (MONTH) 21, 2019 at 2:00 p.m. She stated the glucometer daily testing logs are to be completed every night shift to make sure all glucose tests are accurate. Staff #72 stated the importance is to ensure residents with diabetes and on insulin have accurate glucose monitoring machines to regulate the amount of insulin to be administered. Staff #72 further stated any nurse on the night shift could have noticed the gaps in the testing and reported it to the DON. A request for the facility policy for glucometers was identified to be the same as the manufacturer's insert instructions, which included the purpose is to validate the glucose monitoring system. A control test that falls within the acceptable range indicates the user's techniques are appropriate and the test strip and monitor are functioning properly.",2020-09-01
265,HERITAGE COURT POST ACUTE OF SCOTTSDALE,35083,3339 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2019-03-22,926,E,1,1,Y7PT11,"> Based on observations, clinical record review, resident and staff interviews and policy review, the facility failed to implement their policy to ensure safety measures and adequate supervision were provided to residents who smoked, in order to ensure a safe environment. As the facility identified the smoking concerns and implemented correction action, this is cited at past non-compliance. Findings include: The State Agency received information on (MONTH) 29, (YEAR) that residents had been fighting on the smoking patio and flicking cigarettes at each other, smoking in the sitting area inside the building by the front door, and smoking in their rooms. The information also included cigarette butts were all over the parking garage and residents' clothing and bed linens had burn holes. An interview was conducted with a Certified Nursing Assistant (CNA) on (MONTH) 19, 2019 at 10:43 AM. The CNA stated that the facility had become a non-smoking facility at the beginning of the year because residents were not following the smoking rules. The CNA said residents were mad that they had to wait for designated smoking times, so they started smoking whenever they wanted to. The CNA stated that residents would hide their cigarettes and smoke in their rooms. The CNA stated that the residents would put a towel at the bottom of their doors, open their windows, and smoke cigarettes in their rooms to mask the smell of marijuana that they were smoking. The CNA also stated that one resident with oxygen snuck a cigarette outside and asked for light. The CNA stated the resident was not given a light. The CNA further stated that there was smoke smell in the facility which put everyone at risk. On (MONTH) 19, 2019 at 11:51 PM, an interview was conducted with one of the residents who currently smokes. He stated that administration changed the smoking policy about a month ago. He said the change in policy occurred because some smokers were not following the rules. The resident stated that residents were smoking all over the place including inside the facility, whenever they wanted, and no one was cleaning up their butts. He stated that he is currently one of two residents who still have smoking privileges. The resident stated that he is only allowed to smoke a few times per day, and that he must be supervised while he smokes. An interview was conducted with laundry (staff #74) on (MONTH) 19, 2019 at 12:33 PM. He stated that he saw burn holes in the blankets from the beds of the residents who smoked and also saw burn holes in their clothing. Staff #74 stated that he reported his observations to the head of the department (staff #18). On (MONTH) 20, 2019 at 8:57 AM, an interview was conducted with the Activities Coordinator (staff #38). She stated that smoking privileges were reinstated in the fall of (YEAR) which did not require residents to be supervised. She said the smoking rules changed again in (MONTH) and required residents to be supervised while smoking and to only smoke during scheduled smoking times. The Activities Coordinator stated that was when the problems started. She said all of the smokers refused to follow the rules and that there were at least 15 residents who smoked. She stated that staff would take their cigarettes away, but the families would bring them more. Staff #38 stated some of the residents were given a 30 day discharge notice. She said staff tried to educate the residents, but they would not listen. She stated that when it got bad, staff came together to address the problem and came to the conclusion that it was safer for everyone if they became a non-smoking facility. On (MONTH) 20, 2019 at 9:10 AM, an interview was conducted with the Director of Nursing (DON/staff #72). She stated that there were quite a few residents who smoked when she started working in (MONTH) 2019. The DON stated the residents were non-compliant, they smoked in non-smoking areas, and smoked during non-smoking hours. She said she may have heard that some had been caught smoking in their rooms. The DON stated staff would take their cigarettes away or offer to help them find placement in another facility. At 9:16 AM, the Clinical Resource Nurse (staff #68) and the Administrator (staff #71) joined the DON interview. The Clinical Resource Nurse stated that she knew there were going to be problems when they started allowing the residents to smoke again. She recalled the staff commenting that they thought it would help them get more residents into the facility. She said she knew with the population they had, there would be problems. The Administrator (staff #71) stated that approximately two weeks to a month ago the leadership team discussed the smoking issue and came up with a plan to convert to a non-smoking facility. The administrator also stated that two residents continue to smoke, but that they are compliant with the smoking rules. The Activities Coordinator (staff #38) stated on (MONTH) 20, 2019 at 2:04 PM that the policy implemented the summer of (YEAR) did not allow smoking in the facility, all residents had to be supervised while smoking, and that the smoking times were 8:45 AM, 1:15 PM, 4:00 PM, and 7:45 PM. Staff #38 stated that the times for smoking were no more than 15 minute increments or 2 cigarettes and that there was to be no smoking between the hours of 8:00 PM and 8:45 AM. The Administrator provided documentation of the following measures that were implemented regarding smoking: -The decision to become a non-smoking facility was set with a goal date of (MONTH) 1, 2019. -Appropriate placement would be offered to current smoking residents. -A few residents would continue with supervised smoking. -Documentation of the new policy would be included in the nursing and new admissions packets. -Information would be updated in brochures and on the website to reflect the new policy. -Hospitals/referring partners would be notified of upcoming change. Review of the facility's list of residents who currently smoke revealed there were two residents that currently smoked in the facility. Review of the two residents' clinical records revealed the residents were assessed and care planned for smoking. Observations were conducted of the two residents who smoked on (MONTH) 19, 2019 at 8:34 AM and (MONTH) 20, 2019 at 1:20 PM. The residents were supervised and no concerns were identified. During an interview conducted with a CNA (staff #3) on (MONTH) 19, 2019 at 10:26 AM, the CNA stated that they are now a non-smoking facility but that two residents were grandfathered in. The CNA stated that the residents that currently smoke are supervised even if the resident is alert and oriented. The CNA stated that the residents' cigarettes are kept locked up. As the facility identified the concern with smoking and developed and implemented a plan of action, and there were no concerns with current practice, this will be cited at past non-compliance. The facility's smoking policy dated (MONTH) 1, 2019 stated the facility does not allow smoking of any kind to occur within the facility and that smoking for visitors and residents will be confined to the designated smoking area. The policy included that a resident who desires to smoke will be assessed by the Interdisciplinary Team by completion of the Smoking Evaluation Form and review of the resident's clinical record. The results of the evaluation will be placed in the resident's clinical record and the Interdisciplinary Team recommendations will be care planned. In addition, no lighting materials (e.g., matches, lighters), tobacco products, smoking devices or e-cigarette devices will be allowed to be kept in the possession of the residents, either on their person or in their room. The policy revealed the frequency of smoking for all residents will be with staff supervision at 8:45 AM, 1:15 PM, 4:00 PM, and 7:45 PM. These times will be no more than 15 minute increments or 2 cigarettes. There will be no smoking between the hours of 8:00 PM and 8:45 AM. The policy included the facility reserves the right to immediately confiscate smoking materials as well as to rescind individual smoking privileges if failing to take such measures would jeopardize resident safety.",2020-09-01
266,HERITAGE COURT POST ACUTE OF SCOTTSDALE,35083,3339 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2017-11-10,281,D,1,0,STJ711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interview and policy, the facility failed to develop an interim care plan for one resident (#5). Findings include: Resident #5 was admitted to the facility on (MONTH) 24, (YEAR) with [DIAGNOSES REDACTED]. Review of the discharge Minimum Data Set assessment dated (MONTH) 4, (YEAR) revealed the resident had a Basic Interview for Mental Status score of 15, that indicated the resident was cognitively intact. Review of the functional assessment revealed the resident required limited assistance for all activities. Physician orders dated (MONTH) 24, (YEAR) ordered: -Wound care: Left thumb - Cleanse with wound cleanser, pat dry, Apply [MEDICATION NAME] and cover with Xeroform, then wrap with Kerlix every day shift and as needed for soiling or dislodgement -Wound care: Give pain medication 30 minutes before dressing changes. Cleanse bilateral feet with warm soapy wash cloth (pat), allow to air dry, apply a light layer of [MEDICATION NAME] to Xeroform and use this to cover affected areas. Wrap each individual toe and Wrap foot with Kerlix and secure with burn netting every day shift and as needed for soiling or dislodgement -[MEDICATION NAME] Tablet 875-125 MG ([MEDICATION NAME]-Pot Clavulanate), give 1 tablet by mouth every 12 hours for dog bite until (MONTH) 2, (YEAR) -Tylenol 325 milligrams (mg), give 2 tablet by mouth every 4 hours as needed for mild pain; -Wear splint to left arm until seen by follow up orthopedic appointment in one week -[MEDICATION NAME] tablet (non-steroidal, anti-[MEDICAL CONDITION]) 7.5 mg, give 1 tablet by mouth as needed for muscle spasms as needed every day -[MEDICATION NAME] tablet 5 mg, give 1 tablet by mouth every 4 hours as needed for pain 4-6 out of 10 on the pain scale. Physician orders dated (MONTH) 25, (YEAR) ordered [MEDICATION NAME] Zinc Ointment, apply to bilateral feet topically every day shift for wound care and to monitor skin under cast on left arm every shift for skin integrity Physician orders dated (MONTH) 26, (YEAR) ordered Patient to be seen 5 times each week for 2 weeks physical therapy and gait training to address functional decline. Physician orders dated (MONTH) 27, (YEAR) Occupational therapy, patient to be seen 5 times each week for 2 weeks to maximize independence with activities of daily living (ADLs) and ADL mobility. Review of the care plan revealed a single nutritional care plan initiated on (MONTH) 3, (YEAR). No other care plan problems were identified or developed during the entire admission related to the resident's burn injuries of the feet, dog bite injury, fracture with splint to the right arm, wound care, pain, or antibiotic use, or activities of daily living. In an interview conducted with the Licensed Practical Nurse (LPN/staff #13) conducted on (MONTH) 8, (YEAR) at 10:48 a.m., the LPN stated she has never initiated an admission or interim care plan, but she could update it if it was needed. She further stated she thought it was the Registered Nurse on duty that would initiate the care plan. In an interview conducted on (MONTH) 8, (YEAR) at 11:54 a.m. with the Registered Nurse/Director of Nursing (DON/staff #79), the DON stated the interim care plan are usually initiated by MDS nurse or the DON, or any nurse can enter them. They are to be done upon admission or if not done are completed the next day with chart checks. The DON further stated chart checks look for consents, al the applicable admission assessments, and care plans. The DON stated the interim care plan should include ADLs, Pain, Catheters, Oxygen, Skin Integrity, [MEDICAL CONDITION], Falls Risk or Precautions, and any other specific risks. Review of the facility policy titled Care Planning, the policy documented the resident care plan will be initiated within 24 hours of admission. The policy further documented the resident's plan of care is reviewed and revised on an ongoing basis, quarterly, at a minimum and/or as needed with changes in condition.",2020-09-01
267,HERITAGE COURT POST ACUTE OF SCOTTSDALE,35083,3339 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2016-12-08,248,E,0,1,JKMJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, resident and staff interviews and policy and procedures, the facility failed to provide an ongoing activity program which meets the interests and preferences for three residents (#91, #120 and #231). Findings include: -Resident #91 was readmitted to the facility on (MONTH) 30, (YEAR), with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 31, (YEAR), revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. Review of Section F: Preferences for Customary Routine and Activities revealed the interview for daily and activity preferences and the staff assessment section should be conducted, however, these sections were not completed. According to an Activity Admission assessment dated (MONTH) 31, (YEAR), the resident enjoyed music, arts and crafts, knitting and drawing. The assessment also included to provide the resident with opportunities to participate in activities of expressed interest such as bingo, socializing with others, current events, pet therapy and music entertainment. A review of the activity calendar revealed there were no activities scheduled that included arts and crafts, socializing with others, music or current events. The facility was unable to provide documentation of resident specific activities which had been provided for this resident. During an interview conducted at 2:09 p.m. on (MONTH) 6, (YEAR), the Activity Coordinator (staff #52) stated that on (MONTH) 5, the only activity scheduled was library cart, but the activity was canceled, because she had to work as a certified nursing assistant that day. She said that on (MONTH) 6, one activity was scheduled and a volunteer from a church came to the facility and offered communion to residents. She stated that in the past she would place the activity calendars in the residents' rooms, but the residents did not look at them, so she no longer gives the residents the activity calendars, but there is a big activity calendar located across from the nurses station. During an interview conducted at 1:35 p.m. on (MONTH) 7, (YEAR), the resident stated that activities in the facility were scheduled once a day and included music and pet visits. The resident stated that in the past the facility provided arts and crafts and she enjoyed attending them, however, no such activities are currently offered. She further stated that she asked activity staff if there would be caroling over the Christmas holiday and was told no such activity was scheduled. -Resident #231 was admitted to the facility on (MONTH) 2, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed there was no documentation that an activity assessment had been completed, in order to determine the resident's interests and preferences. There was also no documentation that an interim care plan had been developed to address the resident's activity needs and preferences. During an interview on (MONTH) 5, (YEAR) at 1:15 p.m., a family member stated that no one has ever come in and asked her about activities. She stated that no one has talked with her about providing activities to the resident in her room or attending activities in the facility. Multiple observations of resident #231 were conducted on (MONTH) 5, 6, and 7, at various times throughout the day. Observations revealed that the resident was alone in her room and was not engaged in any activities. Review of the facility's Activity Calendar for (MONTH) (YEAR) which was posted in the main hall by Nursing Station A, revealed a single activity on 22 of the 31 days. The activities listed only consisted of pets on wheels, library cart, church services, Bingo and one birthday celebration. In addition, there were no activities scheduled for (MONTH) 1, 2, 3, 8,10,15,17, 22 or 24. -Resident #120 was admitted to the facility on (MONTH) 17, (YEAR), with [DIAGNOSES REDACTED]. Review of the admission MDS assessment dated (MONTH) 24, (YEAR) indicated in Section F: Preferences for Customary Routine and Activities to complete multiple sections, however, the sections were not completed. An observation was conducted on (MONTH) 8, (YEAR) at 2:13 p.m. of the resident sitting alone in his room, with the TV on. An interview was conducted with the resident at this time and the resident was alert and oriented to person, place and time. The resident stated that he has not attended any activities at the facility and has been here several times, and was not aware of any activities that were offered. He said that he has never seen a singer come around, but if there was music or singing he would love to join in. During an interview conducted on (MONTH) 7, (YEAR) at 10:51 a.m. with a Certified Nursing Assistant (CNA/staffing Coordinator/Restorative Nursing Aide/Activities Coordinator/staff #52), the Activities Coordinator stated that she completes the activity assessments for the MDS, makes the activity calendars plans the events, and coordinates the volunteers who help with activities. She stated that there are no group activities, but she is responsible for doing the one-on-one in room activities for all of the residents. Staff #52 stated she takes the library cart around with books and puzzle books, if she is not busy working on the unit as a CNA or RN[NAME] Regarding the Activity Assessments, she said that she prints a list of the assessments that are needed and attempts to get to the oldest ones first. She stated they are being done very late and on her current list the most out-of-date assessment is eight days overdue. She further stated that there are times when she is not able to enter the assessment information into the MDS, because it has already been transmitted. Staff #52 also stated that she learned how to be an Activities Coordinator by observing the role at another facility and filling in. She stated she has resources at sister facilities, but admitted the program at this facility does not have the frequency or variety of programs that she has seen in the past. Staff #52 stated that up until around (MONTH) of (YEAR), the residents used to go to the dining room to eat and then we would do an activity, and then do restorative work, but we got too busy. She stated dining would take so long, then activities were taking too long and the RNA work could not be completed. Staff #52 stated she does not have an activity log for resident #231 In an interview conducted with the Executive Director (staff #76) on (MONTH) 7, (YEAR) at 12:11 p.m., he stated that he wished the facility could be better at providing activities and have a more robust program. Staff #76 stated the facility had mostly skilled residents and they rotate very frequently, but there are long term residents as well. He further stated the facility has fallen short on daily activities for the residents. Staff #76 stated they have used a sister facility activity staff member in the past, but should look at doing more and recognizes that the facility has to be able to provide activities. Review of the facility policy titled Activity Program revealed, It is the policy of this facility to provide an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interest and the physical, mental, and psychosocial well-being of each resident. According to the policy, activities are defined as any endeavor, other than routine activities of daily living, in which a resident participates that is intended to enhance his/her sense of well being and to promote or enhance physical, cognitive, and emotional health. The procedure section of the policy indicated the activity program shall be provided special rooms specifically for the activity program.",2020-09-01
268,HERITAGE COURT POST ACUTE OF SCOTTSDALE,35083,3339 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2016-12-08,253,E,0,1,JKMJ11,"Based on observations and family and staff interviews, the facility failed to maintain hallway carpets in a clean manner. Findings include: During the initial facility tour conducted on (MONTH) 5, (YEAR) at 7:30 a.m., there were two carpet stains on the 100 hall, which were approximately 12 inches in length and were black in color. There was also a large stain on the carpet on the 100 hall near the nurses station, which was brownish/gray in color and measured approximately 2.5 feet x 3 feet. In addition, there were multiple carpet stains which were brownish/gray in color and varied in size but averaged approximately 1 foot in diameter, which were observed on the 200, 300 and 400 halls. During a family interview conducted on (MONTH) 5, (YEAR) at 1:29 p.m., a family member stated that the carpets are disgusting. During the environmental tour on (MONTH) 8, (YEAR) at 11:30 a.m., the carpet stains remained as seen on the initial tour. At this time, an interview was conducted with the Maintenance Supervisor (staff #10). Staff #10 stated that he normally cleans the carpet every other week and has an outside company that comes in about every six months to complete a deep cleaning, and the last time that occurred was in July. Staff #10 stated that he had tried to work on the two black areas on the 100 hall several times with different chemicals and has not been able to get the area clean. He also stated that he has worked on the large spot on the 100 hall by the nurses station several times with different chemicals and it lightened up. He stated he has not taken the concern regarding the carpet cleaning to the Executive Director. In an interview conducted on (MONTH) 8, (YEAR) at 12:30 p.m. with the Executive Director (staff #76), he stated that the carpets are cleaned every two weeks and more frequently if needed. He also stated he is trying to obtain budget money for next year to replace the carpet, however, no budgets have been approved. A policy was requested regarding maintaining carpets and was advised that the facility does not have a policy regarding this.",2020-09-01
269,HERITAGE COURT POST ACUTE OF SCOTTSDALE,35083,3339 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2016-12-08,272,E,0,1,JKMJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on reviews of clinical records, staff interviews and policy and procedures, the facility failed to thoroughly complete comprehensive assessments for four residents (#'s 91, 178, 221 and 233). Findings include: -Resident #233 was admitted to the facility on (MONTH) 25, (YEAR), with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 2, (YEAR), revealed in Section C: Cognitive Patterns, that the Brief Interview for Mental Status should be conducted for this resident. However, this section was not completed. Further review of Section C revealed that a staff assessment for mental status should also have been conducted, however, this section was not completed. Review of Section D: Mood revealed that the Resident Mood Interview should be Conducted, however, this section was not completed. Review of Section F: Preferences for Customary Routine and Activities revealed that the Interview for Daily and Activity Preferences and the staff assessment should be conducted, however, these sections were not completed. During an interview conducted at 2:09 p.m. on (MONTH) 6, (YEAR), the Activity Coordinator (staff #52) stated she was assigned to complete Section F on the admission MDS assessment, but she was unable to complete the assessment. She reported that the MDS Coordinator also completes sections of the MDS assessments. During an interview conducted at 2:19 p.m. on (MONTH) 6, (YEAR), the MDS Coordinator (staff #35) stated she did not complete sections B, D and F on the admission assessment and was not aware that it was not done. She also stated that the MDS is not complete if the sections are not completed. -Resident #91 was admitted to the facility on (MONTH) 30, (YEAR), with [DIAGNOSES REDACTED]. A review of the admission MDS assessment dated (MONTH) 31, (YEAR), revealed the Brief Interview for Mental Status score was 14, which indicated the resident was cognitively intact. Review of the MDS in Section F: Preferences for Customary Routine and Activities revealed the interview for daily and activity preferences should be conducted, however, these sections were not completed. In addition, review of the resident's two most recent quarterly MDS assessments dated (MONTH) 2, (YEAR) and (MONTH) 2, (YEAR), revealed that Section C of the MDS was also not completed. -Resident #178 was admitted to the facility on (MONTH) 30, (YEAR), with [DIAGNOSES REDACTED]. Review of physician progress notes [REDACTED]. Review of the 14-Day MDS admission assessment dated (MONTH) 14, (YEAR) revealed that Section C: Cognitive Patterns should be completed, however, this section was not completed. This same MDS assessment also revealed that Section F: Preferences for Customary Routine and Activities should be completed, however, this section was not completed. Review of the Significant Change of Status MDS assessment dated (MONTH) 11, (YEAR) revealed revealed that Section C: Cognitive Patterns should be completed, however, this section was not completed. In an interview conducted with the MDS Coordinator (staff #35) on (MONTH) 7, (YEAR) at 12:30 p.m., the MDS Coordinator stated that it is hard to try and catch residents to do the assessments, due to therapy schedules. She further stated that she tries to devote time each day to do them, but she does not always get them done. She said if the MDS's are not completed when it is time to submit them, she has to mark something in some of the sections in order to close them. -Resident #221 was admitted on (MONTH) 5, (YEAR), with [DIAGNOSES REDACTED].>[MEDICAL CONDITION], right distal femur fracture, left midshaft radius fracture and right parietal skull fracture. Review of the clinical record revealed the resident was alert and oriented. Review of the admission MDS assessment dated (MONTH) 12, (YEAR) revealed that Section C, should be completed, however, this section was not completed. Review of a facility policy regarding the Accuracy of the MDS Assessment revealed to ensure that the assessment accurately reflects the resident's status. The purpose was to assure that each resident receives an accurate assessment by staff that are qualified to assess relevant care areas and knowledgeable about the resident's status, needs, strengths, and areas of decline. In addition, the policy stated that a registered nurse (RN) must conduct or coordinate each assessment with the appropriate participation of health professionals.",2020-09-01
270,HERITAGE COURT POST ACUTE OF SCOTTSDALE,35083,3339 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2016-12-08,371,D,0,1,JKMJ11,"Based on observation, staff interview and policy and procedures, the facility failed to ensure two ready to use steam table pans were stored clean and dry. Findings include: A kitchen observation was conducted at 1:40 p.m. on (MONTH) 7, (YEAR). At this time, one steam table pan, which was stored stacked on a metal shelf had droplets of water that dripped when the pan was turned over. Also, there was one quarter steam table pan which was stored stacked and had water droplets on the interior surface. During an interview conducted at the time of the observation, the dietary manager (staff #43) stated that the pans on the shelf were stacked and ready to use. She also stated that the two wet pans would have to be washed and air dried, before they could be used. A review of the Handling Clean Equipment and Utensils policy and procedures revealed Clean equipment and utensils will be stored in a clean, dry location in a way that protects them from splashes, dust or other contaminations .",2020-09-01
271,HERITAGE COURT POST ACUTE OF SCOTTSDALE,35083,3339 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2016-12-08,372,D,0,1,JKMJ11,"Based on observation, staff interview and policy and procedures, the facility failed to ensure two dumpster lids were kept closed. Findings include: An observation was conducted with the dietary manager and dietary consultant at 1:50 p.m. on (MONTH) 7, (YEAR) of the outside garbage dumpsters. It was observed that two of the facility's dumpster lids were open, as the garbage bags were stacked higher than the sides of the dumpsters. The dumpster on the right side had trash bags which were holding one of two lids open approximately 8 to 12 inches. The dumpster on the left had trash bags which were holding one of two lids open approximately 18 inches. The dumpster on the left also had a large paper cup, which was on top of the unclosed lid. During an interview conducted at the time of the observation, the dietary manager stated that the lids should have been closed. A review of the Waste Disposal policy and procedure revealed Prior to disposal, all waste shall be kept in leak-proof, non-absorbent, fireproof containers that are kept covered.",2020-09-01
272,HERITAGE COURT POST ACUTE OF SCOTTSDALE,35083,3339 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2016-12-08,441,D,0,1,JKMJ11,"Based on observations, staff interview and review of policy and procedures, the facility failed to ensure one staff member used appropriate hand washing procedures during food preparation. Findings include: -During an observation of food preparation in the kitchen conducted at 10:25 a.m. on (MONTH) 7, (YEAR), a cook (staff #7) was observed to drop a spatula on the floor. The cook then picked up the spatula and placed it into the sink. The cook then proceeded to prepare the pureed food, without washing her hands. -Another observation was conducted at 10:50 a.m. on (MONTH) 8, (YEAR) in the kitchen food prep area. Staff #7 was observed to wash her hands, and then turned off the water faucets using her wet, bare hands. Staff #7 then tapped the motion activated towel dispenser with her wet bare hand and dried her hands with a paper towel. During an interview conducted at 11:24 a.m. on (MONTH) 8, (YEAR), staff #7 stated that she did not remember dropping the spatula, but the Dietary Manager (staff #43) told her that she saw her drop the spatula too. She stated that after dropping the spatula, she should have washed her hands before preparing the food. She also stated she was aware that she had not used proper handwashing procedures when she used her wet, bare hands to turn off the water faucets. A review of the Hand Washing policy and procedure revealed that after handling soiled equipment or utensils, the staff member should wash their hands. The policy also stated that hands should be washed during food preparation and as necessary to remove soil and contamination, and to prevent cross contamination when changing tasks. The policy further included that paper towels should be used to turn off the faucet after washing hands.",2020-09-01
273,PLAZA HEALTHCARE,35084,1475 NORTH GRANITE REEF ROAD,SCOTTSDALE,AZ,85257,2020-02-14,757,D,0,1,IRMP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident's (#61) drug regimen was free of unnecessary drugs, by failing to administer pain medication according to the physician ordered parameters. The deficient practice could result in residents receiving pain medications that may not be necessary. Findings include: Resident #61 was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's care plan initiated on May 17, 2018 revealed the resident had chronic pain related to spasms and [MEDICAL CONDITION]. The goal was that the resident would express pain relief at a level acceptable to the resident. Interventions included administering medications as ordered and notifying the physician if the medication was ineffective. Review of the physician's orders [REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status (BI[CONDITION]) score of 15, which indicated the resident was cognitively intact. The assessment also included the resident had occasional pain and was administered prn pain medications. Review of the Medication Administration Record [REDACTED] Additional review of the clinical record revealed no documentation that the physician was notified the resident was administered two tablets of [MEDICATION NAME]-[MEDICATION NAME] 5/325 mg outside of the ordered parameters or that the physician gave an order to administer 2 tablets for pain levels outside of the ordered parameters. An interview was conducted with a Licensed Practical Nurse (staff #261) on [DATE] at 10:04 AM. Staff #261 stated that one tablet of [MEDICATION NAME]-[MEDICATION NAME] should have been given for pain levels of 4-7. Staff #261 said if the resident specifically asked for 2 tablets, the nurse should have called the physician for an order to administer 2 tablets and documented it. An interview was conducted with the Chief Clinical Officer (staff #2[AGE]) on 2/14/20 at 10:50 AM. Staff #2[AGE] stated that the 2 tablets of [MEDICATION NAME]-[MEDICATION NAME] were given to the resident in error unless the physician was notified and permission was given to administer 2 tablets. Staff #2[AGE] also stated that if the physician gave permission, it should be documented in the progress notes. The facility's policy for administration of drugs revealed medications must be administered in accordance with the written orders of the attending physician.",2020-09-01
274,PLAZA HEALTHCARE,35084,1475 NORTH GRANITE REEF ROAD,SCOTTSDALE,AZ,85257,2020-02-14,758,D,0,1,IRMP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure an unnecessary drug was not administered to one resident (#127), by failing to ensure a prn (as needed) [MEDICAL CONDITION] medication order was limited to 14 days and/or by failing to provide rationale documentation by the provider for extending the medication beyond 14 days with the duration for the prn order. The deficient practice could result in residents receiving [MEDICAL CONDITION] medications without medical necessity. Findings include: Resident #127 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician order [REDACTED]. The Medication Administration Record [REDACTED]. Review of the February 2020 MAR indicated [REDACTED]. During an interview conducted on February 14, 2020 at 11:25 a.m. with a Registered Nurse (RN/staff#66), the RN stated [MEDICATION NAME] is a schedule II medication and that a stop date is not needed. He stated that in accordance with the law, the electronic medical record system will void the prescription and require a new prescription every [AGE] days. The RN stated he was unaware of any other regulation regarding prn [MEDICATION NAME]. In an interview with the Director of Nursing (DON/staff #2[AGE]) conducted on February 14, 2020 at 11:30 AM, the DON stated that she is a member of the [MEDICAL CONDITION] medication committee that meets monthly and discusses all residents receiving [MEDICAL CONDITION] medications. She stated that it is in this meeting she would be made aware of and address the issue of PRN orders that do not comply with the regulation. The DON stated the pharmacist also attends these meetings and would make recommendations to the physician directly from the meeting. The facility's policy titled Psychoactive Medications revised October 2018 revealed it is the policy of the facility to have a 14-day limitation on all prn orders. The policy also revealed prn orders for [MEDICAL CONDITION] medications (excluding antipsychotic medications) may be extended beyond 14 days and if the provider believes it is appropriate to extend the order, the physician will document the clinical rationale for the extension and provide a specific duration of use.",2020-09-01
275,PLAZA HEALTHCARE,35084,1475 NORTH GRANITE REEF ROAD,SCOTTSDALE,AZ,85257,2020-02-14,806,D,0,1,IRMP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, family and staff interviews, and policy review, the facility failed to ensure one resident's (#128) dietary preferences were honored. The deficient practice could result in residents receiving food not according to their preference. Findings include: Resident #128 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 4 on the Brief Interview for Mental Status (BI[CONDITION]), indicating the resident had severe cognitive impairment. The MDS assessment also included the resident did not have a swallowing disorder, received nutrition via feeding tube, and was receiving speech therapy. A weekly menu dated February 9 through15, 2020 revealed the menu was filled out by the resident's family and included the resident was not to receive slurried bread. On February 11, 2020 at 10:05 a.m., an interview was conducted with the resident's family member. The family member stated the resident requests for meals are not being honored. The family member stated the resident is provided food that the resident will not eat. The family member stated that it was specifically requested the resident not receive slurried bread. The family member stated the staff was spoken to on several occasions about the resident's preferences and yet staff continues to send slurried bread with the resident's meals. During an observation conducted of the resident's lunch tray on February 11, 2020 at 11:16 a.m., the resident's lunch ticket on the tray was observed to have in capital letters no slurried breads. The resident's plate was observed to have slurried bread and pureed carrots on it. An interview was conducted with the Registered Dietitian (RD/Staff #310) on February 11, 2020 at 11:18 a.m. Staff #310 observed resident #128's meal ticket and lunch tray, and stated slurried bread should not be on the resident's plate. She stated the tray line staff should be checking each tray against the ticket to make sure it matches which includes any likes, dislikes, and allergies [REDACTED].>An interview was conducted on February 12, 2020 at 10:34 a.m. with the dietary director (staff #2[AGE]), who stated the meal ticket stays with the tray as it goes through the tray line. Staff #2[AGE] stated the dishwasher puts condiments on the tray, then the cook plates the food, and then the dietary aid adds the beverages and anything else the tray needs and places it on the cart. Staff #2[AGE] stated everyone who looks at the ticket should be making sure the tray matches the ticket. On February 12, 2020 at 1:18 p.m., an interview was conducted with the Certified Nursing Assistant (CNA/staff #42) working on resident #128's hall. Staff #42 stated she delivers the meal trays to the resident rooms on her hall. The CNA stated she checks the tray to make sure it is for the correct resident, the tray does not have anything on it that the resident is not supposed to have, adaptive equipment is present as needed, and that the diet matches. Staff #42 further stated that she is not aware of any residents on her hall receiving the wrong foods on their trays. The CNA also stated that she was not aware of any problems with resident #128's meal trays. During an interview conducted on February 12, 2020 at 1:44 p.m. with the Director of Nursing (DON/ Staff #2[AGE]), the DON stated all of the staff is expected to look at the tray and compare it to the ticket before providing the meal to the resident. The facility's policy on Resident Rights- Food and Nutrition Services Department revised August 31, 2018, revealed reasonable accommodations should be made by the food and nutrition services department to those residents with food preferences.",2020-09-01
276,PLAZA HEALTHCARE,35084,1475 NORTH GRANITE REEF ROAD,SCOTTSDALE,AZ,85257,2017-09-01,241,D,0,1,VY8M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation and staff interviews, the facility failed to ensure one resident (#2) was treated with dignity and respect. Findings include: Resident #2 was admitted to the facility on (MONTH) 10, 2014, with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set assessment dated (MONTH) 8, (YEAR) revealed the resident had a Basic Interview for Mental Status score of 15, which indicated the resident was cognitively intact. Review of a facility's report revealed that on (MONTH) 18, (YEAR) at approximately 2:45 p.m., a Certified Nursing Assistant (CNA/staff #112) reported to the Assistant Director of Nursing (ADON/staff #200) that she witnessed a CNA (staff #308) making negative comments about resident #2. Staff #112 reported that staff #308 stated your s--t stinks to resident #2. According to the report, resident #2 stated that staff #308 was rude and makes inappropriate comments. The resident also requested that staff #308 not be assigned to her in the future. An interview was conducted with staff #112 on (MONTH) 31, (YEAR) at 11:00 a.m. She confirmed that she was working with staff #308, when the incident occurred. She stated staff #308 told resident #2, your s--t stinks when they entered resident #2's room. A telephone interview was conducted with staff #308 on (MONTH) 31, (YEAR) at 1:00 p.m. Staff #308 denied saying your s--t stinks to the resident. An interview was conducted with the Executive Director (staff #243) on (MONTH) 1, (YEAR) at 11:45 a.m. Staff #243 stated he felt the incident was a dignity issue.",2020-09-01
277,PLAZA HEALTHCARE,35084,1475 NORTH GRANITE REEF ROAD,SCOTTSDALE,AZ,85257,2017-09-01,315,D,1,1,VY8M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interviews, the facility failed to ensure one resident (#118) received appropriate care during a catheter care observation. Findings include: Resident #118 was admitted to the facility on (MONTH) 6, (YEAR), with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment dated (MONTH) 20, (YEAR) revealed the resident was rarely to never understood and had memory problems. The MDS also included that the resident had an indwelling urinary catheter. An observation of catheter care for resident #118 was conducted on (MONTH) 29, (YEAR) at 2:30 p.m., by a Certified Nursing Assistant (CNA/staff #66). During the procedure, staff #66 retracted the foreskin of the resident's penis and cleaned the glans penis and the coronal ridge. After catheter care was completed, the CNA left the foreskin retracted below the coronal ridge and did not return the foreskin to the extended position. The CNA then covered the resident with the gown, pulled up the blankets and prepared to leave the room. In an interview with staff #66 conducted on (MONTH) 29, (YEAR) at 2:50 p.m., staff #66 stated she forgot to put the foreskin back to the neutral position. Staff #66 stated that the reason it needed to be put back to the neutral position was because the penis could become sore. She stated the resident is not able to verbalize if that were to cause pain. In an interview conducted with the Assistant Director of Nursing (registered nurse/ADON/staff #200) on (MONTH) 29, (YEAR) at 3:15 p.m., staff #200 stated the process for performing catheter care on an uncircumcised male included pulling back the foreskin, cleansing the penis, then returning the foreskin to the neutral position. She further stated the CNA should have made sure the foreskin was pulled to the neutral position, as the foreskin could become restrictive on the penis and may cause pain or damage. In an interview with the Director of Nursing (DON/staff #59) on (MONTH) 30, (YEAR) at 12:57 p.m., the DON stated the CNA should have made sure the skin was returned to the neutral position. Review of the policy titled Catheter Care, Indwelling revealed the policy did not address the care of an uncircumcised patient.",2020-09-01
278,PLAZA HEALTHCARE,35084,1475 NORTH GRANITE REEF ROAD,SCOTTSDALE,AZ,85257,2017-09-01,371,D,0,1,VY8M11,"Based on observation, staff interviews and facility documentation, the facility failed to ensure food was handled in a sanitary manner. Findings include: An observation of the dining food service was conducted on (MONTH) 28, (YEAR) at 11:45 a.m., in the main dining room. A dietary staff member (staff #122) was observed to don gloves, then adjust his eye glasses, open and close the steamer serving covers, and handle the individual resident menu papers. With the same gloves on, staff #122 then placed a slice of bread on each resident's lunch tray, picked up chicken strips from one plate and placed them onto another plate and returned a piece of corn on the cob from a lunch plate to the steamer. Staff #122 did not change gloves after touching his glasses and other potentially contaminated surfaces, before touching the food. In an interview with staff #122 on (MONTH) 31, (YEAR) at 1:42 p.m., staff #122 stated that he knows better and that his glasses were giving him trouble that day, so he finally took them off. Staff #122 further stated that he should use tongs to pick up food, but he had watched others do that and had picked up some bad habits. In an interview with the Dietary Services Director (staff #216) on (MONTH) 31, (YEAR) at 1:50 p.m., staff #216 stated that staff know better than to pick up food with their hands and that they have all been taught the right way to pick up food. Staff #216 further stated that the bread should have been in plastic and there should not have been any reason to touch the food. Review of a facility document titled, Proper Wearing of Gloves in Healthcare revealed that gloves may be used when working with food to avoid contact with hands, and that gloves must be worn when touching ready-to-eat food. The documentation included that gloves can often give a false sense of security and can carry germs the same as hands. The documentation also included that gloves may be used for one task only.",2020-09-01
279,PLAZA HEALTHCARE,35084,1475 NORTH GRANITE REEF ROAD,SCOTTSDALE,AZ,85257,2017-09-01,441,D,0,1,VY8M11,"Based on observation, staff interviews and policy review, the facility failed to ensure infection control practices were maintained during incontinence care. Findings include: On (MONTH) 29, (YEAR) at 2:11 p.m., a Certified Nursing Assistant (staff #134) was observed providing incontinence care to a resident. Staff #134 applied gloves, then picked up the trash liner from the trash can in the room, which contained trash and placed it on the foot of the resident's bed. Staff #134 also picked up an unused liner that was in the bottom of the trash can and placed it on the bed. Staff #134 then removed her gloves and applied clean gloves and proceeded with perineal care. After cleaning the resident, staff #134 reached into her front right pocket with the soiled gloves and obtained a single use packet of barrier cream. Staff #134 applied the barrier cream to her soiled gloves and applied the cream to the resident's buttock. She then removed her soiled gloves. An interview was conducted on (MONTH) 30, (YEAR) at 12:52 p.m. with another CNA (staff #158), who stated that standard practice is to remove soiled gloves used for perineal care and then apply clean gloves, before touching one's self or other items in the room. She stated that the clean trash liners are to be placed at the foot of the bed. An interview was conducted with staff #134 on (MONTH) 31, (YEAR) at 1:29 p.m. She stated it was a break in infection control by not changing her gloves, and by using the dirty trash bags from the trash can and placing it on the bed. She stated normally she would carry liners with her or find clean liners near the linen carts in the hallway. An interview was conducted with the Chief Clinical Officer (staff #59) on (MONTH) 31, (YEAR) at 1:46 p.m. She stated CNAs may use clean trash liners during incontinence care, however, staff #134 should not have used a liner with trash. She also stated the expectation is that soiled gloves used for care should be removed and changed before touching their person and proceeding with the remaining care. A review of the facility's incontinence care policy revealed that staff are expected to remove soiled gloves, wash hands, and apply clean gloves before applying protective skin lubrications. After applying the lubricate, staff should remove the soiled gloves and wash or sanitize hands.",2020-09-01
280,PLAZA HEALTHCARE,35084,1475 NORTH GRANITE REEF ROAD,SCOTTSDALE,AZ,85257,2019-12-09,610,D,1,0,CKIR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews, staff interviews and review of policies and procedures, and review of the State Agency data base, the facility failed to ensure that an allegation of neglect for one resident (#1) was thoroughly investigated. The deficient practice could result in staff who may have neglected the resident being allowed to continue to provide care to additional residents, which could result in further neglect of residents. The sample size was one resident. Findings include: Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. An annual MDS (Minimum Data Set) assessment dated [DATE] included that the resident had severely impaired skills for daily decision making, was totally dependent on staff assistance from two or more staff for bed mobility, and totally dependent on one staff assist for hygiene. The assessment included that resident #1 had functional limitation in range of motion impairment on both right and left sides and upper and lower extremities, and had multiple active [DIAGNOSES REDACTED]. The assessment included that there were no indications or signs that the resident was experiencing pain. A written plan of care included that the resident has an ADL (Activity of Daily Living) self-care performance deficit related to musculoskeletal impairment, functional [MEDICAL CONDITIONS], [CONDITION]I ([MEDICAL CONDITION]), and incontinence. The care plan included multiple interventions including an intervention added to the care plan on July 13, 2018 that the resident has total dependence for bed mobility and required 2 person physical assistance, and required 1 person physical assistance for personal hygiene. A Nursing Change of Condition note dated November 25, 2019 at 3:41 p.m. included that an aide had informed the nurse (LPN/Licensed Practical Nurse, staff #278) that the resident's right arm had swelling and discoloration. The note included that staff #278 and another nurse (who was not identified in the note) looked at the resident's arm and confirmed the findings (that the resident's right arm was swollen and discolored). The note included that the physician was made aware, an X-Ray was ordered STAT (urgent or immediately) and that the resident did not have any signs of pain or distress. A Nursing Change of Condition note dated November 25, 2019 at 3:53 p.m. included that the physician and the day shift nurse had visualized the resident's right arm in the morning and the physician did not want the resident sent out (to the hospital). An Interact Change in Condition Evaluation dated November 25, 2019 included that the resident had swelling of the right antecubital (elbow), discoloration of the palm of the right hand, and swelling of the front of the right shoulder. The evaluation included that the resident had had an X-Ray with results of a right humerus fracture, the physician was notified at 4:47 p.m. and the resident was sent to the emergency department. Review of the state Agency data base revealed that an alleged injury of unknown origin had been reported to the State Agency on November 25, 2019 at 5:05 p.m. and included that the resident had a confirmed right humerus fracture, the resident was on a ventilator and suffered from a [MEDICAL CONDITION]. A Nursing Change of Condition note dated November 26, 2019 at 2:11 p.m. included that the resident had been sent to the hospital for [MEDICAL CONDITION] to the right upper arm and had returned to the facility with findings of an old fracture. Review of a facility investigative report regarding the injury of unknown origin reported on November 25, 2019 revealed a summary which included that on the morning of November 25, 2019 a nurse had noted that the resident's blood pressure was elevated, and had asked a CNA (Certified Nursing Assistant) to recheck the blood pressure. The report included that when the CNA rechecked the resident's blood pressure, she reported to the nurse that the resident's arm looked wrong and that nurse, after assessing the resident's arm notified the physician, who examined the resident and did not note any changes in the resident's right arm. The report included that later in the day at 2:45 p.m. a CNA who had showered the resident reported the findings two nurses, who assessed the resident and noted some redness and discoloration to the right upper arm,. The report included that the Physician was notified, and ordered and X-Ray, and when results of the X-Ray showed that the resident had a [MEDICAL CONDITION] humerus, the resident was sent to the hospital. The report included a conclusion that read it cannot be determined when this fracture took place but it can be assumed it occurred in or around 11/25/19 and Neither can it be determined how this fracture took place. The report also included in the conclusion that there was no evidence revealed as a result of the investigation of any intentional injury to, or abuse of the resident by employees of the facility. Review of the facility investigation regarding the injury of unknown origin reported on November 25, 2019 reveled the following written interview statements: -A written statement dated November 25, 2019 by a CNA (#314) included that after being assisted by another CNA (#64) to transfer the resident to a shower seat with a mechanical lift, he noticed that he was unable to clean under the resident's right arm, because he was unable to move the resident's arm, and he notified the nurse. -An investigation statement dated November 25, by an LPN (#278) included that on November 25, 2019 at an aide had informed her that the resident's right arm looked off and discolored, and that she and an LPN (#20) confirmed that the resident's arm appeared swollen, discolored and cool to touch. The statement included that the physician was notified, an X-Ray was ordered. The statement included that the X-Ray results were confirmed, and the resident was sent to the hospital. -An investigation statement dated November 27, 2019 by an LPN (#20) included that when passing morning medications, the nurse noticed that the resident's blood pressure was elevated and asked a CNA (#234) to re-check the blood pressure. The statement included that staff #234 then asked the nurse to look at the resident's arm before she attempted to re-check the blood pressure, and when the staff #20 assessed the resident's arm it didn't look right. The statement included that the staff #20 notified the physician, and the physician and the nurse (together) assessed the resident's arm. The statement included that later in the shift, the resident's (right) arm was swollen and discolored and that the physician had been notified. Further review of the facility investigation regarding the injury of unknown origin reported on November 25, 2019 revealed the following items not included in the investigation: -There were no witness statements included in the investigation from the CNA (#287) who had provided direct care to the resident or the night shift LPN (#336) on the over-night shift which began on November 24, and ended on November 25, prior to the morning medication pass when the injury was initially discovered by staff, who may have had knowledge regarding the source of the resident's fracture to the right humerus. -There were no witness statements included in the investigation from the CNA (#234) who was the staff who had actually been first to note the change in the appearance of the resident's right arm on November 25, 2019. -There were no witness statements from the CNA (#64) who had participated in the resident's care that morning , by assisting another CNA (#314) to move the resident onto a shower chair with a mechanical lift, who also may have observed a change in the resident's right arm. During an interview conducted on [DATE] at 10:50 a.m. with the Chief Executive Officer (#327), he stated that the information provided in the investigation reported on November 25, 2019 was the entire investigation and that there were no additional staff interviews that had not been included. An interview was conducted on December 9, 2019 at 8:55 a.m. with a Resource Nurse/staff #226. During then interview, #226 stated that she oversees investigations including the investigation of the injury of unknown source that occurred on November 25, 2019. Staff #226 stated that when conducts an investigation she interviews nurses, and asks staff what happened before, during and after the incident. Staff #226 stated that for the investigation of the injury of unknown origin she established a time frame and looked at the morning when the nurse asked the CNA/#234 to recheck the resident's blood pressure, and that the first person to observe that the resident's arm looked unusual was the CNA (#234) who re-checked the resident's blood pressure in the morning. However, staff #226 stated that she did not interview staff #234 because she was not in the building at the time she was conducting the investigation, however she could have interviewed her over the phone, and she did not. Staff #226 stated she did not interview any staff from the night shift because she felt there had not been an issue on the night shift, and that if anything had happened to the resident the nurse would have documented it in the progress notes, and there were no notes that anything unusual had occurred. When asked how she was able to rule out any unusual occurrences on the night shift without interviewing any staff on the night shift, staff #226 stated something that is a change in condition gets documented in the progress notes and I have no reason to believe that anything happened. During and interview conducted on December 9, 2019 at 10:42 a.m. with the Chief Executive Officer (#327), he stated that when an investigation is conducted they interview the employees who provided care to the resident. Staff #327 stated that regarding this particular investigation it was determined that the resident's injury had occurred the day that it was found by staff and that staff interviews needed to be conducted, including interviews of the night shift staff who provided care top the resident, prior to the day shift, which was when the injury was found. A policy and procedure titled Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property included a statement that abuse and neglect exist in many form and to varying degrees and the abuse and neglect included injuries of unknown origin, when the source of the injury was not observed by any person, or the injury could not be explained by the resident, or the injury is suspicious because of the extent of the injury, or the location of the injury. The policy included a statement that reports of abuse, including injuries of unknown source are promptly and thoroughly investigated, and that the investigative process is used to try to determine what happened.",2020-09-01
281,PLAZA HEALTHCARE,35084,1475 NORTH GRANITE REEF ROAD,SCOTTSDALE,AZ,85257,2019-12-09,689,E,1,0,CKIR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews, staff interviews and review of policies and procedures, the facility failed to ensure that the care was provided to two resident's (#1, #2) in a manner that promoted freedom from accident hazards. The deficient practice could result in residents being injured or suffering pain due to being improperly repositioned without adequate staff assistance. The sample size was two of four residents. Findings include: -Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. An annual MDS (Minimum Data Set) assessment dated [DATE] included that the resident had severely impaired skills for daily decision making, was totally dependent on staff assistance from two or more staff for bed mobility, and totally dependent on one staff assist for hygiene. The assessment included that resident #1 had functional limitation in range of motion impairment on both right and left sides and upper and lower extremities, and had multiple active [DIAGNOSES REDACTED]. A written plan of care included that the resident has an ADL (Activity of Daily Living) self-care performance deficit related to musculoskeletal impairment, functional [MEDICAL CONDITIONS], [CONDITION]I ([MEDICAL CONDITION]), and incontinence. The care plan included multiple interventions including that the resident has total dependence for bed mobility and required 2 person physical assistance. The plan of care also included that the resident had potential for pain related to contractures to bilateral hands, fingers, knees and ankles, foot drop, generalized pain, muscular/skeletal disorder and not being able to verbalize pain or discomfort due related to vegetative state. The care plan included to provide non-pharmacological interventions included repositioning, and to observe and report non-verbal signs of pain to the nurse. Review of clinical record revealed a form titled Documentation Survey Report v2 for November 2019. The form included an entry dated November 25, 2019 at 3:51 a.m. initialed by a CNA (#287) that documented the resident was totally dependent on on 2 person physical assist for bed mobility. A Nursing Change of Condition note dated November 25, 2019 at 3:41 p.m. included that the resident's right arm had swelling and discoloration, and an X-Ray was ordered. An Interact Change in Condition Evaluation dated November 25, 2019 included that the resident had swelling of the right antecubital (elbow), discoloration of the palm of the right hand, and swelling of the front of the right shoulder. The evaluation included that the resident had had an X-Ray with results of a right humerus fracture, the physician was notified and the resident was sent to the emergency department. A Nursing Change of Condition note dated November 26, 2019 at 2:11 p.m. included that the resident had returned to the facility with findings of an old fracture. A physician's Progress Note dated November 26, 2019 included that the resident had an old history of previous fracture (right humerus) and that an X-Ray showed that the old fracture had been re-fractured. The note included that the resident had contractures and poor bone quality from having been bed bound for [AGE] years. The note included that the re-[MEDICAL CONDITION] was not preventable and that there were no signs of trauma or abuse. An interview was conducted on [DATE] at 10:25 a.m. with a CNA (#234). The CNA stated that she had provided care to resident #1, was familiar with the resident and his care needs and was sometimes assigned to provide care to him. Staff #234 stated that she thought that resident #1 required assistance from only one staff to be turned and repositioned and that she turned and repositioned him by herself when she provides him with care. Staff #234 stated that it was easy to find out the care needs of the resident by looking in the computer, or if an off-going CNA gives her a report on the resident at the beginning of her shift, but this does not always happen. During an interview conducted on [DATE] at 11:30 a.m. with a night shift CNA (#287) he stated that on the night shift of November 25, 2019 he had provided care to resident #1 and that there were not enough staff that night. Staff #287 stated that he did not have any assistance from another staff to provide care to resident #1 and that he turned and repositioned the resident by himself when providing ADL care. Staff #287 stated that he used a draw sheet to turn and reposition the resident without additional assistance and that because the resident was unresponsive, he did not know if the resident experienced pain when being turned and repositioned. During an interview conducted on December 12, 2019 at 10:30 a.m. with a CNA (#198) she stated that it takes 2 CNA's to safely turn and reposition resident #1 because his knee is contracted and when you turn him you might bang his knee on the bed. -Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. A Quarterly MDS assessment dated [DATE] included that resident #2 had a BI[CONDITION] score of 15, which indicated the resident was cognitively intact, had function impairment of bilateral upper and lower extremities, and was totally dependent on 2 or more staff for bed mobility and personal hygiene. A written care plan included that the resident has an ADL self care performance deficit related to chronic pain, limited mobility, musculoskeletal impairment, [MEDICAL CONDITION] and [MEDICAL CONDITION]. The care plan included multiple interventions including that the resident required the assistance of 2 staff for bed mobility. The care plan also included that the resident had pain related to debility, generalized pain and discomfort, lower back pain, bilateral shoulder pain, muscle spasms, and is at risk for breakthrough pain. The care plan included that the resident's pain is aggravated by movement and repositioning. Review of a Documentation Survey Report v2 for entries dated November 1, through November 25, 2019 revealed initialed entries that the resident was totally dependent on 2 staff physical assist for bed mobility each day. An interview was conducted on [DATE] at 11:30 a.m. with CNA/#287, who stated that he had provided care to resident #2 on November 25, 2019 on the night shift. Staff #287 stated that when he reported for duty that night, the off-going CNA told him that staff #2 required two CNA's to turn and reposition the resident and to provide incontinence care, and to get help before providing care to the resident. Staff #287 stated that the there was not enough staff that night so he turned and repositioned the resident by himself, but was unable to complete incontinent care alone because it was too difficult for him to do without additional assistance. Staff #287 stated that when he repositioned the resident onto his right side he thought the resident may have had pain, but he wasn't sure, and he did not report it to the nurse and stated I didn't think it was a big deal, but I should have reported it. During an interview conducted on December 12, 2019 at 10:30 a.m. with a CNA/#198 12/9/19 at 10:30 a.m., she stated that it takes two CNA's to safely turn and reposition resident #2. An interview was conducted on December 9, 2019 at 8:35 a.m. with the Director of Nursing/staff #323. Staff #323 stated that the care needs of residents who are dependent on staff for turning and repositioning, whether to use one or two staff depends on the resident's ability to move easily. Staff #323 stated that for resident's who are totally dependent on staff, they require two staff assistance to be repositioned for safety, and to prevent pain and discomfort to the resident. A policy and procedure titled Resident Occurrence included a statement that read It is the policy of this facility to be aware of a risk for falls or accidents due to medical complexities. A policy and procedure titled Resident Care Plans included a statement that read It is the policy of this facility for each resident to have a plan of care. The resident's plan of care will serve as a guide to rendering care and services to the resident.",2020-09-01
282,PLAZA HEALTHCARE,35084,1475 NORTH GRANITE REEF ROAD,SCOTTSDALE,AZ,85257,2018-12-12,695,D,0,1,9XZX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, resident and staff interviews, and policy, the facility failed to ensure one resident (#58) who needed respiratory care was provided care consistent with professional standards of practice. Findings include: Resident #58 was readmitted on (MONTH) 8, (YEAR), with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated (MONTH) 9, (YEAR) revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. The assessment also included the resident was receiving oxygen therapy. Review of the physician's orders [REDACTED]. The care plan revealed the resident required oxygen therapy related to dyspnea and ineffective gas exchange with a goal of having no signs or symptoms of poor oxygen absorption. Interventions included giving medications as ordered by the physician, observing and documenting side effects and effectiveness, observing for signs and symptoms of respiratory distress and reporting to the physician as needed. During an observation conducted on (MONTH) 10, (YEAR) at 1:47 p.m., the resident was observed receiving 4 liters of oxygen per nasal cannula. Review of nursing notes dated (MONTH) 10, (YEAR) revealed no evidence the resident was receiving 4 liters of oxygen or that the physician was notified. During an interview conducted with the resident on (MONTH) 12, (YEAR) at 10:38 a.m., the resident was observed receiving oxygen at 4 liters via nasal cannula. The resident stated that she has been on oxygen for two years and that a couple of months ago the oxygen rate was changed to 4 liters. An interview was conducted on (MONTH) 12, (YEAR) at 11:01 a.m. with a licensed practical nurse (LPN/staff #101). Staff #101 stated that if a resident's oxygen saturation is 90% or less and/or the resident is having shortness of breath, nurses are to notify the physician for orders, implement the orders, and document the incident. After checking resident #58 oxygen rate, she stated that the rate may have been increased last night because of decreased oxygen saturation. The LPN reviewed the clinical record and stated the oxygen order is for 2 liters and that the resident should not be on 4 liters. An interview was conducted on (MONTH) 12, (YEAR) at 1:21 p.m. with a registered nurse (RN/staff #187). He stated that nursing staff are to follow physician's orders [REDACTED]. During an interview conducted on (MONTH) 12, (YEAR) at 1:39 a.m. with the Assistant Director of Nursing (ADON/staff #30), the ADON stated that if a change is made to a resident's oxygen rate, the nurse is expected to notify the physician and obtain orders to titrate the oxygen rate. An interview was conducted on (MONTH) 12, (YEAR) at 1:50 p.m. with the Director of Nursing (DON/staff#80), a nurse consultant (staff #313), and the Director of Quality Assurance (staff #248). The DON stated that the expectation is for the nursing staff to follow the physician's orders [REDACTED].#80 stated that if a resident begins to experience respiratory distress, nurses are to initiate oxygen therapy, notify the physician, complete a nursing assessment, and continue to monitor the resident's respiratory status. After reviewing the oxygen order, the DON stated that if the oxygen rate was increased to 4 liters, the expectation is that the nurse notify the physician. The facility's policy titled Oxygen Administration revealed oxygen therapy be administered upon a physician order [REDACTED]. The policy included to set oxygen flow rate as ordered. The policy also revealed in the absence of a physician's orders [REDACTED].",2020-09-01
283,PLAZA HEALTHCARE,35084,1475 NORTH GRANITE REEF ROAD,SCOTTSDALE,AZ,85257,2018-12-12,761,D,0,1,9XZX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and policy review, the facility failed to ensure expired medications and biologicals were not available for resident use and failed to ensure medications were secured in a locked storage cart. Findings include: During an observation conducted of the medication storage on station 3 on 12/12/18 at 09:03 AM, the Intravenous (IV) cart was observed to have 4 [MEDICATION NAME] flush syringes with an expiration date of (MONTH) (YEAR). An interview was conducted on 12/12/18 at 09:03 AM with Registered Nurse (RN/staff #204) who stated the [MEDICATION NAME] flush syringes are used for residents with implanted ports and that the [MEDICATION NAME] syringes have not been used for several months. The RN further stated that all supplies are checked before use, but that the night nurse is supposed to stock and check the supplies every Tuesday night. During an observation conducted of a Respiratory Care Cart on Station 3 on 12/12/18 at 09:10 AM, a 250 ml (milliliter) single-resident-use bottle of 0.9% sterile normal saline solution was observed opened and used with no resident's name and no open date marked. An interview was conducted on 12/12/18 09:10 AM with the Respiratory Therapist (RT/staff #99), who stated the sterile bottles are single-resident-use and should be thrown out if not completely used. During an observation conducted of a second Respiratory Care Cart on Station 3 on 12/12/18 at 09:15 AM with RT (staff #40), staff #40 retrieved the keys to open the cart from a box containing face masks on top of the cart. The cart had been observed unattended in the hall and contained inhalant and nebulizer medications. An interview was immediately conducted with staff #40, who stated that she was keeping the keys in the box instead of on her person. She also stated that she was aware there were medications in the cart and that they were supposed to be locked up. During an observation conducted of a Respiratory Care Cart on Station 4 on 12/12/18 at 09:20 AM, a 100 ml single-resident-use bottle of 0.9% sterile normal saline solution was observed opened and used with no resident's name and no open date marked. During an interview conducted on 12/12/18 at 09:20 AM with the RT (staff #300), the RT stated that the sterile bottles are for single-resident-use and should be thrown out once they have been opened and used. An interview was conducted on 12/12/18 at 09:38 AM with the Respiratory Director (staff #1), who stated the carts should be checked weekly by the RT. Staff #1 stated that if a single-resident-use bottle is opened and not used, it should be disposed of. An interview was conducted on 12/12/18 at 10:00 AM with the RN/Chief Clinical Officer (staff #80), who stated the consulting pharmacist conducts a courtesy check for the facility to check for expired medications and supplies on the medications carts. Staff #80 further stated the RT's check the RT carts, the wound nurses check the wound carts, and the IV nurses check the IV carts for expired medications and biologicals. The RN stated that the pharmacist checked the medication carts last month. Review of the facility's policy titled Storage of Medications included the policy statement, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The policy included that only those lawfully authorized to administer medications are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access.",2020-09-01
284,HAVEN OF SAGUARO VALLEY,35085,6651 EAST CARONDELET DRIVE,TUCSON,AZ,85710,2019-03-13,600,D,1,1,PZ8F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, resident and staff interviews, facility documentation and policies and procedures, the facility failed to ensure two of three sampled residents (#'s 18 and 29) were free from abuse. The resident census was 50. Findings include: -Resident #18 was readmitted to the facility on (MONTH) 21, (YEAR), with [DIAGNOSES REDACTED]. A review of the annual MDS (Minimum Data Set) assessment dated (MONTH) 28, (YEAR), revealed a BIMS (Brief Interview for Mental Status) score of 15, which indicated the resident had intact cognition. Regarding an incident on 8/19/18: Review of the facility's investigative documentation revealed that the Director of Nursing (DON/staff #14) was informed on 8/20/18 that the resident had been blocked in her room on 8/19/18 at approximately 8 a.m. for less than 15 minutes. A therapy device had been attached to her room door and the bathroom door, making it impossible for the resident to leave the room. A statement by resident #18 dated (MONTH) 19, (YEAR) around 8:30-9 a.m., revealed the resident reported to the social services director that a housekeeper had entered her room. They had a discussion about her hair, and then the housekeeper left. The resident reported that she continued to watch TV. She said that she became hot and wanted someone to come in and adjust the air, so she went towards the control box and the call light did not go on. She said when she turned around, she noticed that her blue therapy stick was attached to the bathroom door handle and was out stretched and it was attached to the bedroom door handle. She said that this caused the path out of her room to be blocked. The resident said she saw a caregiver (staff #83) walking in the hall and yelled out for him. She said that staff #83 took the blue therapy stick off the door and corrected the call lights on the wall. The statement further included the social services director asked the resident if she had seen the person who had placed the therapy stick on the doors and the resident replied that she had not. The resident reported that the housekeeper was the only one who was in her room since breakfast. According to a written statement from a Licensed Practicable Nurse (LPN/staff #97), the resident reported to her at 11:00 a.m. on 8/19/18 that a housekeeper (staff #99) took a therapy stick from her room and placed one of the open ends on the bathroom door and the other end on the bedroom door. Staff #97 said the resident also reported that the housekeeper had switched the call light cords around, so bed A was hooked into bed B. A statement from a Certified Nursing Assistant (CNA/staff #83) included the resident notified him on 8/19/18 at 8 a.m. that her call lights were switched, and that a therapy band had been placed on the bathroom doorknob and the entrance room door. Staff #83 reported that he entered the resident's room and a therapy band was attached to the entrance room doorknob and extended to the bathroom doorknob, and that the call lights were switched around. He reported that when the resident first brought this to his attention, she was quick to insinuate that he or another CNA might have been the culprits. He told the resident that he had nothing to do with it and did not know who was responsible. His statement included that he told the LPN (staff #97) however, it did not include what time he reported the incident to staff #97. Further review of the facility's investigative documentation revealed that the housekeeper (staff #99) was displaying strange behavior on 8/19/18 and left the facility. The report included that staff #99 was terminated and abuse was substantiated. An interview was conducted with a LPN (staff #97) on (MONTH) 12, 2019 at 10:15 a.m. Staff #97 stated the day of the incident the housekeeper (staff #99) was laughing about everything and her conversations made no sense. The LPN stated that staff #99 continued to work after the incident, until she walked off the job approximately two hours later. An interview was conducted with the housekeeper (staff #99) on (MONTH) 12, 2019 at 1:30 p.m. Staff #99 stated that she cleaned the resident's room but did not place a therapy band on the bathroom and bedroom door. Staff #99 stated that she did not know what happened, but she was terminated. During an interview conducted on (MONTH) 12, 2019 at 2:15 p.m., the resident stated that she was in her room watching television, when she noticed the therapy band on the doors. The resident stated the housekeeper (staff #99) was the only one who had been in her room and that it had to be the housekeeper who put the therapy band on her doors. During an interview conducted with the Director of Nursing (DON/staff #14) on (MONTH) 13, 2019, the DON stated they substantiated the allegation. Regarding an incident on 11/18/18: -A review of the facility's Reportable Event Record/Report revealed a LPN on duty noted that on 11/18/18 during the 10 p.m. - 6 a.m. shift, resident #18's call light was unplugged from the wall and a spoon was in it's place. The report included the resident was alert and oriented, able to make needs known. The resident was interviewed who stated that her call light did not seem to be working that night. The report also included that the resident's CNA (staff #100) stated that she did not go in her room all night, did not know there was a problem with the call light and denied the allegations. The LPN (staff #101) on duty stated the resident's call light was working at 12:00 a.m., when medications were given. Review of a written statement by a LPN (staff #101) dated (MONTH) 18, (YEAR) at 5:15 a.m. revealed, This writer entered (resident #18's room) with morning medications. Patient said 'I'm not getting up this morning. Do you want to know why I'm not getting up? I have been calling for help all night and no one came.' This writer went to wastebasket to throw away med cups and noticed that the cord to the call bell wasn't plugged into the wall and there was a plastic spoon in it's place. Spoon was removed and call bell cord was replaced. This writer went to CNA (staff #100) and told her she needs to go to (resident's room) because she had been calling all night for help and no one came. CNA replied 'She didn't call all night.' I held up the spoon and replied 'I'm sure her light didn't go on because someone unplugged her call bell cord and replaced it with this spoon.' CNA didn't reply, just looked at this writer like she didn't have a clue how spoon got stuck in the hole .Call bell cord was in place and working when this writer gave patient 12:00 a.m. medications. Further review of the investigative documentation revealed staff #100 was suspended pending the investigation and later terminated on (MONTH) 21, (YEAR). An interview was conducted with the resident on (MONTH) 12, 2019 at 2:15 p.m. The resident stated that she was hitting her call light all night long and no one came. She said when the LPN (staff #101) came in her room that morning, she asked her what was going on, as she had been ringing the call light all night and didn't have an aide. The resident stated that staff #101 told her that staff #100 was her CN[NAME] The resident stated that her call light was not plugged in right, as someone purposely put a plastic spoon in the outlet. An interview was conducted with the CNA (staff #100) on (MONTH) 12, 2019 at 2:40 p.m. Staff #100 stated that she was fired because the DON told her that she stuck a spoon in the resident's call light. The CNA stated that she did not do it and that she did not go in the resident's room all night. The CNA stated they are not supposed to go in the resident's room at night unless she puts her call light on and that her call light never went on. During an interview conducted with the DON (staff #14) on (MONTH) 13, 2019 at 8:30 a.m., the DON stated that they substantiated the allegation. The DON stated that staff #101 knew the call light was working at midnight and observed a spoon in the outlet five hours later. Staff #14 stated staff #100 was the only CNA that worked. An interview was conducted with the LPN (staff #101) on (MONTH) 13, 2019 at 10:40 a.m. The LPN stated she always administers the resident's medications at midnight and her call light was working then. Staff #101 stated when she entered the resident's room between 5:00 a.m. and 5:30 a.m., the resident asked what's going on that she had been calling all night. Staff #101 stated that she told the resident her call light never came on during the night and that is when she noticed the spoon in the call light control on the wall. Staff #101 stated the CNA (staff #100) was the only one who had been in the resident's room during that time. Staff #101 stated the resident was upset, because she was calling all night and no one came. Staff #101 said the resident had been administered a laxative on the previous shift and had stomach cramps all night. -Resident #29 was admitted to the facility on (MONTH) 6, (YEAR), with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment dated (MONTH) 1, (YEAR), revealed a BIMS (Brief Interview for Mental Status) score of 15, which indicated the resident was cognitively intact. Review of the facility's investigation revealed a statement dated (MONTH) 22, (YEAR) around 10-11 a.m. from the resident, who reported that she went to the nurse's station in her wheelchair and a certified nursing assistant (CNA/staff #96) told her that she needed to do her fingerstick. The resident told her no, that it was too early. She reported that the nurse (staff #97) also told the CNA that it was too early to do the fingerstick. The resident reported that at approximately 12:00 p.m., she put on her call light to request that her finger stick be done. Staff #97 came to the resident's room and said that staff #96 told her that she had already done the finger stick and that her blood sugar reading was 129. The resident stated that staff #96 did not do the finger stick and that staff #96 told her that she was going to punch the resident in the face. The resident said that she told staff #96 that she was going to call the police and staff #96 walked out of the room and the resident heard staff #96 say, Go to hell. The resident further stated that she felt threatened and called the front desk and asked to speak with the Director of Nursing (DON). Review of a statement by the licensed practical nurse (LPN/staff #97) revealed that at 10 a.m., she saw the aid (staff #96) about to do a blood sugar check on the resident. She told staff #96 that it was too early to do the finger stick, as she just finished breakfast and that it needed to be done at 11:30 a.m. The aid replied that she would not be able to do it as she still had people to get up. She said that she told the aid it will be done at that time. Around 11:30 a.m., the CNA approached her and said that the resident's blood sugar was 197. Staff #97 then went to the resident's room and commented about her blood sugar not being as high as it usually is. The resident responded by saying that the CNA was a liar and that she never took her blood sugar. When she confronted the CNA, she was writing a statement that the resident had threatened to punch her in the face. She told the CNA that the resident reported that she did not take her blood sugar. She reported that she had another CNA (staff #37) take the resident's blood sugar which was 126 per the machine and the machine did not have a blood sugar reading of 197. Staff #97 also reported that the resident came to her and said that the CNA (staff #96) threatened her and said that she would punch her in the nose. According to a statement by the CNA (staff #96), she went into the resident's room to get a finger stick and the resident told her that she lied and to get out of her room and that the resident said she was going to punch her in the face. Per the statement, she told the resident that she would get someone else to do it and quietly walked out of the room. Review of a statement from a CNA (staff #37) revealed that she and staff #96 were at the nurse's station, when staff #96 told her that she wanted to hit the resident in the nose and take the resident's blood sugar level from the blood that comes out of the resident's nose. Staff #37 then took food to the resident and the resident told staff #37 what staff #96 wanted to do to her. Staff #37 reported that the resident was still waiting for someone to take her blood sugar level, so she did a finger stick and the reading was 126. Review of the personnel file for staff #96 revealed that she was involuntarily terminated on (MONTH) 22, (YEAR), for reporting a blood sugar level that was not done, and for making inappropriate comments to another employee about the resident. An interview was conducted on (MONTH) 12, 2019 at 11:56 a.m. with staff #37, who stated that staff #96 told her that she wanted to punch the resident in the nose. An interview was conducted on (MONTH) 12, 2019 at 12:24 p.m. with resident #29, who stated that staff #96 did not do a finger stick when she came to her room around 11:30 a.m., because she said no. She said that staff #96 said just let me do the finger stick and when she said no, staff #96 threatened to punch her in the face. The resident said that she told staff #96 that she was going to call the police. She said it was reported to the DON and after the glucometers were checked, it was proven that staff #96 did not do the finger stick. An interview was conducted on (MONTH) 13, 2019 at 1:40 p.m. with the DON staff #14), who stated that staff #96 was terminated. She said the allegation was more than a he said, she said thing, because another staff corroborated the story. She said the resident's story was corroborated as staff #96 told another staff member that she wanted to hit the resident in the nose. Review of the Abuse policy revised (MONTH) 2019 revealed that Our facility will not condone any form of resident abuse . Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility is committed to protecting our residents from abuse by anyone including, but not limited to facility staff, other residents, friends, family or any other individual. Per the policy, the definition of abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment, resulting in physical harm or mental anguish.",2020-09-01
285,HAVEN OF SAGUARO VALLEY,35085,6651 EAST CARONDELET DRIVE,TUCSON,AZ,85710,2019-03-13,607,E,1,1,PZ8F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, facility documentation, and policies and procedures, the facility failed to implement their abuse policy, by failing to report two allegations of abuse for one (#18) of three sampled residents immediately to the administrator and to the State Survey Agency, within two hours after the allegations were made, and by failing to prevent the potential for further abuse during an investigation. The deficient practice could result in the potential for further abuse among residents. The facility census was 50. Findings include: Resident #18 was readmitted to the facility on (MONTH) 21, (YEAR), with [DIAGNOSES REDACTED]. A review of the annual MDS (Minimum Data Set) assessment dated (MONTH) 28, (YEAR) revealed a BIMS (Brief Interview for Mental Status) score of 15, which indicated the resident was cognitively intact. Regarding the incident on 8/19/18: Review of the facility's investigative documentation revealed that the Director of Nursing (DON/staff #14) was informed on 8/20/18 that the resident had been blocked in her room for less than 15 minutes on 8/19/18 at approximately 8 a.m. A therapy device had been attached to her room door and the bathroom door making it impossible for the resident to leave the room. A statement by resident #18 dated (MONTH) 19, (YEAR) around 8:30-9 a.m., revealed the resident reported to the social services director that a housekeeper had entered her room. They had a discussion about her hair, and then the housekeeper left. The resident reported that she continued to watch TV. She said that she became hot and wanted someone to come in and adjust the air, so she went towards the control box and the call light did not go on. She said when she turned around, she noticed that her blue therapy stick was attached to the bathroom door handle and was out stretched and attached to the bedroom door handle. She said that this caused the path out of her room to be blocked. The resident said she saw a caregiver (staff #83) walking in the hall and yelled out for help. She said that staff #83 took the blue therapy stick off of the door and corrected the call lights on the wall. The statement further included the social services director asked the resident if she had seen the person who had placed the therapy stick on the doors and the resident replied that she did not. The resident reported that the housekeeper was the only one that was in her room since breakfast. According to a written statement from a Licensed Practicable Nurse (LPN/staff #97), the resident reported to her at 11:00 a.m. on 8/19/18 that a housekeeper (staff #99) took her therapy stick which was in her room and placed one of the open ends on the bathroom door and the other end on the bedroom door. Staff #97 said the resident also reported that the housekeeper had switched the call light cords around, so bed A was hooked into bed B. A statement from a Certified Nursing Assistant (CNA/staff #83) included the resident notified him on 8/19/18 at 8 a.m. that a therapy band had been placed on the bathroom doorknob and the entrance room door and that her call lights were switched. Staff #83 reported that he entered the resident's room and a therapy band was attached to the entrance room doorknob and extended to the bathroom doorknob, and that the call lights were switched around. He said that when the resident first brought this to his attention, she was quick to insinuate that he or another CNA might have been the culprits. He told the resident that he had nothing to do with it and did not know who was responsible. His statement included that he told the LPN (staff #97) however, it did not include what time he reported the incident to staff #97. Further review of the investigative documentation revealed the housekeeper (staff #99) was displaying strange behavior on 8/19/18 and left the facility. The report included that staff #99 was terminated and abuse was substantiated. Per the report, the incident occurred at 8:00 a.m. on 8/19/18, however, the housekeeper (staff #99) continued to work for another three hours when she walked off the job at 11:00 a.m. The report also included the incident was not reported to the State Survey Agency until (MONTH) 20, (YEAR). An interview was conducted with a LPN (staff #97) on (MONTH) 12, 2019 at 10:15 a.m. Staff #97 stated the day of the incident the housekeeper (staff #99) was laughing about everything and her conversations made no sense. The LPN stated that staff #99 continued to work after the incident, until she walked off the job approximately two hours later. An interview was conducted with the housekeeper (staff #99) on (MONTH) 12, 2019 at 1:30 p.m. Staff #99 stated that she cleaned the resident's room but did not place a therapy band on the bathroom and bedroom door. Staff #99 stated that she did not know what happened, but she was terminated. During an interview conducted on (MONTH) 12, 2019 at 2:15 p.m., the resident stated that she was in her room watching television, when she noticed the therapy band on the doors. The resident stated the housekeeper (staff #99) was the only one who had been in her room and that it had to be the housekeeper who put the therapy band on her doors. An interview was conducted with the Director of Nursing (DON/staff #14) on (MONTH) 13, 2019 at 8:30 a.m. Staff #14 stated that the incident occurred about 8:00 a.m. on (MONTH) 19, (YEAR). Staff #14 stated the incident should have been reported to her immediately, so she could have reported it to the State Survey Agency within two hours, but she was not notified about the incident until the next day. She said the CNA (staff #83) did not report the incident to the LPN (staff #97) until 11 a.m. on 8/19/18, and that staff #97 did not report the incident to her until 8/20/18. Staff #14 further stated that the housekeeper (staff #99) should have been suspended immediately and not allowed to continue to work for another three hours. Regarding the incident on 11/19/18: -A review of the facility's Reportable Event Record/Report revealed a LPN on duty noted that on 11/18/18 during the 10 p.m. - 6 a.m. shift, resident #18's call light was unplugged from the wall and a spoon was in it's place. The report included the resident was alert and oriented, able to make needs known. The resident was interviewed who stated that her call light did not seem to be working that night. The report also included that the resident's CNA (staff #100) stated that she did not go in her room all night, did not know there was a problem with the call light and denied the allegations. The LPN (staff #101) on duty stated the resident's call light was working at 12:00 a.m., when medications were given. Review of a written statement by a LPN (staff #101) dated (MONTH) 18, (YEAR) at 5:15 a.m. revealed This writer entered (resident #18's room) with morning medications. Patient said 'I'm not getting up this morning. Do you want to know why I'm not getting up? I have been calling for help all night and no one came.' This writer went to wastebasket to throw away med cups and noticed that the cord to the call bell wasn't plugged into the wall and there was a plastic spoon in it's place. Spoon was removed and call bell cord was replaced. This writer went to CNA (staff #100) and told her she needs to go to (resident's room) because she had been calling all night for help and no one came. CNA replied 'She didn't call all night.' I held up the spoon and replied 'I'm sure her light didn't go on because someone unplugged her call bell cord and replaced it with this spoon.' CNA didn't reply, just looked at this writer like she didn't have a clue how spoon got stuck in the hole .Call bell cord was in place and working when this writer gave patient 12:00 a.m. medications. Further review of the facility's Reportable Event Record/Report dated (MONTH) 19, (YEAR) revealed the incident occurred at 5:15 a.m. on (MONTH) 18, 2019, however, was not reported to the State Survey Agency until 9:02 a.m. (MONTH) 18. An interview was conducted with the resident on (MONTH) 12, 2019 at 2:15 p.m. The resident stated that she was hitting her call light all night long and no one came. She said when the LPN (staff #101) came in her room that morning, she asked her what was going on, as she had been ringing the call light all night and didn't have an aide. The resident stated that staff #101 told her that staff #100 was her CN[NAME] The resident stated that her call light was not plugged in right, as someone purposely put a plastic spoon in the outlet. During an interview conducted with the DON (staff #14) on (MONTH) 13, 2019 at 8:30 a.m., the DON stated that they substantiated the allegation. The DON stated that staff #101 knew the call light was working at midnight and observed a spoon in the outlet five hours later. Staff #14 stated that staff #100 was the only CNA that worked. Staff #14 further stated the incident was not reported to the State Survey Agency within two hours, as she was not notified of the incident immediately. Staff #14 said staff waited until she arrived at work to report the incident to her. Review of the Abuse policies revised (MONTH) 2019 revealed that Our facility will not condone any form of resident abuse . Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility is committed to protecting our residents from abuse by anyone including, but not limited to facility staff, other residents, friends, family or any other individual. Per the policy, the definition of abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment, resulting in physical harm or mental anguish. The policy further included .The facility, with the support of the physicians, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations .Each covered individual shall report to the State Agency .not later than 2 hours after forming the suspicion . The Abuse policy also included .Employees of this facility who have been accused of resident abuse will be suspended immediately pending the outcome of the investigation . Review of the facility's policy regarding Grievances/Complaints, Filing revealed .All alleged violations of neglect, abuse .will be reported and investigated under guidelines for reporting abuse, neglect . Further review of the facility's Abuse policies revealed they did not included that allegations of abuse should be reported immediately to the administrator and/or designee.",2020-09-01
286,HAVEN OF SAGUARO VALLEY,35085,6651 EAST CARONDELET DRIVE,TUCSON,AZ,85710,2019-03-13,609,D,1,1,PZ8F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, facility documentation and policies and procedures, the facility failed to report two allegations of abuse for one (#18) of three sampled residents to the State Survey Agency, within two hours after the allegations were made. The facility census was 50. Findings include: Resident #18 was readmitted to the facility on (MONTH) 21, (YEAR), with [DIAGNOSES REDACTED]. Regarding the incident on 8/19/18: -Review of the facility's investigative documentation revealed that the Director of Nursing (DON/staff #14) was informed on 8/20/18 that the resident had been blocked in her room for less than 15 minutes on 8/19/18 at approximately 8 a.m. A therapy device had been attached to her room door and the bathroom door, making it impossible for the resident to leave the room. According to a written statement from a Licensed Practicable Nurse (LPN/staff #97), the resident reported to her at 11:00 a.m. on 8/19/18 that a housekeeper (staff #99) took her therapy stick which had two open ends and placed one end on the bathroom door and the other end on the bedroom door. Staff #97 said the resident also reported that the housekeeper had switched the call light cords around, so bed A was hooked into bed B. According to a statement from a Certified Nursing Assistant (CNA/staff #83), the resident notified him on 8/19/18 at 8 a.m. that a therapy band had been placed on the bathroom doorknob and the entrance room door and that her call lights were switched. Staff #83 said he entered the resident's room and observed that a therapy band was attached to the entrance room doorknob, which extended to the bathroom doorknob and that the call lights were switched around. He reported that when the resident first brought this to his attention, she was quick to insinuate that he or another CNA might have been the culprits. He told the resident that he had nothing to do with it and did not know who was responsible. His statement included that he told the nurse (Licensed Practicable Nurse/staff #97) however, it did not include what time he reported the incident to staff #97. A statement by resident #18 dated (MONTH) 19, (YEAR) around 8:30-9 a.m., revealed the resident reported to the social services director that a housekeeper had entered her room. They had a discussion about her hair, and then the housekeeper left. The resident reported that she continued to watch TV. She said that she became hot and wanted someone to come in and adjust the air, so she went towards the control box and the call light did not go on. She said when she turned around, she noticed that her blue therapy stick was attached to the bathroom door handle and it was out stretched and attached to the bedroom door handle. She reported that this caused the path out of her room to be blocked. The resident said she saw a caregiver (staff #83) walking in the hall and yelled out for him to help. She said that staff #83 took the blue therapy stick off the door and corrected the call lights on the wall. The statement further included the social services director asked the resident if she had seen the person who had placed the therapy stick on the doors, and the resident replied that she had not. The resident reported that the housekeeper was the only one who was in her room since breakfast. Further review of the facility's investigative documentation revealed the incident of abuse occurred at 8:00 a.m. on (MONTH) 19, (YEAR), however, it was not reported to the State Survey Agency until (MONTH) 20, (YEAR). An interview was conducted with the Director of Nursing (DON/staff #14) on (MONTH) 13, 2019 at 8:30 a.m. Staff #14 stated that the incident occurred about 8:00 a.m. on (MONTH) 19, (YEAR). Staff #14 stated the incident should have been reported to her immediately, so she could have reported it to the State Survey Agency within two hours. She said the CNA (staff #83) did not report the incident to the LPN (staff #97) until 11 a.m. on 8/19/18, and that staff #97 did not report the incident to her until 8/20/18. Regarding an incident on 11/18/18: -A review of the facility's Reportable Event Record/Report revealed a LPN on duty noted that on 11/18/18 during the 10 p.m. - 6 a.m. shift, resident #18's call light was unplugged from the wall and a spoon was in it's place. The report included the resident was alert and oriented, able to make needs known. The resident was interviewed who stated that her call light did not seem to be working that night. The report also included that the resident's CNA (staff #100) stated that she did not go in her room all night, did not know there was a problem with the call light and denied the allegations. The LPN (staff #101) on duty stated the resident's call light was working at 12:00 a.m., when medications were given. Further review of the facility's Reportable Event Record/Report revealed the incident occurred at 5:15 a.m. on (MONTH) 18, (YEAR), however, it was not reported to the State Survey Agency until 9:02 a.m. (MONTH) 18, (YEAR). An interview was conducted with the Director of Nursing (DON/staff #14) on (MONTH) 13, 2019 at 8:30 a.m. Staff #14 stated that she was not notified about the alleged incident immediately therefore, it was not reported to the State Survey Agency within two hours. Staff #14 stated that staff waited until she arrived at work to report the incident to her. Review of the facility's policy regarding Grievances/Complaints, Filing documented .All alleged violations of neglect, abuse .will be reported and investigated under guidelines for reporting abuse, neglect . Review of the facility's Abuse policies revealed .The facility, with the support of the physicians, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations .Each covered individual shall report to the State Agency .not later than 2 hours after forming the suspicion . Further review of the facility's Abuse policies revealed they did not include that allegations of abuse should be reported immediately to the administrator and/or designee.",2020-09-01
287,HAVEN OF SAGUARO VALLEY,35085,6651 EAST CARONDELET DRIVE,TUCSON,AZ,85710,2019-03-13,610,E,1,1,PZ8F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interview, facility documentation and policies and procedures, the facility failed to prevent the potential for further abuse while an investigation was in progress for one (#18) of three sampled residents. The deficient practice could result in the potential for further abuse to residents. The facility census was 50. Findings include: Resident #18 was readmitted to the facility on (MONTH) 21, (YEAR), with [DIAGNOSES REDACTED]. Review of the facility's investigative documentation revealed that the Director of Nursing (DON/staff #14) was informed on 8/20/18 that the resident had been blocked in her room for less than 15 minutes on 8/19/18 at approximately 8 a.m. A therapy device had been attached to her room door and the bathroom door, making it impossible for the resident to leave the room. A statement by resident #18 dated (MONTH) 19, (YEAR) around 8:30-9 a.m., revealed the resident reported to the social services director that a housekeeper had entered her room. They had a discussion about her hair, and then the housekeeper left. The resident reported that she continued to watch TV. She said that she became hot and wanted someone to come in and adjust the air, so she went towards the control box and the call light did not go on. She said when she turned around, she noticed that her blue therapy stick was attached to the bathroom door handle and was out stretched and it was attached to the bedroom door handle. She reported that this caused the path out of her room to be blocked. The resident said she saw a caregiver (staff #83) walking in the hall and yelled out for help. She said that staff #83 took the blue therapy stick off the door and corrected the call lights on the wall. The statement further included the social services director asked the resident if she had seen the person who had placed the therapy stick on the doors and the resident replied that she had not. The resident reported that the housekeeper was the only one who was in her room since breakfast. According to a written statement from a Licensed Practicable Nurse (LPN/staff #97), the resident reported to her at 11:00 a.m. on 8/19/18 that a housekeeper (staff #99) took her therapy stick which was in her room and placed one of open ends on the bathroom door and the other end on the bedroom door. Staff #97 said the resident also reported that the housekeeper had switched the call light cords around, so bed A was hooked into bed B. A statement from a Certified Nursing Assistant (CNA/staff #83) included the resident notified him on 8/19/18 at 8 a.m. that her call lights were switched and that a therapy band had been placed on the bathroom doorknob and the entrance room door. Staff #83 said he entered the resident's room and observed that a therapy band was attached to the entrance room doorknob and extended to the bathroom doorknob and that the call lights were switched around. He said that when the resident first brought this to his attention, she was quick to insinuate that he or another CNA might have been the culprits. He told the resident that he had nothing to do with it and did not know who was responsible. His statement included that he told the LPN (staff #97) however, it did not include what time he reported the incident to staff #97. Further review of the facility's investigative documentation revealed the incident occurred at 8:00 a.m. on (MONTH) 19, (YEAR), however the housekeeper (staff #99) continued to work for another three hours until she walked off the job at 11:00 a.m. on (MONTH) 19. The report included that staff #99 was terminated and abuse was substantiated. An interview was conducted with a LPN (staff #97) on (MONTH) 12, 2019 at 10:15 a.m. Staff #97 stated the day of the incident the housekeeper (staff #99) was laughing about everything and her conversations made no sense. The LPN stated that staff #99 continued to work after the incident, until she walked off the job approximately two hours later. An interview was conducted with the Director of Nursing (DON/staff #14) on (MONTH) 13, 2019 at 8:30 a.m. Staff #14 stated that the housekeeper (staff #99) should have been suspended immediately and not allowed to continue to work for another three hours. Review of the facility's policy regarding Abuse Investigations revealed .Employees of this facility who have been accused of resident abuse will be suspended immediately pending the outcome of the investigation .",2020-09-01
288,HAVEN OF SAGUARO VALLEY,35085,6651 EAST CARONDELET DRIVE,TUCSON,AZ,85710,2019-03-13,622,D,0,1,PZ8F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy and procedure, the facility failed to ensure the required discharge information was documented for 1 of 3 sampled residents (#49) for closed record review. The deficient practice could result in residents not receiving needed information regarding their care. Findings include: Resident #48 was admitted to the facility on (MONTH) 21, (YEAR), with [DIAGNOSES REDACTED]. A physician's order dated (MONTH) 14, 2019 included for home health, medication management and for a front wheel walker. A nurses note dated (MONTH) 18, 2019 included documentation that the resident left with a family member at 12 p.m. However, review of the clinical record revealed there was no physician's order for discharge. Review of the clinical record revealed the discharge instructions were signed by the resident on (MONTH) 18, 2019. However, review of the interdisciplinary discharge summary revealed the final summary for nursing services was left blank. An interview was conducted with a Licensed Practical Nurse (LPN/staff #68) on (MONTH) 12, 2019 at 11:33 PM. The LPN stated that upon discharge the nurse is responsible to make sure that all paperwork is signed and completed. She stated she would also document any teaching she provided, what paperwork was completed and any discharge instructions given. An interview with the Director of Nursing (DON/staff #14) was conducted on (MONTH) 13, 2019 at 9:36 AM. The DON stated the nurse is responsible for getting the discharge orders and medications, and going through everything with the patient. She stated these things should be documented in the chart. She stated there probably should have been more written on this patients discharge note. She stated that she did not see an order for [REDACTED].>A review of the facility policy for the Discharge of Residents revealed that nursing services in conjunction with social services or care managers are responsible for obtaining orders for discharge or transfer, as well as the recommended discharge services and equipment. It also states nursing services are responsible for completing a discharge note in the medical record to include a discharge summary, which includes a recapitulation of the residents stay, resident final status and reconciliation of pre and post discharge medications.",2020-09-01
289,HAVEN OF SAGUARO VALLEY,35085,6651 EAST CARONDELET DRIVE,TUCSON,AZ,85710,2019-03-13,638,D,0,1,PZ8F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, review of the CMS (Centers for Medicare and Medicaid Services) QIES ASAP (Quality Improvement Evaluation System Assessment Submission and Processing) system, the RAI manual and policy review, the facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed timely for 2 of 5 sampled residents (#4 and #6). The facility census was 50. Findings include: -Resident #4 was admitted to the facility on (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed an admission MDS assessment dated (MONTH) 21, (YEAR). Further review of the clinical record revealed that a quarterly MDS assessment was not completed in the required time frame of 92 days after the previous assessment. The next quarterly MDS assessment was dated (MONTH) 14, 2019. In an interview with the MDS coordinator (staff #92) on (MONTH) 13, 2019 at 10:30 a.m., he stated there should have been a quarterly MDS assessment done and was not sure how it was missed. -Resident #6 was admitted to the facility on (MONTH) 18, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed the last quarterly MDS assessment which was completed was dated (MONTH) 24, (YEAR). There was no evidence that a quarterly MDS assessment was completed in (MONTH) 2019. Review of the CMS QIES ASAP data base revealed the last quarterly MDS assessment was submitted in (MONTH) (YEAR). In an interview with staff #92 on (MONTH) 13, 2019 at 10:30 a.m., he stated the quarterly MDS for (MONTH) 2019 was not done and was also missed. In an interview with the Director of Nursing (DON/staff #14) on (MONTH) 13, 2019 at 1:25 p.m., she stated her expectation is that the quarterly MDS assessments should be done and transmitted on time. Review of a facility policy titled, MDS Completion and Submission Timeframe's with a revision date of (MONTH) 2019, revealed our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframe's. The Assessment Coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS QIES ASAP system in accordance with current federal and state guidelines. Review of the RAI manual includes that quarterly MDS assessments are due 92 calendar days after the previous assessment.",2020-09-01
290,HAVEN OF SAGUARO VALLEY,35085,6651 EAST CARONDELET DRIVE,TUCSON,AZ,85710,2019-03-13,657,D,0,1,PZ8F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy and procedure, the facility failed to ensure a care plan was revised to reflect Hospices services for 1 of 2 sampled residents (#48). Findings include: Resident #48 was admitted to the facility on (MONTH) 18, 2019, with a [DIAGNOSES REDACTED]. A review of the discharge care plan dated (MONTH) 21, 2019 revealed the resident intended to be discharged to home. A physician's order dated (MONTH) 31, 2019 included to admit the resident on Hospice services for [MEDICAL CONDITION]. Further review of the resident's care plans revealed they were not revised to reflect that the resident was on Hospice services. An interview was conducted with the MDS coordinator (Minimum Data Set/staff #92) on (MONTH) 13, 2019 at 8:21 a.m. Staff #92 when a significant change occurs such as admission to Hospice, the care plan should be updated. He stated there is a new process for updating the care plans, but essentially everyone is responsible for doing it. An interview was conducted with the Director of Nursing (DON/staff #14) on (MONTH) 13, 2019 at 9:36 p.m. The DON stated she did not know why the care plan had not been updated for this resident. She also stated that the MDS coordinator was responsible for updating the care plans. Review of the facility policy for Care Plans revealed that assessments of residents are ongoing and care plans are revised as information about the resident and the residents' conditions change. The interdisciplinary team must review and update the care plan when there has been a significant change in the resident's condition and when the desired outcome is not met.",2020-09-01
291,HAVEN OF SAGUARO VALLEY,35085,6651 EAST CARONDELET DRIVE,TUCSON,AZ,85710,2019-03-13,658,E,0,1,PZ8F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy and procedure, the facility failed to meet professional standards of quality, by failing to administer a medication to 1 of 6 sampled residents (#47), as ordered by the physician. The deficient practice could result in an increase in symptoms of depression. Findings include: Resident #47 was admitted to the facility on (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A care plan dated (MONTH) 20, (YEAR) included the resident had a [DIAGNOSES REDACTED]. A goal was that the resident would have no episodes of crying. Interventions included to administer medication as ordered and note/report adverse effects. Review of a 14-day Minimum Data Set assessment dated (MONTH) 31, (YEAR), revealed the resident received an antidepressant medication for 7 out of 7 days in the look-back period. Review of the (MONTH) (YEAR) Medication Administration Record (MAR) revealed the order for [MEDICATION NAME] daily at bedtime for depression. However, the documentation showed that for [MEDICATION NAME], the nurse's had circled their initials each day, indicating that the medication was not administered from (MONTH) 19-31. Review of the back of the (MONTH) (YEAR) MAR revealed the following nursing entries: 12/20: waiting for delivery 12/21: not available; waiting for delivery 12/24: not available; waiting for delivery 12/28: waiting delivery 12/31: ordered Further review of the clinical record revealed there was no documentation of any follow up that was done by the nurses from (MONTH) 20-30, regarding the medication not being available. Despite documentation that the medication was ordered on [DATE], the (MONTH) 2019 MAR showed the nurses' initials were circled each day from (MONTH) 1-7, indicating the medication was not administered. A monthly behavior monitoring flowsheet for (MONTH) 1-7, 2019 revealed the resident was being monitored for signs and symptoms of sadness. The documentation included that the resident had two episodes of sadness. Continued review of the clinical record revealed there was no documentation that the physician had been notified of the missed doses of [MEDICATION NAME]. The resident was transferred to the hospital on (MONTH) 7, 2019, for an unrelated condition. An interview was conducted with a Licensed Practical Nurse (LPN/staff #19) on (MONTH) 13, 2019 at 1:37 p.m. Staff #19 stated that if a medication was not available, she would circle her initials on the MAR and document on the back why the medication was not given. Staff #19 said if the medication was unavailable for more than three days, she would contact the pharmacy to find out why it had not been delivered. She also stated if a medication was not available she would notify the doctor, the resident and document it in a nursing note. An interview was conducted with a LPN (staff #68) on (MONTH) 13, 2019 at 1:47 p.m. She stated if a medication was unavailable she would check to see if it was available in the pyxis. Staff #68 then confirmed that [MEDICATION NAME] was not available in the pyxis. She stated that she would contact the pharmacy to get the medication immediately and notify the provider. Staff #68 stated if the medication had been missing for several days, she said she would monitor the patient for side effects and notify the provider for further instructions. She said she would document this in the charting. An interview was conducted with the Director of Nursing (DON/staff #14) on (MONTH) 13, 2019 at 2:05 p.m. The DON stated if a medication is not administered the nurse should circle her initials on the MAR and document on the back of the MAR, why the medication was not given. She said if there is a problem with availability, the nurse should pull the medication from the stat safe. She also stated that if the medication has been missing for several days, she expects the nurse to notify the physician and contact the pharmacy and document it. The DON stated she did not know why the medication was unavailable. Review of the policy and procedure for administering medication revealed that medication must be administered in accordance with the orders, including any required time frame.",2020-09-01
292,HAVEN OF SAGUARO VALLEY,35085,6651 EAST CARONDELET DRIVE,TUCSON,AZ,85710,2019-03-13,732,B,0,1,PZ8F11,"Based on observations and staff interviews, the facility failed to post the total number and actual hours worked by registered and licensed practical nurses on a daily basis. Findings include: An observation of the Daily Nurse Staffing information dated (MONTH) 12, 2019 was posted in the facility's main lobby. Review of the Daily Nurse Staffing information revealed that the total number and actual hours worked were documented as Nurses however, it did not differentiate whether the nurses were registered nurses or licensed practical nurses. Further review of the Daily Nurse Staffing information from the previous three months also revealed that the nurse's hours did not differentiate between registered nurses or licensed practical nurses. An interview was conducted with the administrator (staff #27) on (MONTH) 13, 2019 at 11:50 a.m. Staff #27 stated that the Daily Nurse Staffing Forms used to reflect if the nurses working were registered nurses or licensed practical nurses and that he did not know when the form was changed. Staff #27 further stated that the facility did not have a policy regarding the posting of nurse staffing information, but that it was standard operating procedure. An interview was conducted with the staffing coordinator/scheduler (staff #44) on (MONTH) 13, 2019 at 12:20 p.m. Staff #44 stated that the Daily Nurse Staffing Forms were the same forms that had been used for the past three months.",2020-09-01
293,HAVEN OF SAGUARO VALLEY,35085,6651 EAST CARONDELET DRIVE,TUCSON,AZ,85710,2019-03-13,761,D,0,1,PZ8F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, review of the Saunders Nursing Drug Handbook 2019 and policy and procedure, the facility failed to ensure one bottle of insulin was dated when opened on 1 of 3 medication carts. The deficient practice could result in a decrease in the effectiveness of the medication for residents. Findings include: An observation was conducted on (MONTH) 13, 2019 at 9:17 a.m., with a registered nurse (RN/staff #35) of the Santa Rita back hall medication cart. In the drawer, there was an opened bottle of [MEDICATION NAME] 100 units/ml (milliliters) which was partially used, and there was no open date on the bottle or box. An interview was immediately conducted with staff #35. She stated that she could not find the open date on the bottle or on the insulin box and that she did not know when it had been opened. An interview was conducted with the Director of Nursing (DON/staff #14) on (MONTH) 13, 2019 at 9:36 a.m. The DON stated that insulin should always be dated when it is opened. Review of the Saunders Nursing Drug Handbook 2019 revealed that [MEDICATION NAME], after first use is stable at room temperature for 28 days. Review of the Administering Medications policy revealed that when opening a multi-dose container, the date opened shall be recorded on the container.",2020-09-01
294,HAVEN OF SAGUARO VALLEY,35085,6651 EAST CARONDELET DRIVE,TUCSON,AZ,85710,2018-07-12,561,D,1,1,FYQM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, and facility documents, the facility failed to ensure one resident (#236) was transported to a scheduled physician appointment. Findings include: Resident #236 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was discharged from the facility on 03/12/18. Consent for Transportation signed on 02/04/18 revealed, The benefits of accepting transportation are quicker diagnoses, medical/therapy upgrades, and faster recovery as well as alleviating the burden of your family arranging transportation. The consent included if a resident refused transportation and/or appointments, .this may result in delay of care resulting in extending illness, delaying upgrades in medical/therapy status, or causing medical complications [REDACTED].>A physician's orders [REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. The functional assessment revealed the resident required extensive assistance or was totally dependent for all activities except eating. A Nurse Practitioner's (NP) progress note dated 02/12/18, revealed the resident's follow up appointment with the surgeon was scheduled for 02/14/18. The note also included the resident was recovering slowly and that she was ongoing NWB to the right leg with PT. A NP progress note dated 02/15/18, revealed the resident missed the appointment with the orthopedic surgeon yesterday due to transportation issues. The note included that if the resident is able to see the orthopedic surgeon, obtain weight bearing as tolerated (WBAT) status and progress with therapies in the next week. The note revealed the resident was ongoing NWB to the right leg with PT/OT and to follow up with the orthopedic physician as soon as it can be arranged. The Appointment and Follow-up form revealed the original appointment was 02/14/18 at 10:30 AM and that the pick-up time for the resident was 9:30 AM. The form also included the rescheduled appointment date of 02/21/18 at 10:30 AM with the pick-up time at 9:30 AM. A letter from the resident's orthopedic surgeon to the facility dated 02/21/18, revealed the resident should be mobilizing by this time. The note also included that the resident is weight bearing as tolerated and has been since her surgery. The note revealed the resident is to ambulate with a walker and exercise posterior hip precautions and should receive PT daily for strengthening, balance, and gait training. A physician order [REDACTED]. An interview was conducted on 07/11/18 at 12:00 PM with the Staffing Coordinator (staff #54). Staff #54 stated that a resident's appointments are reviewed upon admission, and that once the payment source is verified, they arrange transportation for the resident to the appointment. He further stated that the transport may leave if they do not see them outside and that he would call them again. Staff #54 stated there are times an appointment is missed and has to be rescheduled. On 07/11/18 at 12:38 PM, the office of the orthopedic surgeon was contacted. The scheduler stated that resident #236 had an appointment on 02/14/18, but was a no-show. The scheduler further stated the appointment was rescheduled for 02/21/18 and that the resident did show for the appointment. During an interview conducted with the Director of Rehabilitation (staff #44) on 07/12/18 at 08:55 AM, staff #44 stated they do not progress a resident until they receive an order from the orthopedic physician. Staff #44 also stated the resident was at a functional plateau with NWB, and that missing the appointment may have extended her stay at the facility by about a week. An interview was conducted on 07/12/18 at 10:03 AM with a NP (staff #96). Staff #96 stated that the missed appointment probably delayed the resident's discharge by a week or less. The NP also stated that once the resident was WBAT, she did really well and was able to go home on 3/12/18. The facility did not have a policy for appointment scheduling and transportation, but did provide a typed document dated 7/2018 that included the following: -Resident appointments come with orders for follow-up with specialists or personal physician. The facility scheduler then makes the appointment for the resident to include transportation to and from the appointment if needed. -Scheduling is performed by the designated scheduler making sure to check with the resident on times and dates. -Transport is set up by the scheduler is needed, transport consent is signed by the resident if they wish the facility to set up transportation or it the resident will set up personal transportation.",2020-09-01
295,HAVEN OF SAGUARO VALLEY,35085,6651 EAST CARONDELET DRIVE,TUCSON,AZ,85710,2018-07-12,567,D,0,1,FYQM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interviews, and review of facility policies and procedures, the facility failed to ensure that residents had access to their personal funds on the weekend. Findings include: Resident #319 was readmitted to the facility on (MONTH) 21, (YEAR), with a [DIAGNOSES REDACTED]. An interview was conducted with the resident on (MONTH) 12, (YEAR) at 9:00 a.m. The resident stated that the business office manager stated that residents were unable to have access to their personal funds on the weekend. A posting observed in the front lobby of the facility entitled Resident Trust Banking revealed Hours, Monday - Friday. 9:00 a.m. - 3:00 p.m. An interview was conducted with the business office manager, staff #56 on (MONTH) 12, (YEAR) at 10:30 a.m. The business office manager stated that residents can have access to their personal funds Monday through Friday from 9:00 a.m. until 3:00 p.m. The business office manager further stated that if residents needed money on the weekends that they would have to withdraw money by 3:00 p.m. on Friday. An interview was conducted with the administrator, staff #23 on (MONTH) 12, (YEAR) at 11:00 a.m. The administrator stated that it is the resident's money and the money should be available to the residents whenever they want it. Review of the facility's policy Resident Trust Funds revealed It is the policy that a resident trust fund be made available to every resident .The administrator establishes trust fund banking hours reasonable and convenient to the residents and families seven days a week. Banking hours are posted in the facility .",2020-09-01
296,HAVEN OF SAGUARO VALLEY,35085,6651 EAST CARONDELET DRIVE,TUCSON,AZ,85710,2018-07-12,607,D,0,1,FYQM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, clinical record reviews, facility documents, and policies and procedures, the facility failed to implement their policies and procedures regarding an injury of unknown origin for one resident (#2) and an allegation of abuse for one resident (#26). Findings include: -Resident #2 was admitted on (MONTH) 18, (YEAR), with [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment dated (MONTH) 8, (YEAR), included the resident had a BIMS (Brief Interview for Mental Status) score of 10 which indicated the resident had moderately impaired cognition. An interview was conducted with resident #2 was on (MONTH) 9, (YEAR) at 1:00 p.m. During the interview, an observation was made that the resident had a dark purple bruise at the outer aspect of her left eye, and lighter colored bruising around the eye. The resident stated that she did not know how her left eye was bruised. Review of the resident's clinical record did not reveal any documented evidence that a bruise to the left eye had been assessed by staff, or that the cause of the bruise had been investigated or reported to the State Agency. An interview was conducted on (MONTH) 11, (YEAR) at 11:05 a.m. with the Director of Nursing (DON/staff #53). During the interview, the Director stated that the resident had chronic bruising since childhood all over her head, around her eye, on top of her head. The DON stated that the resident may have bumped her head on a door several days prior to the interview which may have caused the bruise around the left eye. She stated the resident is known to go in and out of the facility's courtyard without staff assistance to open the door. The DON stated that she did not document that the resident had bumped her head on the door, but that someone should have written a note about the bruise. She stated that it took a while for the bruise on the resident's left eye to show up. The DON also stated that there was no incident report regarding the bruised left eye, or any additional documentation regarding the bruised left eye, and that the origin of the bruise was not investigated. An interview was conducted on (MONTH) 11, (YEAR) at 12:00 p.m. with an LPN (Licensed Practical Nurse/staff #38). The LPN stated that she had observed the bruise around the resident's left eye the day before, and that it was an old bruise. She stated the bruise was an injury of unknown origin because the resident had cognitive impairment and could not explain how she got the bruise. The LPN stated that if the bruise had been fresh, she would have reported the bruise to the DON. During an interview conducted on (MONTH) 11, (YEAR) at 12:14 p.m. with a CNA (Certified Nursing Assistant/staff #24), the CNA stated that she had observed the day before that the resident had a bruise around her left eye, and had reported the bruise to staff #38. She stated that staff #38 stated to her that she already knew about bruise. The CNA stated that the bruise was an injury of unknown origin and needed to be reported to the nurse because the resident was unable to tell her how she had bruised her eye. An interview was conducted on (MONTH) 11, (YEAR) at 12:15 with a CNA (staff #62). The CNA stated that she had observed the bruise on the resident's left eye a week ago. The CNA stated that the bruise was an injury of unknown origin because when she asked the resident about the bruise, the resident was unable to explain how she obtained the bruise. The CNA stated that she did report the bruise to a nurse when she first observed it. During an interview conducted on (MONTH) 11, (YEAR) at 12: 30 p.m. with a Staff Development Coordinator (staff #35), the Coordinator stated that all of the staff had been provided with in-service education regarding the abuse prevention policy including reporting all injuries of unknown origin. An interview was conducted with the DON (staff #53) on (MONTH) 11, (YEAR) at 12:50 p.m. The DON stated that it is policy is to investigate allegations of abuse (including injuries of unknown origin) immediately. She stated the investigation is to include resident and staff interviews and that allegations of abuse are reported to the State Agency, the ombudsman, and if indicated, the police. The DON stated that facial bruising could be suspicious and could be caused by abuse. She stated that the bruising around the resident's left eye was not investigated because by the time the bruise was evident, one or more days had passed and the resident was unable to explain the bruise. The DON further stated it was a mistake on our part and on the nurses part not doing an incident report. An interview was conducted on (MONTH) 11, (YEAR) at 2:00 p.m. with the Administrator (staff #23). The administrator stated that an injury of unknown source is an injury that cannot be explained, this includes bruising that cannot be explained. The Administrator stated that all injuries of unknown source are investigated. The Administrator further stated that if he had been informed about the resident's bruising around her left eye he would have investigated it. He stated that all injuries of unknown source are reported to the State Agency within 24 hours. On (MONTH) 11, (YEAR) at 2:20, staff #35 provided an incident report that she stated had been previously completed and had been misplaced. Review of the report dated (MONTH) 4, (YEAR) at 2:00 p.m., revealed check boxes that were checked for corridor/hall, and bruise with a notation that read 'eye with no additional details. The report included that the Director of Nursing Services had been notified, and that it had not been reported to the State Agency. -Resident #26 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. During an interview conducted on 07/09/18 at 12:46 PM with resident #26, the resident stated that a CNA hit her leg with the buckle of the gait belt. She stated She took the buckle and hit my leg. She did not say anything. She hit the bone and it really hurt. It was not too long after I got here that it happened. She (CNA) has a routine and was mad because I had someone help me to bed and she could not stick to her routine. Resident #26 identified the CNA as staff #3, who was present in the room assisting the roommate. The Administrator (staff #23) was advised of the allegation on 07/09/18 at approximately 1:45 PM. A statement from CNA/staff #3 dated 06/03/18 was provided by the DON (staff #53). The DON stated that the statement was all of the investigation documents. The statement included that CNA #3 answered the call light to change resident #26 on 06/03/18, and that after changing the resident, the resident stated she hit her on Saturday, 06/02/18 when she laid her down. The statement included the resident called a family member and told them what occurred. The statement further included the resident's family member approached the CNA on 06/03/18 at 12:30 PM and stated that she hit the resident's ankle with the gait belt while transferring the resident and for her to be more careful. During an interview conducted with CNA (staff #3) on 07/10/18 at 01:37 PM, staff #3 stated she has a routine and that when I can't get my routine completed I am in trouble with myself because I am a perfectionist. I have to stay with my routine and if I go off my routine, then I would end up getting lost. I don't like it and I feel like I am not giving my time to the residents. Staff #3 stated the incident with resident #26 occurred on a Saturday when she was assisting the resident to the bathroom with the gait belt. She stated the next day (Sunday) when she gave the resident her breakfast; the resident stated that she had hit her. Staff #3 stated she did not think anything of it because she knew she did not do it. She stated the resident's family approached her about 12:30 PM and stated that she had hit the resident. Staff #3 stated she replied that she did not hit the resident and that she would try to be more careful. She stated she was sent home at 13:15 PM after she placed her statement under the DON's door. Staff #3 further stated that all allegations of abuse have to go be reported immediately to her supervisor and then to the DON. An interview conducted on 07/11/18 at 09:51 AM with the Supervisor/Registered Nurse (staff #35). She stated she interviewed resident #26 on 07/10/18 and that the resident changed her story several times from the ankle that was hit to her shin up by her knee. During an interview conducted on 07/11/18 at 02:55 PM with the DON (staff #53), the DON stated the investigation included the statement from the CNA (staff #3) and an assessment that she conducted of the resident's leg. She stated there were no welts, bruising, or open areas to the leg, so she felt the allegation was not substantiated and she let CNA #3 come back to work. An interview was conducted on 07/11/18 at 03:05 PM with the Administrator (staff #23). The administrator stated the State Agency should have been notified within 2 hours and others should have been notified such as the Ombudsman, Adult Protective Services, the police, and the family. He further stated Social Services will obtain a statement from the resident, the abuser, anyone on shift, and other residents (if they were in the room). The administrator stated that as soon as the data is collected, a decision is made regarding the suspended staff. Staff #23 stated he was not informed about the incident and just found out about it this week. Review of the facility's investigation only revealed a statement from staff #3. The facility's policy titled Reporting Abuse to Facility Management included that it is the responsibility of employees to report any incident of abuse or injury of unknown origin to facility management. The policy included that the administration and director of nursing services must be promptly notified of suspected abuse or incidents of abuse. The policy also included that when an incident of abuse or injury of unknown origin is reported, the administration or designee will notify the State agency, Ombudsman, the resident's representative, Adult Protective Services, law enforcement officials, the attending physician, and the facility's Medical Director. The policy included that upon receiving the report of abuse, a licensed physician or nurse will examine the resident, complete a Resident Abuse Report form, document the findings of the examination, and sign/date the form.",2020-09-01
297,HAVEN OF SAGUARO VALLEY,35085,6651 EAST CARONDELET DRIVE,TUCSON,AZ,85710,2018-07-12,608,D,0,1,FYQM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, clinical record reviews, facility documents, and policies and procedures, the facility failed to implement their policy by failing to report to law Enforcement Officials and the State Agency an injury of unknown origin for one resident (#2) and an allegation of physical abuse for one resident (#26). Findings include: -Resident #2 was admitted on (MONTH) 18, (YEAR), with [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment dated (MONTH) 8, (YEAR), included the resident had a BIMS (Brief Interview for Mental Status) score of 10 which indicated the resident had moderately impaired cognition. An interview was conducted with resident #2 was on (MONTH) 9, (YEAR) at 1:00 p.m. During the interview, an observation was made that the resident had a dark purple bruise at the outer aspect of her left eye, and lighter colored bruising around the eye. The resident stated that she did not know how her left eye was bruised. Review of the clinical record did not reveal any documented evidence that an injury of unknown origin had been reported to law enforcement or the State Agency. An interview was conducted with the Director of Nursing (DON/staff #53) on (MONTH) 11, (YEAR) at 12:50 p.m. The DON stated that the policy is to report allegations of abuse (including injuries of unknown origin) to the State Agency and the Ombudsman within 24 hours and if indicated, the police department. The DON stated that facial bruising could be suspicious and could be caused by abuse. An interview was conducted on (MONTH) 11, (YEAR) at 2:00 p.m. with the Administrator (staff #23). During the interview, the administrator stated that an injury of unknown source is an injury that cannot be explained which includes unexplained bruising. The Administrator stated that all injuries of unknown source are investigated and reported to the State Agency within 24 hours. -Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. During an interview conducted on 07/09/18 at 12:46 PM with resident #26, the resident stated that a CNA hit her leg with the buckle of the gait belt. She stated She took the buckle and hit my leg. She did not say anything. She hit the bone and it really hurt. It was not too long after I got here that it happened. She (CNA) has a routine and was mad because I had someone help me to bed and she could not stick to her routine. Resident #26 identified the CNA as staff #3, who was present in the room assisting the roommate. The Administrator (staff #23) was advised of the allegation on 07/09/18 at approximately 1:45 PM. A statement from CNA/staff #3 dated 06/03/18 was provided by the DON (staff #53). The statement included that CNA #3 answered the call light to change resident #26 on 06/03/18, and that after changing the resident, the resident stated she hit her on Saturday, 06/02/18, when she laid her down. There is no documentation that law enforcement was notified of the suspicion of abuse. The statement from staff #3 is the only documentation from this investigation. During an interview conducted on 07/11/18 at 03:05 PM with the Administrator (staff #23), he stated the State Agency should have been notified within 2 hours and others agencies should have been notified such as the police. Staff #23 stated that he was not informed in (MONTH) about the alleged abuse, which he just found out about it this week. He also stated that the DON knew and never reported it to him. The facility's policy titled Reporting Abuse to Facility Management included that it is the responsibility of employees to report any incident of abuse or injury of unknown origin to facility management. The policy included that the administration and director of nursing services must be promptly notified of suspected abuse or incidents of abuse. The policy included that when an incident of abuse of injury of unknown origin is reported, the administration or designee will notify the State agency and law enforcement officials.",2020-09-01
298,HAVEN OF SAGUARO VALLEY,35085,6651 EAST CARONDELET DRIVE,TUCSON,AZ,85710,2018-07-12,609,D,0,1,FYQM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, clinical record reviews, and review of facility documents, and policies and procedures, the facility failed to report to the State Agency and Adult Protective Services an injury of unknown origin for one resident (#2) and an allegation of abuse for one resident (#26). Findings include: -Resident #2 was admitted on (MONTH) 18, (YEAR), with [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment dated (MONTH) 8, (YEAR), included the resident had a BIMS (Brief Interview for Mental Status) score of 10 which indicated the resident had moderately impaired cognition. An interview was conducted with resident #2 was on (MONTH) 9, (YEAR) at 1:00 p.m. During the interview, an observation was made that the resident had a dark purple bruise at the outer aspect of her left eye, and lighter colored bruising around the eye. The resident stated that she did not know how her left eye was bruised. Review of the clinical record did not reveal any documented evidence that an injury of unknown origin had been reported to the State Agency or Adult Protective Services. During an interview conducted with the Director of Nursing (DON/staff #53) on (MONTH) 11, (YEAR) at 12:50 p.m., the DON stated that the policy is to report allegations of abuse (including injuries of unknown origin) to the State Agency and the Ombudsman within 24 hours. An interview was conducted on (MONTH) 11, (YEAR) at 2:00 p.m. with the Administrator (staff #23). The administrator stated that an injury of unknown source is an injury that cannot be explained which includes unexplained bruising. He stated that all injuries of unknown source are reported to the State Agency within 24 hours. -Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. During an interview conducted on 07/09/18 at 12:46 PM with resident #26, the resident stated that a CNA hit her leg with the buckle of the gait belt. She stated She took the buckle and hit my leg. She did not say anything. She hit the bone and it really hurt. It was not too long after I got here that it happened. She (CNA) has a routine and was mad because I had someone help me to bed and she could not stick to her routine. Resident #26 identified the CNA as staff #3, who was present in the room assisting the roommate. The Administrator (staff #23) was advised of the allegation on 07/09/18 at approximately 1:45 PM. A statement from CNA/staff #3 dated 06/03/18 was provided by the DON (staff #53). The statement included that CNA #3 answered the call light to change resident #26 on 06/03/18, and that after changing the resident, the resident stated she hit her on Saturday, 06/02/18, when she laid her down. During an interview conducted on 07/11/18 at 03:05 PM with the Administrator (staff #23), he stated the State Agency should have been notified within 2 hours and others agencies should have been notified such as the Ombudsman, Adult Protective Services, the police, and the family. Staff #23 stated that he was not informed in (MONTH) about the alleged abuse, which he just found out about it this week. He also stated that the DON knew and never reported it to him. The facility's policy titled Reporting Abuse to Facility Management revealed that when an incident of abuse or injury of unknown origin is reported, the administration or designee will notify the State agency, the Ombudsman, the resident's representative, Adult Protective Services, law enforcement officials, the attending physician, and the facility's Medical Director.",2020-09-01
299,HAVEN OF SAGUARO VALLEY,35085,6651 EAST CARONDELET DRIVE,TUCSON,AZ,85710,2018-07-12,610,D,0,1,FYQM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, clinical record reviews, review of facility documents, and review of policies and procedures, the facility failed to investigate an injury of unknown origin for one resident (#2) and failed to investigate an allegation of abuse for one resident (#26). Findings include: -Resident #2 was admitted on (MONTH) 18, (YEAR), with [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment dated (MONTH) 8, (YEAR), included the resident had a BIMS (Brief Interview for Mental Status) score of 10 which indicated the resident had moderately impaired cognition. An interview was conducted with resident #2 was on (MONTH) 9, (YEAR) at 1:00 p.m. During the interview, an observation was made that the resident had a dark purple bruise at the outer aspect of her left eye, and lighter colored bruising around the eye. The resident stated that she did not know how her left eye was bruised. Review of the resident's clinical record did not reveal any documented evidence that the cause of the bruise had been investigated. An interview was conducted on (MONTH) 11, (YEAR) at 11:05 a.m. with the Director of Nursing (DON/staff #53). The DON stated that there was no incident report regarding the bruised left eye, or any additional documentation regarding the bruised left eye, and that the origin of the bruise was not investigated. An interview was conducted with the DON (staff #53) on (MONTH) 11, (YEAR) at 12:50 p.m. The DON stated that it is policy is to investigate allegations of abuse (including injuries of unknown origin) immediately. She stated that facial bruising could be suspicious and could be caused by abuse. The DON stated the investigation is to include resident and staff interviews. She stated that the bruising around the resident's left eye was not investigated because by the time the bruise was evident, one or more days had passed and the resident was unable to explain the bruise. The DON further stated it was a mistake on our part and on the nurses part not doing an incident report. An interview was conducted on (MONTH) 11, (YEAR) at 2:00 p.m. with the Administrator (staff #23). The administrator stated that an injury of unknown source is an injury that cannot be explained which includes bruising that cannot be explained. The Administrator stated that all injuries of unknown source are investigated. -Resident #26 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission MDS assessment dated [DATE], revealed a BIMS score of 15 which indicated the resident was cognitively intact. During an interview conducted on 07/09/18 at 12:46 PM with resident #26, the resident stated that a CNA hit her leg with the buckle of the gait belt. She stated She took the buckle and hit my leg. She did not say anything. She hit the bone and it really hurt. It was not too long after I got here that it happened. She (CNA) has a routine and was mad because I had someone help me to bed and she could not stick to her routine. Resident #26 identified the CNA as staff #3, who was present in the room assisting the roommate. The Administrator (staff #23) was advised of the allegation on 07/09/18 at approximately 1:45 PM. A statement from CNA/staff #3 dated 06/03/18 was provided by the DON (staff #53). The DON stated that the statement was all of the investigation documents. The statement included that CNA #3 answered a call light to change resident #26 on 06/03/18, and that after changing the resident, the resident stated she hit her on Saturday, 06/02/18 when she laid her down. The statement included the resident called a family member and told them what occurred. The statement further included the resident's family member approached the CNA on 06/03/18 at 12:30 PM and stated that she hit the resident's ankle with the gait belt while transferring the resident and for her to be more careful. During an interview conducted on 07/11/18 at 02:55 PM with the DON (staff #53), the DON stated the investigation included the statement from the CNA (staff #3) and an assessment that she conducted of the resident's leg. She stated there were no welts, bruising, or open areas to the leg, so she felt the allegation was not substantiated and she let CNA #3 come back to work. An interview was conducted on 07/11/18 at 03:05 PM with the Administrator (staff #23). The administrator stated the investigation will include Social Services obtaining a statement from the resident, the abuser, anyone on shift, and other residents (if they were in the room). Staff #23 stated that he was not informed about the incident and just found out about it this week. Review of the facility's investigation only revealed a statement from staff #3. The facility's policy titled Reporting Abuse to Facility Management included that upon receiving reports of physical abuse, a licensed nurse or physician shall immediately examine the resident. The policy included that the findings of the examination must be recorded in the resident's medical record. The policy also included a completed copy of the Resident Abuse Report Form and written statements from witnesses must be provided to the administrator within 24 hours of the occurrence. The policy included an immediate investigation will be made and a copy of the findings of such investigation will be provided to the administrator within 2 working days of the occurrence.",2020-09-01
300,HAVEN OF SAGUARO VALLEY,35085,6651 EAST CARONDELET DRIVE,TUCSON,AZ,85710,2018-07-12,636,D,0,1,FYQM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that comprehensive assessments were completed timely for four residents (#'s 2, 5, 6, and 7). Findings include: -Resident #6 was admitted to the facility on (MONTH) 4, 2014, with [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed the most recent comprehensive assessment was a significant change in status MDS (Minimum Data Set) assessment that had an Assessment Reference Date (ARD) of (MONTH) 27, (YEAR). Further review of the resident's clinical record revealed that a comprehensive MDS assessment was not completed in (MONTH) (YEAR), as required. -Resident #7 was admitted to the facility on (MONTH) 31, (YEAR), with [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed the most recent comprehensive MDS assessment was a significant change in status MDS assessment with an ARD of (MONTH) 7, (YEAR). Further review of the resident's clinical record revealed that a comprehensive MDS assessment was not completed in (MONTH) (YEAR), as required. An interview was conducted with the MDS coordinator (staff #81) on (MONTH) 11, (YEAR) at 12:00 p.m. The MDS coordinator stated that the previous MDS coordinator left at the end of (MONTH) (YEAR). The MDS coordinator stated that no one completed MDS assessments until she started working at the facility a month ago. The MDS coordinator stated that the completions of the MDS assessments are overdue. -Resident #5 was admitted to the facility on (MONTH) 17, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed an annual MDS assessment with an ARD of (MONTH) 22, (YEAR), was the most recent comprehensive assessment. Continued review of the clinical record revealed the comprehensive MDS assessment was not completed in (MONTH) (YEAR), as required. An interview was conducted with the MDS coordinator (staff #81) on 7/11/2018 at 10:19 AM. She stated there was not a MDS coordinator during the month of (MONTH) and that is why the assessment has not been completed. Staff #81 stated this resident is on her list of assessment to complete and that she is attempting to complete the assessments that are overdue. -Resident #2 was admitted on (MONTH) 18, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed the most recent comprehensive MDS assessment was a significant change in status MDS assessment with an ARD of (MONTH) 8, (YEAR). Further review of the clinical record revealed the comprehensive MDS assessment due (MONTH) (YEAR), was not completed as required. During an interview conducted on (MONTH) 11, (YEAR) at 2:10 p.m. with the MDS coordinator (staff #81), she stated that the next MDS assessment due (MONTH) (YEAR), had not been completed. The RAI manual instructs that a comprehensive assessment is due within 366 days after the ARD of the most recent comprehensive assessment.",2020-09-01
301,HAVEN OF SAGUARO VALLEY,35085,6651 EAST CARONDELET DRIVE,TUCSON,AZ,85710,2018-07-12,638,D,0,1,FYQM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that quarterly MDS (Minimum Data Set) assessments were completed timely for three residents (#'s 1, 4, and 9). Findings include: -Resident #1 was admitted to the facility on (MONTH) 26, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed a quarterly MDS assessment with an Assessment Reference Date (ARD) of (MONTH) 1, (YEAR), was the most recent assessment. Further review of the clinical record revealed a quarterly MDS assessment was not completed in (MONTH) (YEAR), as required. In an interview with the MDS coordinator (Staff #81) on (MONTH) 12, (YEAR) at 8:21 a.m., she stated the most recent quarterly MDS assessment was opened (MONTH) 1, (YEAR). She further stated the assessment had not been completed or submitted. -Resident #4 was admitted to the facility on (MONTH) 16, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed the significant change in status MDS assessment with an ARD of (MONTH) 16, (YEAR), was the most recent assessment. Additional review of the clinical record revealed a quarterly MDS assessment was not completed in (MONTH) (YEAR), as required. -Resident #9 was admitted to the facility on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed the admission MDS assessment with an ARD of (MONTH) 16, (YEAR), was the most recent assessment. Further review of the clinical record revealed a quarterly MDS assessment was not completed in (MONTH) (YEAR), as required. An interview was conducted on (MONTH) 11, (YEAR) at 1200 p.m. with the MDS Coordinator (staff #81) who stated that the previous MDS coordinator had left in (MONTH) (YEAR) and many MDS assessments were behind schedule. She stated that she is aware that several MDS assessments are overdue. The RAI manual included that a quarterly MDS assessment for a resident must be completed at least every 92 days following the previous OBRA assessment of any type. The manual also included that the quarterly assessment is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored.",2020-09-01
302,HAVEN OF SAGUARO VALLEY,35085,6651 EAST CARONDELET DRIVE,TUCSON,AZ,85710,2018-07-12,640,D,0,1,FYQM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, facility documents, and policy, the facility failed to ensure an admission Minimum Data Set assessment was transmitted within 14 days after completion for one resident (#26). Findings include: Resident #26 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. An interview was conducted on 07/11/18 at 11:01 AM with the MDS Coordinator (staff #81). Staff #81 stated for the month of (MONTH) (YEAR), they did not have a MDS Coordinator. She stated that she is still working on (MONTH) (YEAR) and (MONTH) (YEAR) MDS assessments and that the (MONTH) (YEAR) MDS assessments are up to date. Staff #81 stated the admission MDS assessment for resident #26 was not transmitted until (MONTH) 22, (YEAR). She provided the transmittal record for review. Review of the MDS transmittal record for the admission MDS assessment dated [DATE] for resident #26 revealed the date of transmittal was on 06/22/18. The admission MDS assessment dates for Resident #26 were an admission date of [DATE], an ARD of 05/29/18, a Care Plan Completion date of 06/05/18, and an MDS transmission date of 06/22/18. The facility's policy titled MDS Completion and Submission Timeframes revealed: Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. The policy included that The Assessment Coordinator or designee shall be responsible for ensuring that resident assessments are submitted to CMS' (Centers for Medicare and Medicaid) QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines.",2020-09-01
303,HAVEN OF SAGUARO VALLEY,35085,6651 EAST CARONDELET DRIVE,TUCSON,AZ,85710,2018-07-12,641,D,1,1,FYQM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, clinical record review, resident and staff interviews, policy, and the RAI (Resident Assessment Instrument) manual, the facility failed to accurately assess and code the dental status for one resident (#26) on the MDS (Minimum Data Set) assessment. Findings include: Resident #26 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During an interview conducted on 07/09/18 at 12:54 PM with resident #26, the resident stated, my teeth are bad and they have been going downhill. The resident was observed to have many broken teeth and darkened areas. A review of the nursing Admission assessment dated [DATE], revealed the resident had her own teeth, but did not include any documentation under the section titled Condition of teeth. A Nutrition Risk Review dated 05/24/18, revealed the resident was on a regular mechanical soft diet and had poor dentition. A nutrition status care plan initiated on 05/24/18, revealed Dysphagia/Chewing/Swallowing problems/Aspirates was selected and that the resident needed a mechanically altered diet. A review of the admission MDS assessment dated [DATE] revealed the resident had no dental problems, including obvious or likely cavity or loose or broken natural teeth. An interview was conducted on 07/11/18 at 10:01 AM with a Certified Nursing Assistant (CNA/staff #69) who stated the resident has bad teeth and that the resident brushes and cares for her teeth. An interview was conducted on 07/11/18 at 11:01 AM with the Licensed Practical Nurse/MDS Coordinator (staff #81), who stated a dental assessment is conducted when a resident is first admitted . Staff #81 stated she conducted an interview with the resident to obtain dental information to complete the MDS assessment. She stated she was not working at the facility when this assessment was completed. She stated that she discovered many of the MDS assessments were incomplete, but that some parts of the assessment had been coded but were not certified (signed). Staff #81 stated she certified (signed) and transmitted the assessment, but did not check the assessment for accuracy. The facility's policy titled Charting Errors and/or Omissions included Accurate medical records shall be maintained by this facility. The RAI Manual instructs the staff to check L0200D of the assessment if the resident has obvious or likely cavity or broken natural teeth.",2020-09-01
304,HAVEN OF SAGUARO VALLEY,35085,6651 EAST CARONDELET DRIVE,TUCSON,AZ,85710,2018-07-12,658,E,1,1,FYQM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, and policies, the facility failed to ensure three residents (#236, #286, and #86) were provided and administered medications as ordered. Findings include: -Resident #236 was admitted to the facility on [DATE] at 2:13 PM, with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. The risk for fall care plan initiated 02/04/18, included the resident had [MEDICAL CONDITION] and to administer medications as ordered. Review of the hospital's discharge instructions dated 02/04/18, revealed the resident was to be administered [MEDICATION NAME]-[MEDICATION NAME] (anti-Parkinson medication) 25-100 milligrams (mg) one tablet by mouth four times a day and two tablets by mouth at bedtime. Review of the physician's orders [REDACTED]. Review of the faxed prescriptions received by the facility on 02/05/18 from the resident's [MEDICAL CONDITION] specialist revealed prescriptions for [MEDICATION NAME]-[MEDICATION NAME] 10-100 mg 1.5 tablets four times a day 3-4 hours apart and for [MEDICATION NAME] ER (Extended Release)-[MEDICATION NAME] 25-100 mg 6 tablets daily, take the first four tablets with the 1.5 tablets and take the last two tablets at bedtime. The third prescription marked the [MEDICATION NAME]-[MEDICATION NAME] 10-100 mg done. A physician's orders [REDACTED]. A Nurse Practitioner's (NP) note dated 02/08/18 revealed the nursing staff was concerned about the resident being snowed when she first arrived. The note included the [MEDICATION NAME]-[MEDICATION NAME] dose was adjusted to the resident's home dose and that the resident has been more alert the past two days. Review of the fax from the resident's Parkinson specialist received on 02/27/18 at 8:55 PM, revealed a cover sheet with a hand written note Dr. Please read from neurology. Thanks. The cover sheet also contained the NP's initials and the date of 02/28/18. The fax included -[MEDICATION NAME]-[MEDICATION NAME] 10-100 mg, take 6 tablets by mouth daily divided 1.5 tablets four times each day; Originally prescribed on 09/09/17. -[MEDICATION NAME] ER-[MEDICATION NAME] 25-100 mg 6 tablets daily per schedule; originally ordered on [DATE]. Review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. A NP Transition note dated 03/12/18 revealed the resident was to be discharged home with a caregiver as before. The note included [MEDICATION NAME]-[MEDICATION NAME] 25-100 mg one tablet four times each day and two tablets at bedtime. An interview was conducted on 07/12/18 at 10:18 AM with the NP (staff #96) who stated that when the resident was first admitted she was started on the dose that came from the hospital until the resident reported that it was not what she was taking and stated to them what she was taking. Staff #96 stated that she did not see the prescriptions that were faxed on 02/05/18, but that she did see and initial the fax sent on 02/27/18. The NP stated she that she saw both medications listed on the medications list, but did not realize the resident was supposed to take both medications. She further stated that she did not call the resident's physician or the [MEDICAL CONDITION] specialty clinical to clarify. -Resident #286 was admitted to the facility on (MONTH) 3, (YEAR), with [DIAGNOSES REDACTED]. The resident was discharged from the facility on (MONTH) 10, (YEAR). The admission physician's orders [REDACTED]. Review of the MAR (Medication Administration Record) for (MONTH) (YEAR), revealed documentation the resident was only administered the aspirin on (MONTH) 3 and 4, (YEAR). However, no order to discontinue the aspirin was able to be located in the clinical record. In an interview with the Director of Nursing (DON/ Staff #53) on (MONTH) 11, (YEAR) at 2:34 p.m., she reviewed the clinical record and was unable to find an order to discontinue the aspirin. -Resident #86 was admitted on (MONTH) 24, (YEAR), with [DIAGNOSES REDACTED]. Review of the hospital discharge orders dated (MONTH) 24, (YEAR), revealed the following medications were included: - [MEDICATION NAME] (treats [MEDICAL CONDITION] reflux disease (GERD)) 40 mg (milligrams) daily. - [MEDICATION NAME] (treats [MEDICAL CONDITIONS]) 5 mg daily. - [MEDICATION NAME] (anticonvulsant) 100 mg TID (Three Times Daily). - [MEDICATION NAME] (anticonvulsant) 100 mg extended release capsule TID. - [MEDICATION NAME] (antidepressant) 37.5 mg PO (by mouth) daily. A nurse's note dated (MONTH) 24, (YEAR) at 6:30 p.m. revealed the physician's orders [REDACTED]. Review of the physician's admission orders [REDACTED] - [MEDICATION NAME] 40 mg daily. - [MEDICATION NAME] 5 mg daily. - [MEDICATION NAME] 100 mg TID. - [MEDICATION NAME] 100 mg extended release capsule TID. However, the [MEDICATION NAME] 37.5 mg PO daily was not included in the physician's admission orders [REDACTED]. Review of the care plan revealed the resident was at risk for falls related to a [MEDICAL CONDITION] disorder and to administer medication as ordered for the [MEDICAL CONDITION] disorder. The care plan also revealed the resident had [MEDICAL CONDITION] and to administer the medication as ordered for [MEDICAL CONDITION]. Included in the care plan was that the resident was at nutritional risk related [MEDICAL CONDITION] to administer the medication as ordered for GERD. Review of the MAR (Medication Administration Record) dated (MONTH) (YEAR), revealed no documentation that the [MEDICATION NAME] 100 mg and [MEDICATION NAME] 100 mg were administered to the resident on (MONTH) 24, (YEAR) at 8:00 p.m. Continued review of the MAR for (MONTH) 25 and 26, (YEAR), revealed the [MEDICATION NAME] 40 mg, [MEDICATION NAME] 5 mg, [MEDICATION NAME] 100 mg, [MEDICATION NAME] 100 mg had circled initials for all times of administration and that the administration entries for [MEDICATION NAME] 37.5 mg were blank. Additional review of the MAR indicated [REDACTED]. Further review of the clinical record revealed no documentation regarding why the nurses had circled their initials on the MAR. An interview was conducted on (MONTH) 10, (YEAR) at 1:10 p.m. with an LPN (Licensed Practical Nurse/staff #39). The LPN stated that when admission medication orders are verified they are faxed to the pharmacy and that for critical medications the pharmacy delivers the medication within 2-4 hours after notification. The nurse stated that blank spaces on the MAR indicated [REDACTED]. The LPN stated that the nurse would document an explanation on the reverse side of the MAR indicated [REDACTED]. During an interview conducted on (MONTH) 10, (YEAR) at 3:32 p.m. with the DON (staff #53), the DON stated that medication orders are faxed to the pharmacy and that the pharmacy has two delivery runs during the daytime and an afternoon delivery run. Staff #53 stated the E-Kits are available for critical or time sensitive medications. The DON stated that if medications are not delivered, the nurse could request the medications be delivered STAT, and that they would be delivered within 2-4 hours. Staff #53 stated that there are to be no blank spaces on MARs and that if there are blank spaces, it cannot be proven that the medication was administered. The DON stated If it isn't written, it isn't done. The facility's policy titled Administering Medications included that medications shall be administered in a safe and timely manner and as prescribed. The policy also included that medications must be administered in accordance with the orders, and that if a drug is withheld, refused, or administered at a time other than the scheduled time, the nurse shall initial and circle the MAR indicated [REDACTED] Review of the facility's policy titled Medication and Treatment Orders revealed that medication and treatment orders will be consistent with principles of safe and effecting order writing. The policy also included that medications will only be administered upon the written order of a physician licensed to prescribe in the State and that medications ordered must be recorded on the physician's orders [REDACTED]. A facility's policy titled Charting and Documentation included that all medications administered must be documented in the resident's clinical record.",2020-09-01
305,HAVEN OF SAGUARO VALLEY,35085,6651 EAST CARONDELET DRIVE,TUCSON,AZ,85710,2018-07-12,684,E,1,1,FYQM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on closed record review, staff interviews, and review of policies and procedures, the facility failed to ensure that one resident (#86) received skin treatments and care in accordance with professional standards of practice. Findings include: Resident #86 was admitted on (MONTH) 24, (YEAR), with [DIAGNOSES REDACTED]. An admission assessment form dated (MONTH) 24, (YEAR), included notations Left sided buttocks open area and Redness Blanchable with an arrow that pointed at a figure of a buttocks. The assessment included that the general skin condition of the resident was reddened, warm, and dry, and that the resident required assistance with bathing and hygiene, two person assistance for transferring, and that the resident was oriented. Review of the physician's admission orders [REDACTED]. Review of the clinical record did not reveal any additional documentation regarding an open area on the left side of the buttocks, or clarification regarding whether the open area was a pressure wound, or some other type of wound. Additionally, there was no documentation the resident was provided an assessment by the treatment nurse. A Braden Scale assessment dated (MONTH) 24, (YEAR), included a total pressure risk score of 15 which indicated the resident was at high risk for developing a pressure sore. A care plan initiated on (MONTH) 24, (YEAR), revealed the resident was at risk for skin breakdown due to limited mobility, [MEDICAL CONDITION], variable oral intake, steroid use, and decreased functional ability. The care plan included a goal that there would be no signs and symptoms of infections or complications. Interventions included to notify the physician of worsening or abnormalities, provide treatment as ordered, and observe for signs and symptoms of infection or complications. A Nutrition Risk Review dated (MONTH) 25, (YEAR), included the resident had an open area to the left buttock. Review of an additional care plan for the risk of skin breakdown dated (MONTH) 25, (YEAR), included interventions to provide weekly skin assessments and to note and report signs or symptoms of skin breakdown. A physician's orders [REDACTED]. Review of the TAR (Treatment Administration Record) for (MONTH) 26 through (MONTH) 6, (YEAR), revealed blank spaces or missing documentation for Dermaseptin to the excoriation in the gluteal fold and for turning and repositioning for (MONTH) 29, 30, and 31, (YEAR). The TAR for (MONTH) had no documentation for the Dermaseptin treatments, or for turning and repositioning. A discharge MDS (Minimum Data Set) assessment dated (MONTH) 6, (YEAR), included that the resident had a BIMS (Brief Interview for Mental Status) score of 15 which indicated the resident was cognitively intact and that the resident required extensive assistance with bed mobility and personal hygiene, and had no unhealed pressure ulcers. Continued review of the clinical record revealed a physician's orders [REDACTED]. However, there was no documented evidence that the redness and excoriation in the gluteal fold had been re-evaluated or that any additional skin assessments had been conducted prior to the resident's discharge. A interview was conducted on (MONTH) 10, (YEAR) at 12:30 p.m. with a wound nurse/Licensed Practical Nurse (LPN/staff #36). The wound nurse stated that excoriation is like a rash from moisture or shearing and that if a resident has an open wound, then the top layer of skin would be missing at a minimum. The LPN stated that if the resident had excoriated skin, it would not be assessed as an open wound. The nurse stated that open wounds are measured and staged by the nurse. The nurse also stated that if there are blank or unsigned spaces on a TAR, the nurse cannot prove that treatment was provided. An interview was conducted on (MONTH) 10, (YEAR) at 1:09 p.m. with an LPN (staff #42). The nurse stated that blank or unsigned spaces on a TAR may indicate a treatment was not provided. An interview was conducted on (MONTH) 10, (YEAR) at 3:32 p.m. with the Director of Nursing (DON/staff #53). The DON stated that if a resident is assessed to have an open skin area, then the nurse was supposed to measure and stage the wound. Staff #53 stated that there was no stage or measurement on the admission assessment for resident #86. The DON stated that if a wound is not assessed or staged properly, it would not be possible to obtain the correct treatment for [REDACTED].#86 admission assessment, she was unable to determine what type of wound it was. The DON further stated that the nurses are to initial all the spaces on the MARs and TARs and that If it isn't written, it isn't done. Review of the facility's policy and procedure for the prevention of pressure ulcers included that residents are to be provided a comprehensive risk assessment upon admission (within eight hours) including skin integrity-any evidence of existing or developing pressure ulcers or injuries. The policy also included to repeat the risk assessment weekly upon any changes in condition. The facility's policy for administering medications revealed that medications shall be administered in a safe and timely manner, and that topical medications used in treatments must be recorded on the resident's treatment record.",2020-09-01
306,HAVEN OF SAGUARO VALLEY,35085,6651 EAST CARONDELET DRIVE,TUCSON,AZ,85710,2018-07-12,686,G,1,1,FYQM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, clinical record reviews, staff interviews, and review of facility policies and procedures, the facility failed to prevent pressure ulcer development and failed to provide appropriate care and treatment for [REDACTED]. Findings include: -Resident #7 was admitted to the facility on (MONTH) 15, 2011, with [DIAGNOSES REDACTED]. Review of a Treatment Record dated (MONTH) (YEAR), revealed Weekly skin check per facility protocol. There was no documentation on the Treatment Record to indicate if a weekly skin check was conducted. Review of a Skin Integrity Risk care plan dated (MONTH) 3, (YEAR), revealed the resident was at risk for skin breakdown. The approaches included Weekly skin check . There was no documentation in the clinical record that the weekly skin checks were being conducted. Review of a quarterly MDS (Minimum Data Set) assessment dated (MONTH) 4, (YEAR), revealed the resident did not have any pressure ulcers but was at risk for developing pressure ulcers. Review of a wound care log dated (MONTH) 4, (YEAR), revealed the resident had a facility acquired stage 2 pressure ulcer to her lateral left heel filled with serosanguinous fluid. Review of a Daily Medicare Note dated (MONTH) 5, (YEAR), revealed Left lateral heel Stage 2 blister 4 centimeters by 4.6 centimeters filled with serosanguinous. [MEDICATION NAME] and Kerlix daily. There was no documented evidence on the (MONTH) (YEAR) Treatment Record that [MEDICATION NAME] was applied to the resident's left heel and wrapped with Kerlix until (MONTH) 21, (YEAR). Review of the clinical record revealed no documented evidence that the weekly skin assessments were being conducted after a stage 2 pressure ulcer was observed on the resident's heel. A Daily Medicare Note dated (MONTH) 19, (YEAR) revealed Right (left) great toe 2 centimeters by 2 centimeters eschar. Right (left) heel 7.5 centimeters by 5 centimeters. Blister forming eschar. Continue [MEDICATION NAME]. Cover with Kerlix daily. A Wound Care Note dated (MONTH) 19, (YEAR) revealed .Large blood filled blister to left heel. Wears protective boots, unusual to develop an unstageable pressure ulcer without pressure or shoe. She has protection with the boots and does not walk. Hoyer lift .She has 7.5 centimeters by 5 centimeters has become eschar, flatter and measurements have increased. Will continue [MEDICATION NAME] and Kerlix daily attempting to maintain the cap. It has been noted that a second blood filled blister has appeared medial right great toe and is reabsorbing with a smaller eschar .Pressure injury .Offloading and wound clean and dry .7.5 centimeters by 5 centimeters by 0.1 centimeters eschar 100% unstageable (left heel) .2 centimeters by 2 centimeters eschar 100% unstageable . Review of a physician's orders [REDACTED]. Change daily. Diagnosis: [REDACTED]. A Left Heel Wound Daily Medicare Note dated (MONTH) 21, (YEAR), revealed .Heel dressing changed and intact. Patient awaiting transport to her surgeon appointment. Patient returns from appointment early due to daughter canceling her second appointment . Review of a Resident Weekly Skin Check Sheet dated (MONTH) 28, (YEAR) revealed Left heel-Eschar intact. [MEDICATION NAME] every shift . A Daily Medicare Note dated (MONTH) 1, (YEAR), revealed Dressing to left heel. [MEDICATION NAME] applied to eschar-eschar is intact . Review of a wound care log dated (MONTH) 2, (YEAR), revealed Vascular. Left heel. Left great toe. No measurements were documented on the wound care log. A Daily Medicare Note dated (MONTH) 2, (YEAR) revealed Dressing to left heel done .Eschar intact . Review of a Resident Weekly Skin Check Sheet dated (MONTH) 3, (YEAR), revealed Left heel-Eschar intact. 5 centimeters by 4.6 centimeters . Review of an undated wound care log revealed Vascular. Left heel. 5 centimeters by 4.6 centimeters. Eschar intact . A Daily Medicare Note dated (MONTH) 9, (YEAR), revealed Dressing to left heel done-eschar remains intact. No drainage or odor noted .[MEDICATION NAME] applied to eschar wrapped with Kerlix, boot applied to left foot, pillow placed under legs for comfort and pressure relief. Review of a Resident Weekly Skin Check Sheet dated (MONTH) 10, (YEAR), revealed Left heel-eschar intact. 5 centimeters by 4.6 centimeters . Review of a wound care log dated (MONTH) 17, (YEAR), revealed Vascular left heel 5 centimeters by 4.6 centimeters. [MEDICATION NAME]. Review of a Resident Weekly Skin Check Sheet dated (MONTH) 17, (YEAR), revealed Eschar remains intact . A wound care log dated (MONTH) 24, (YEAR), revealed Stage 3. Left heel. 2.2 centimeters by 2.9 centimeters. Sharp debridement. Eschar cap lifting. Review of a Resident Weekly Skin Check Sheet dated (MONTH) 24, (YEAR), revealed Eschar cap lifted . Review of a physician's orders [REDACTED]. Discontinue previous wound care orders. Cleanse with normal saline. Pat dry. Apply Medi Honey to wound bed. Apply Foam/Silicone Border. Change Monday, Wednesday, Friday. A wound care log dated (MONTH) 7, (YEAR), revealed Vascular. Left heel. 3 centimeters by 2 centimeters by 0.1 centimeter. Eschar . An interview was conducted with an LPN (licensed practical nurse), staff #39 on (MONTH) 11, (YEAR) at 12:30 p.m. The LPN stated that the resident's skin is assessed upon admission to the facility and by CNAs (certified nursing assistants) during showers. The LPN stated that the CNAs notify the licensed nurses if a resident has any skin issues. The LPN stated that when she administers medications throughout the day, she looks at the resident's skin and tries to look at the resident's skin when CNAs showered the residents. The LPN stated that the facility did not have any scheduled structure as to how often residents should have their skin assessed and that it is not documented in the clinical record. The LPN stated that if she observed a pressure ulcer on a resident, she would notify the DON (director of nursing) and wound nurse. The LPN further stated that weekly skin assessments are conducted if an identified concern is observed. An interview was conducted with the DON, staff #53 on (MONTH) 11, (YEAR) at 1:50 p.m. The DON stated that a skin check is performed on admission and by the CNAs at every shower. The DON stated that if the CNAs identify a skin issue, it is reported to a licensed nurse. The DON stated the licensed nurse should also observe the resident's skin during a shower and should probably document it on the CNA shower sheet. The DON stated the licensed nurses only document on the residents who have pressure ulcers, not on the residents who are without pressure ulcers. The DON further stated that the resident's wound that she assessed on (MONTH) 10, (YEAR), was an unstageable wound from a debridement from a previous pressure ulcer. Review of the facility's policy Prevention of Pressure Ulcers/Injuries included .Assess the resident on admission for existing pressure ulcer/injury risk factors. Repeat the risk assessment weekly . -Resident #5 was admitted to the facility on (MONTH) 17, (YEAR), with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment dated [DATE], (YEAR), revealed a BIM's score of 14 which indicated the resident was cognitively intact. The assessment also included the resident was at risk for pressure ulcers. The current care plan revealed the resident was at risk for skin breakdown related to limited mobility. The care plan goal was to have no signs or symptoms (s/s) of infections or complications. The interventions included to provide treatment as ordered, turn and reposition as tolerated, observe for s/s of infection, and to notify the physician of any abnormalities or worsening. Review of the weekly skin checks dated (MONTH) 20 and 29, (YEAR), revealed the resident had a small non-blanchable spot on the left heel and that the left heel was being floated. Further review of the clinical record revealed there was no additional documentation in (MONTH) (YEAR) regarding the left heel. Review of the Weekly Skin check dated (MONTH) 5, (YEAR), revealed the resident had a small non-blanchable spot on the left heel. Review of the clinical record revealed no other documentation regarding the left heel. During an interview conducted with the resident on (MONTH) 9, (YEAR) at 9:58 a.m., the resident stated that she has a pressure ulcer on her left heel and that she is keeping her heel elevated. An observation of the heel revealed reveal a light to moderate black/purple darkened area on the left heel. The resident's heels were observed floated. During an interview conducted on 07/10/18 at 11:31 AM with the DON (staff #53), the DON stated that the resident does not have a pressure ulcer on the left heel. She stated that it is a skin callous or excoriation. An observation was conducted of the resident's left heel on 7/10/18 at 1:35 p.m., with staff #53. The DON stated the light to moderate black/purple darkened area on the resident's left heel measured 1.7 cm (centimeters) x 1.2 cm and was irregular in shape and the surrounding tissue was light pink. The DON also stated the left heel was excoriated and not a pressure ulcer. Staff #53 stated that there was no order treatment and that they have not provided a treatment to the left heel. During an interview conducted on 7/10/18 at 10:27 AM with LPN (staff #38), she stated that she was unaware the resident has a pressure ulcer on the left heal. She also stated the resident has not said anything regarding a pressure ulcer on either of her heels and has not complained of pain. The LPN further stated that if she observed a pressure ulcer or skin change on a resident, she would notify the wound nurse, who would document the skin issue and contact the physician for orders. An interview was conducted with the wound nurse (staff #36) on 07/10/18 at 10:42 AM. The wound nurse stated that she is unsure when the dark area on the resident's left heel was first observed, but that she was made aware of it maybe about 3 weeks ago. She stated that she is applying skin prep to the site. The wound nurse also stated that there is no order to apply skin prep to the heel or to off-load pressure to the heel. She further stated that she conducts weekly skin checks and has not observed the ulcer getting better or worse. Staff #36 stated the staff prevents pressure ulcers by turning and repositioning residents and off loading pressure points for residents that are at risk. She also stated that she documents on pressure ulcers and wounds at least weekly. An interview was conducted with staff #53 on 07/11/18 at 9:55 AM. The DON stated that her definition of Excoriation is a pink area of skin that is warm, or a friction or tear of the skin usually caused by pulling or rubbing the skin on a surface such as a bed sheet. She also stated that the excoriation may appear as a darkened area. The DON stated the excoriation was first observed about 2 weeks ago. The facility's policy regarding wounds revealed a wound is identified by skilled assessment on the resident's initial placement into the facility. If the wound nurse has no orders, she would contact the physician for record and for wound orders. The wound nurse then follows the orders using proper technique. -Resident #236 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. The admission physician's orders [REDACTED]. The nursing Admission assessment dated [DATE], revealed a surgical wound to the right hip with an [MEDICATION NAME] dressing in place. A Braden Scale for Predicting Pressure sore Risk was completed on 02/04/18. The resident's score was 14 which indicated the resident was a low risk for the development of a pressure injury. A Skin Integrity Risk Care Plan initiated on 02/04/18, revealed the resident was at risk due to limited mobility, nutritional compromise, variable intake, dementia, decreased functional ability, incontinence of bowel and bladder, and advanced [MEDICAL CONDITION]. Interventions included to notify the physician for worsening abnormalities, promote adequate nutrition and hydration, supplements as ordered, treatments as ordered, Registered Dietician consult, promote good hygiene and pericare, keep skin clean and dry as much as possible, turn and reposition as tolerated, pressure relieving device to the chair as needed, preventative measures (i.e. gerigloves, pads, etc), and encourage the resident to get out of bed as tolerated. The interim care plan included to perform weekly skin assessments. A physician's orders [REDACTED]. A Daily Nurse's Progress note for the evening shift on 02/18/18, revealed the resident was repositioned every 2 hours, Dermaseptine was applied to the open area on the coccyx, and the resident's heels were floated. A Daily Nurse's Note dated 02/19/18, revealed the resident was turned and positioned and skin care was provided with each incontinent episode as needed. The note included cream was applied to the buttocks and open area as ordered. Review of the Wound Nurse rounding notes for 02/20/18, revealed the resident was receiving Dermaseptine each shift, was reposition while in bed, and the heels were floated. The note did not include a description of the skin or wound. Review of the Wound Team rounding report dated 02/21/18 documented resident #236 had sutures removed from a surgical wound, but there was no mention of an open area to the coccyx. A Daily Progress Note dated 02/22/18, revealed the resident was repositioned every 2-3 hours and that Dermaseptine was applied to the open area. A Daily Progress Note dated 02/23/18, revealed the resident was repositioned every 2 hours and Dermaseptine was applied to the coccyx. A NP Progress note dated 02/26/18, revealed the resident is being seen for follow-up of a right [MEDICAL CONDITION] and a new pressure ulcer. The Skin Observation section included that there is a dime-sized ulcer on the resident's coccyx and the right gluteal fold is reddened and excoriated and blanchable. The Plan included a [DIAGNOSES REDACTED]. Turn every 2 hours while in bed. A physician's orders [REDACTED]. A Daily Nurses Note dated 02/27/18, revealed Decubitus precautions in place. Review of the Wound Team rounding report dated 02/28/18, revealed resident #236 had cream applied to the perineum and gluteal fold. The measurements and treatments section included Dermaseptine every shift/reposition while in bed/float heels. There was mention of an open area to the coccyx. Review of the Certified Nursing Assistant (CNA) ADL (Activities of Daily Living) Tracking Form for (MONTH) (YEAR), revealed the resident was total dependence for bed mobility and required the assistance of one person on the day shift and required extensive assistance of one person on the evening and night shift. Review of the Treatment Record for (MONTH) (YEAR), revealed the following: -the application of Dermaseptine was not documented as completed 4 times; -repositioning while in bed each shift was not documented as completed 4 times. A Daily Nurse's Note dated 03/01/18, revealed the resident was repositioned in bed every 2 hours. A physician's orders [REDACTED]. Review of a Daily Progress Note dated 03/03/18, revealed the resident was turned every 2-3 hours, and wound care was administered as ordered to the coccyx. A Daily Progress Note dated 03/04/18, revealed the resident was repositioned every 2-3 hours, and wound care was administered as ordered to the open area on the coccyx. Review of the Wound Team rounding report dated 03/07/18 revealed resident #236 had a wound to the coccyx with measurements of 4.6 cm (centimeters) x 2.5 cm x 0.6 cm and undermining from 9 o'clock to 1 o'clock at 2.4 cm. [MEDICATION NAME] was applied to the wound. Bed roll gauze to the wound and undermining with Dermafilm 6 x 6; change daily. This was the only description and measurement of the open area to the coccyx found in the clinical record and there were no orders found in the clinical record for this treatment. A Daily Progress Note dated 03/10/18, revealed the resident was repositioned every 2-3 hours, and the dressing was changed to the open area on the coccyx. Review of the CNA ADL Tracking Form for (MONTH) (YEAR), revealed the resident was total dependent for bed mobility and required the assistance of one person on the day shift, limited assistance of one person for the first 5 days of the month, and then extensive assistance of one person for the remainder of the admission. The resident consistently required extensive assistance of one person on the night shift. Review of the Treatment Record for (MONTH) (YEAR), revealed the following: -The application of Dermaseptine to the gluteal fold/peri-area was not documented one shift; -The Saline/[MEDICATION NAME] dressing was not documented as completed on 2 days; Of the 27 Daily Progress Notes completed on this resident, there were only 9 notes that had documentation interventions or treatments were provided. Only one note had documentation that Decubitus Precautions were in place. An interview was conducted on 07/11/18 at 10:10 AM with the Licensed Practical Nurse/Wound Nurse (staff #36). The nurse stated a wound consult would not be ordered for redness and excoriation. She stated that if she saw an order for [REDACTED]. A telephonic interview was conducted on 07/11/18 at 08:40 PM with the former Registered Nurse/Wound Nurse (staff #97) who was the nurse at the time of this resident's admission. Staff #97 stated a [MEDICATION NAME] dressing can be used for any type of open wound, including a pressure ulcer. Staff #97 stated the facility did not have a wound specialist that would come in and see residents, and that if a Wound Consult was ordered, she would see the resident in conjunction with the resident's physician. An interview was conducted on 07/12/18 at 10:10 AM with the Nurse Practitioner (staff #96), who stated when she was made aware of the wound to the resident's coccyx, she and the former wound nurse assessed the wound. Staff #96 stated the resident's backside had been reddened for a while and then it opened up. She further stated the Dermaseptine was the appropriate treatment to continue at that time. Staff #96 stated that in regards to the use of [MEDICATION NAME] on the wound and no order, that it was possible the wound nurse asked about it and then neither of them wrote the order. Review of the facility's policy titled Prevention of Pressure Ulcers/Injuries revealed the purpose was to provide information regarding the identification of pressure injury risk factors and interventions for specific risk factors. Under the Mobility/Repositioning section, the policy included a resident should be repositioned hourly if bed- or chair-bound, every 2 hour if dependent on staff for positioning, and more frequently or as needed based on the condition of the skin and the resident's comfort. The policy also included staff will evaluate, report, and document potential changes in the skin. Review of a document titled Wound Policy presented by the Director of Nursing included the wound nurse or appointee will follow physician's orders [REDACTED].",2020-09-01
307,HAVEN OF SAGUARO VALLEY,35085,6651 EAST CARONDELET DRIVE,TUCSON,AZ,85710,2018-07-12,695,E,1,1,FYQM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on closed record review, staff interviews, and policies and procedures, the facility failed to ensure that one resident (#86) was provided with physician ordered respiratory care. Findings include: Resident #86 was admitted on (MONTH) 24, (YEAR), with [DIAGNOSES REDACTED]. Review of the physician's admission orders [REDACTED]. A nurse's note dated (MONTH) 24, (YEAR), revealed the physician's orders [REDACTED]. Review of the care plan initiated on (MONTH) 24, (YEAR), included the resident was at risk for respiratory distress related to [MEDICAL CONDITION] and that the resident would not experience signs and symptoms of respiratory distress. The care plan interventions included to Administer respiratory medications as ordered. The physician's orders [REDACTED]. Review of the MAR (Medication Administration Record) for (MONTH) (YEAR), revealed the [MEDICATION NAME] 3 ml via SVN QID for [MEDICAL CONDITION] was to be administered at 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. The MAR indicated [REDACTED] Continued review of the MAR for (MONTH) and (MONTH) (YEAR) revealed the following: - [MEDICATION NAME] SVN treatments: A blank space on (MONTH) 24, (YEAR) at 8:00 p.m. and circled initials for the entire day on (MONTH) 25 and 26, (YEAR). - [MEDICAL CONDITION]: Circled initials on (MONTH) 27, (YEAR); blank spaces from (MONTH) 28 - 31, (YEAR); blank spaces from (MONTH) 2 - 5, (YEAR). Further review of the clinical record revealed no documentation regarding the blank spaces and circled initials for the [MEDICATION NAME] SVN treatments and the [MEDICAL CONDITION]. An interview was conducted on (MONTH) 10, (YEAR) at 1:10 p.m. with an LPN (Licensed Practical Nurse/staff #39). The nurse stated that when admission (medication) orders are verified, they are faxed to the pharmacy. The LPN stated that for critical medications, the pharmacy is able to deliver them within 2-4 hours after receiving the notification. The nurse stated that blank spaces on the MAR indicated [REDACTED]. The LPN further stated that the nurse would document an explanation on the reverse side of the MAR indicated [REDACTED]. The nurse stated that there is no reason for a resident not to receive medications for two days. The LPN stated that an emergency kit is available and contains [MEDICATION NAME]-[MEDICATION NAME] for SVN treatments. During an interview conducted on (MONTH) 10, (YEAR) at 3:32 p.m. with the Director of Nursing (DON/staff #53), staff #53 stated that medication orders are faxed to the pharmacy and that the pharmacy has daytime delivery run and an afternoon delivery run. The DON stated E-Kits are available for critical or time sensitive medications including [MEDICATION NAME] for SVN treatments. Staff #53 stated that if medications are not delivered, the nurse could request the medications be delivered STAT, and that they would be delivered within 2-4 hours. The DON stated that there were to be no blank spaces on MARs and that if there are blank spaces on the MAR, it cannot be proven that the medication or treatment was administered. Staff #53 stated If it isn't written, it isn't done. An interview was conducted on (MONTH) 12, (YEAR) at 1:50 p.m. with a Staff Development Nurse (staff #35). The nurse stated that the facility does not have a written policy for the use of the [MEDICAL CONDITION]. Staff #35 stated that the policy of the facility is to follow the physician's orders [REDACTED]. The facility's policy titled Administering Medications through a Small Volume (Handheld) Nebulizer included to follow the policy titled Administering Medications and that the date, time, length of treatment, and the initials of the person providing the treatment are recorded in the resident's medical record. Review of a facility's policy titled Administering Medications included that medications shall be administered in a safe and timely manner, and as prescribed. The policy also included that medications must be administered in accordance with the (physician's) orders, and that if a medication is withheld, refused, or given at a time other than the scheduled time, the nurse shall initial and circle the MAR indicated [REDACTED].",2020-09-01
308,HAVEN OF SAGUARO VALLEY,35085,6651 EAST CARONDELET DRIVE,TUCSON,AZ,85710,2018-07-12,698,D,0,1,FYQM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interviews, and review of policy, the facility failed to ensure a contract was in place with the [MEDICAL TREATMENT] center where one resident (#287) was receiving [MEDICAL TREATMENT]. Findings include: Resident #287 was admitted to the facility on (MONTH) 28, (YEAR), with [DIAGNOSES REDACTED]. Upon admission to the facility, the resident had a physician's orders [REDACTED]. Review of the resident's clinical record revealed the resident went to the [MEDICAL TREATMENT] center as ordered. However, it was revealed the facility did not have a contract in place between the facility and the [MEDICAL TREATMENT] center where the resident was going. In an interview with the Administrator (Staff #23) on (MONTH) 12, (YEAR) at 12:10 p.m., he stated that he was unable to locate a previous contract so a new one was obtained and is now in place. The current contract was provided and stated the effective date was (MONTH) 11, (YEAR). Review of facility's policy titled, [MEDICAL CONDITION], Care of a Resident with included, Residents with [MEDICAL CONDITIONS] will be cared for according to currently recognized standards of care. The policy further included Agreements between this facility and the contracted [MEDICAL CONDITION] facility include all aspects of how the resident's care will be managed.",2020-09-01
309,HAVEN OF SAGUARO VALLEY,35085,6651 EAST CARONDELET DRIVE,TUCSON,AZ,85710,2018-07-12,759,D,0,1,FYQM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interview, and policy review, the facility failed to ensure the medication error rate was not 5% or greater. The medication error rate was 7.69%. Findings include: -Resident #25 was admitted to the facility on (MONTH) 5, (YEAR), with [DIAGNOSES REDACTED]. Review of the physician's recapitulation orders revealed an order dated (MONTH) 5, (YEAR), for Aspirin ([MEDICATION NAME] and nonsteroidal anti-[MEDICAL CONDITION] drug) 81 mg (milligrams) twice daily by mouth. During a medication administration observation conducted on (MONTH) 18, (YEAR) at 7:50 a.m., a Licensed Practical Nurse (LPN/staff #39) prepared the resident's medications including one Aspirin 81 mg [MEDICATION NAME] Coated tablet. The nurse then administered the medication to the resident. -Resident #13 was admitted to the facility on (MONTH) 20, (YEAR), with [DIAGNOSES REDACTED]. Review of the physician's recapitulation orders revealed an order dated (MONTH) 20, (YEAR), for [MEDICATION NAME] (antiemetic) 25 mg oral three times daily 30 minutes before all meals. During a medication administration observation conducted on (MONTH) 10, (YEAR) at 8:14 a.m., a LPN (staff #38) prepared the resident's medications including one [MEDICATION NAME] 25 mg tablet and administered the medications to the resident after breakfast. An interview was conducted on (MONTH) 10, (YEAR) at 9:42 a.m. with staff #38. The LPN stated that medications that are ordered prior to meals are timed but that she spoke to the physician regarding the resident not wanting to take medications prior to meals, even though there is no clarification order to reflect it. Staff #38 stated that according to the current orders and the MAR (Medication Administration Record), the medication was not administered according to the physician's orders [REDACTED].>-Resident #337 was admitted to the facility on (MONTH) 30, (YEAR), with [DIAGNOSES REDACTED]. Review of the physician's recapitulation orders revealed a clarification order dated (MONTH) 5, (YEAR), for APAP ([MEDICATION NAME]) 325 mg 2 tablets by mouth every 6 hours as needed for a pain level of 1-3 on a pain scale of 1-10. During a medication administration observation conducted on (MONTH) 10, (YEAR) at 9:38 a.m., the LPN (staff #38) administered APAP 325 mg 2 tablets for a pain level of 5 on a pain scale of 1-10. An interview was conducted on (MONTH) 10, (YEAR) at 9:42 a.m. with the LPN (staff #38). The LPN stated that the order for APAP 325 mg had parameters to administer the medication for pain levels of 1-3 and that she administered it for a pain level of 5. Staff #38 stated that she should call the provider to get clarification since the 1-3 pain scale is not the facility's normal pain scale. Staff #38 stated she was unaware that the medication was administered outside the parameters. An interview was conducted on (MONTH) 10, (YEAR) at 10:28 a.m. with the Director of Nursing (DON/staff #53). Staff #53 stated that the pain parameters for pain medication should be followed. The DON stated that if a medication is scheduled to be administered 30 minutes prior to a meal, it should be administered on time and that the 1 hour before and after medication administration guidelines do not apply. Staff #53 stated that the expectation is that medications be administered as ordered. The DON stated that if the order is for Aspirin 81 mg and does include [MEDICATION NAME] Coated, then the [MEDICATION NAME] Coated Aspirin should not be administered. Review of the facility's policy titled Administering Medications included the following: -medications must be administered in accordance with the orders, including any required time frame. -Medication must be administered within 1 hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) -The individual administering the medication must check the label THREE times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.",2020-09-01
310,HAVEN OF SAGUARO VALLEY,35085,6651 EAST CARONDELET DRIVE,TUCSON,AZ,85710,2018-07-12,761,E,0,1,FYQM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, manufacturer's information and policies, the facility failed to ensure that one multi-dose bottle of a perishable medication was discarded, and failed to ensure that multiple controlled medications were stored in a double locked container. Findings include: During multiple observations conducted (MONTH) 9 through (MONTH) 12, (YEAR), the door to the office of the Director of Nursing (DON/staff #53) was observed unlocked or open with no staff observed inside of the DON's office. An observation of the medication storage was conducted on (MONTH) 12, (YEAR) at 9:30 a.m. During the observation, a 1 ml (milliliter) vial of [MEDICATION NAME] PPD (Purified Protein Derivative) which was half empty was stored ready to use in the medication refrigerator on the skilled unit. The vial of [MEDICATION NAME] did not have the date it was opened on it. An interview was conducted on (MONTH) 12, (YEAR) at 9:35 with an LPN (Licensed Practical Nurse/staff #38). The nurse stated that she did not know when the vial of [MEDICATION NAME] was opened, or how long it had been stored in the refrigerator. The nurse stated that when controlled medications have been discontinued or when the resident who was prescribed the medication has been discharged , the controlled medications are delivered to the DON (staff #53) for disposal. During an observation conducted of the DON's office on (MONTH) 12, (YEAR) at 9:45 a.m., a cabinet was observed with a locked drawer. Medications inside of the locked drawer included the following: - [MEDICATION NAME] (opioid) 5 mg (milligram) 69 tablets. - [MEDICATION NAME] (opioid) 10 mg 32 tablets. - [MEDICATION NAME] (opioid) 50 mg 36 tablets. - Klonopin (benzodiazepines) 0.5 mg 24 tablets. - [MEDICATION NAME] (benzodiazepines) 0.25 mg 47 tablets. - [MEDICATION NAME] (benzodiazepines) 0.25 mg 5 tablets. A narcotic E-Kit (Emergency Medication Kit) was also observed stored in the locked drawer. The E-kit which was open and not sealed contained multiple controlled medications that included opioid medications and benzodiazepines medications. An interview was conducted with the DON on (MONTH) 12, (YEAR) at 10:00 a.m. The DON stated that regarding [MEDICATION NAME] PPD, it is the policy of the facility that the nurse writes the date it is opened on the vial and that if an undated vial of [MEDICATION NAME] PPD is found in a medication refrigerator, it is to be discarded. The DON stated that narcotic medications are collected by her and stored in the locked drawer in her office. She also stated that some narcotic medications are stored outside in a storage area until a disposal company can pick them up for destruction. Observation of an outdoor wooden storage compartment conducted on (MONTH) 12, (YEAR) at 10:15 a.m. The outdoor storage compartment was adjacent to a parking area and had a single padlock. Observation of the storage compartment revealed empty boxes for the placement of medications. No medications were observed being stored in the compartment. Review of the manufacturer's information for the [MEDICATION NAME] PPD 1 ml vial, included that vials in use for more than 30 days should be discarded, and that failure to store and handle [MEDICATION NAME] as recommended may result in a loss of potency and inaccurate test results. A facility's policy titled Storage of Medications included the facility shall store all drugs and biologicals in a safe secure and orderly manner. The policy also included that the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. A facility's policy and procedure titled Controlled Substances revealed the facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled substances. The facility's policy and procedure titled Discarding and Destroying Medications revealed medications will be disposed of in accordance with federal, state, and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste, and controlled substances. All unused controlled substances shall be retained in a securely locked area with restricted access until disposed of. Schedule II, III, and IV controlled substances will be disposed of in accordance with state regulations and federal guidelines.",2020-09-01
311,HAVEN OF SAGUARO VALLEY,35085,6651 EAST CARONDELET DRIVE,TUCSON,AZ,85710,2018-07-12,842,D,0,1,FYQM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to ensure records were accurate for one resident (#24) regarding advanced directives. Findings include: Resident #24 was admitted to the facility on (MONTH) 29, (YEAR), with [DIAGNOSES REDACTED]. A prehospital medical care directive (Do Not Resuscitate) form dated (MONTH) 29, (YEAR), was included in the resident's record. This form revealed that in the event of cardiac or respiratory arrest, the resident refuses resuscitation measures. It was signed by the resident's representative, a licensed health care provider, and a witness. Review of the current physician's orders [REDACTED]. However, review of the resident's face sheet revealed the resident's advanced directive was to resuscitate. An interview was conducted with a Licensed Practical Nurse (LPN/Staff # 39) on (MONTH) 11, (YEAR) at 10:54 a.m. She stated the first place she would look for a resident's code status would be her report sheet, which for resident #24 was DNR. She also stated that she would look at the resident's face sheet. After observing the face sheet was different, she stated that she would look at the resident's advanced directive paperwork. The LPN stated there was a discrepancy in the resident's record. During an interview conducted with the Director of Nursing (DON/Staff # 53) on (MONTH) 11, (YEAR) at 2:31 p.m., she stated advanced directives are discussed with residents at the time of admission. The DON stated whatever decision the resident makes, should be reflected correctly on the resident's face sheet, as well as other documentation in the clinical record.",2020-09-01
312,HAVEN OF SAGUARO VALLEY,35085,6651 EAST CARONDELET DRIVE,TUCSON,AZ,85710,2018-07-12,867,E,0,1,FYQM11,"Based on multiple concerns identified during the annual recertification survey, staff interview, and review of facility policies and procedures, the facility's quality assessment (QA) and assurance committee failed to identify quality concerns and implement plans of action to correct the deficiencies. Findings include: During the facility's annual recertification survey multiple quality care concerns were identified due to the facility's failure to identify the concerns through their QA process. An interview was conducted with the administrator, staff #23 on (MONTH) 12, (YEAR) at 12:57 p.m. The administrator stated that he had attended one QA meeting since he started his employment at the facility in (MONTH) (YEAR). The administrator stated that nothing major was discussed at the facility's QA meeting in (MONTH) (YEAR). During the interview with the administrator, the administrator described the QA process as follows: Facility staff bring their concerns to the department heads and the concerns are discussed in QA meetings. The administrator stated that staff, residents, and family members can bring concerns to the QA committee. The administrator stated that concerns are then tracked by the QA committee and remain in QA until the concerns are resolved. The administrator stated that none of the concerns identified during the facility's annual recertification survey were identified by the QA committee with the exception of MDS (Minimum Data Set) assessments concerns. Review of the facility's policy Quality Assurance and Performance Improvement (QAPI) Program revealed This facility shall develop, implement, and maintain an ongoing, facility-wide QAPI program that builds on the Quality Assessment and Assurance Program to actively pursue quality of care and quality of life goals. The primary purpose of the Quality Assurance and Performance Improvement Program is to establish data-driven, facility-wide processes that improve the quality of care, quality of life and clinical outcomes of our residents .",2020-09-01
313,HAVEN OF SAGUARO VALLEY,35085,6651 EAST CARONDELET DRIVE,TUCSON,AZ,85710,2018-07-12,880,D,0,1,FYQM11,"Based on observations, staff interviews, and policy review, the facility failed to ensure that infection control practice was used during medication administration. Findings include: During a medication administration observation conducted on (MONTH) 10, (YEAR) at 8:14 a.m., a Licensed Practical Nurse (LPN/ staff #38) was observed putting medications in a cup with her fingers. An interview was conducted on (MONTH) 10, (YEAR) at 8:15 a.m. with staff #38, who stated that she had washed her hands prior to preparing these medications and that her hands were clean. When asked, staff #38 stated prior to touching the medications, she had opened the cart and had prepared other medications, so her hands were no longer clean. Staff #38 then discarded the cup of medication to restart that medication administration. During a medication administration observation conducted on (MONTH) 10, (YEAR) at 8:32 a.m., staff #38 was observed bringing the medication back to the med cart to cut some of the medication in half, per the resident's request. Staff #38 used a tissue taken from the tissue box at the nurse's station to wipe off the pill splitter prior to cutting the pills. Staff #38 donned gloves prior to wiping the pill splitter, but did not change gloves before using her fingers to pull the large pills from the med cup, split them, and place them back into the med cup. An interview was conducted on (MONTH) 10, (YEAR) at 9:42 a.m. with staff #38, who stated that she used a tissue to clean the pill splitter because a resident once complained that they tasted the alcohol from the alcohol wipe she had cleaned it with. Staff #38 stated she would like to see the pill splitter hand washed with soap and water. The LPN stated that she did use her hands with the same gloves on to split the pills. Staff #38 stated that the pill splitter was nasty and that she is unaware of the last time the pill splitter was cleaned. An interview was conducted on (MONTH) 10, (YEAR) at 10:28 a.m. with the Director of Nursing (DON/staff #53), who stated the expectation is that the nurses would not pop pills into their hands but rather into the medication cups provided. Staff #53 stated that the medication cards in the cart have been touched by many people and there is no way to sanitize the medication cards. Review of the facility's policy titled Administering Medications included the following: -Staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable.",2020-09-01
314,HAVEN OF SAGUARO VALLEY,35085,6651 EAST CARONDELET DRIVE,TUCSON,AZ,85710,2019-09-25,742,D,0,1,GF7R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and policy reviews, the facility failed to provide the appropriate behavioral health treatment and services for one resident (#295). The deficient practice could result in residents not receiving individualized person-centered care and treatment, in order to reach their highest practicable well-being. Findings include: Resident #295 was admitted on (MONTH) 8, 2019, with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]., wound care consultant, psychiatrist and audiologist of choice as needed. A physician's orders [REDACTED]. A [MEDICAL CONDITION] medication informed consent for dated (MONTH) 10, 2019 for [MEDICATION NAME] included that the resident did not consent to the medication. Further review of the physician orders [REDACTED]. A health status note dated (MONTH) 10, 2019 included that the Nurse Practitioner recommended [MEDICATION NAME] for a [DIAGNOSES REDACTED]. The consent with the risks and benefits were reviewed with the resident, but the resident declined it's use. A signed declination was on file. A social services progress note written by the social services manager (staff #3) dated (MONTH) 10, 2019 at 9:47 a.m., included that social services spoke with the resident about a request for in house psychiatric services. This note stated the resident was informed that the facility did not currently have in-house psychiatric services, but that outpatient services were available. Per the note, the resident declined out-patient services. Another social services progress note written by staff #3 dated (MONTH) 10, 2019 at 1:04 p.m., included that social services and the Director of Nursing (DON) spoke with the resident about her yelling and disrupting the care of the other residents. The resident was educated on acceptable noise levels and if she needs assistance she can use the call light for assistance. The note included that the resident understood and was also educated on possible consequences of continued behavior. A care plan dated (MONTH) 10, 2019 identified the resident has the potential to demonstrate verbal outburst behaviors, related to ineffective coping skills and the refusal of ordered medication. The goal was the resident will verbalize understanding of the need to control verbal outburst behaviors. Interventions were to evaluate for side effects of refusing to take psychoactive medications, provide psychiatric/psychogeriatric consult as needed, assessing the resident's coping skills and anticipating the residents needs with food, thirst, toileting needs, comfort level, body positioning and pain. A physician's note dated (MONTH) 11, 2019 revealed that social services and the DON spoke with the resident yesterday letting her know that her screaming and outbursts were not acceptable. The note stated that for some reason this was enough to change her behaviors. An alert charting Change of Condition Summary dated (MONTH) 13, 2019 included the resident was wakeful and weepy through the night and that one on one time was spent with patient, with little effect. An alert charting note dated (MONTH) 15, 2019 stated the resident continues to be noisy and weepy and reassurance is given repeatedly. Per the note, the resident continues to call for assistance every ten to fifteen minutes. Review of a Minimum Data Set assessment dated (MONTH) 15, 2019 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS identified the resident had verbal behaviors directed towards others and rejected care 1-3 days of the 6 day look back period. Review of the behavioral monitoring documentation from (MONTH) 8 through 25, 2019 revealed the following: -Verbal symptoms such as screaming or disruptive sounds not directed at others was noted on (MONTH) 9, 12, 13, 14, 15, 16, 17, 18, 19, 21, 23 and 24. - Frequent crying was noted on (MONTH) 8, 9, 10, 13, 14, 15, 16, 17, 18, 19, 21, 23 and 24. - Yelling or screaming was noted on (MONTH) 12, 13, 14, 15, 16, 18, 19, 20, 21, 22, 23 and 24. - Behavioral symptoms directed at others including threatening, screaming or cursing at others were noted on (MONTH) 16, 18, 19, 20, 21, 22, 23 and 24. Per the documentation, the charge nurse was notified of the resident's behaviors on (MONTH) 8, 9, 10, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23 and 24. Despite the resident's ongoing behaviors, there were no additional treatments, services or interventions which were implemented to assist the resident in maintaining their highest practicable well-being. In an interview conducted with the resident on (MONTH) 23, 2019 at 1:58 p.m., the resident stated that a CNA told her that the number of times that CNA's go into her room is documented, and if she screams then the CNA will report her to the social worker and the social worker will get rid of her. An observation was conducted on (MONTH) 23, 2019 at 2:35 p.m. of the resident in her room. When asked if she wanted the door open or closed, the resident started crying loudly and putting her hands to her face. At this time, a CNA entered the room and attempted to console the resident that the door would not be closed. Another interview was conducted on (MONTH) 24, 2019 at 12:24 p.m., with a certified nursing assistant (CNA/staff #61). He stated that he hears the resident cry almost every day. Staff #61 said when the resident cries, he attempts to calm her down. He said that usually it is a pretty simple problem, but not always. In an interview conducted on (MONTH) 24, 2019 at 12:36 p.m. with a licensed practical nurse (LPN/ staff #5), he stated that he talks to this resident all the time and that she will cry on a daily basis. He said that she gets easily upset and if something doesn't go her way, she cries. He said that he tries to redirect her and explain what's going on. He said it helps to keep an upbeat attitude, but sometimes it works and sometimes it doesn't. He stated that he doesn't know if she's seen a psychiatrist, as he is not that familiar with this hall. In an interview conducted on (MONTH) 24, 2019 at 12:41 p.m. with the social services manager (staff #3), he stated that he did tell the resident that if the yelling continued they would have to consider alternate arrangements. He said the resident used to yell out when she needed something, but he was told that she's much better at pressing the call light now, since he and the DON talked to her about it. Regarding the social services note dated (MONTH) 10, which documented that the facility did not have in-house psychiatric services, staff #3 stated the facility does have an in house psychiatrist and has had an in house psychiatrist since the new owner (August 2019). He said the psychiatrist will be here in (MONTH) and he is the person who puts residents on the list. He stated this resident is not on the list to see the psychiatrist and that he is not sure if she needs to be on the list or not. He stated that he would know about patient outburst from the tasks that have flagged from the night before at daily meetings. He stated that all of the management team including the DON, the Executive Director, and the managers go over what triggered every meeting. In an interview conducted on (MONTH) 24, 2019 at 12:56 p.m., the DON (staff #22) stated that the resident was seen in the hospital by a psychiatrist prior to admission, and the psychiatrist did not diagnose her with a psychiatric diagnosis. She stated the Nurse Practioner who was following this resident tried to prescribe a psychiatric medication for her, but the resident didn't want it. The DON said they do have in house psychiatric services at this time and that they have had psychiatric services since August, 2019. The DON said there is a list of patients to see the psychiatrist in (MONTH) and the social services director manages that list. In a later interview at 2:35 p.m., the DON confirmed that in patient psychiatric services have been available since (MONTH) 19, 2019. A social services progress note dated (MONTH) 24, 2019 now included that the resident is requesting private personal counseling services. Per the note, the resident was informed that the facility does not have private counseling, but can be referred to in-house psychiatric services for an evaluation. The note included the resident is in agreement and will be seen at the next evaluation. In a follow up interview with the LPN (staff #5) conducted on (MONTH) 25, 2019 at 10:14 a.m., staff #5 stated that when a resident refuses a medication, he documents the refusal, updates the doctor and re-approaches the resident three times and documents on the Medication Administration Record [REDACTED] Another interview was conducted with the DON on (MONTH) 25, 2019 at 10:18 a.m., who stated that when a patient refuses a new medication, the expectation is to notify the doctor who wrote the order and document the refusals and the order may be continued. She stated that for a medication that needs a consent like a [MEDICAL CONDITION], a re-approach is expected to be done multiple times. She stated that if the resident continues refusing, then they inform the doctor and this is usually documented in the progress notes. She stated that she informed the nurse practitioner the day the order was given (regarding the [MEDICATION NAME]) and the nurse practitioner stated to discontinue the order as she would re-approach the resident personally. When asked for documentation of this, the DON was unable to provide any. An observation was conducted on (MONTH) 25, 2019 at 10:54 a.m. in the hallway where resident # 295 resided. The resident was observed in her room crying and a CNA (staff #61) was also in the room and was reassuring the resident. Review of a policy regarding Advance Directives revealed that if the resident refuses treatment, the facility and the care providers will reassess the resident for significant change of condition related to the refusal, determine the decision-making capacity of the resident, document specifically what the resident/representative is refusing, assess and document the stated reason for the refusal, advise the resident of the consequences of refusal, offer pertinent alternative treatments, modify the care plan as appropriate, providing all other appropriate services (i.e. those that will allow him or her to maintain the highest practicable physical, mental and psychosocial well-being.)",2020-09-01
315,HAVEN OF SAGUARO VALLEY,35085,6651 EAST CARONDELET DRIVE,TUCSON,AZ,85710,2019-09-25,812,D,0,1,GF7R11,"Based on observations, staff interview and policy review, the facility failed to serve food in accordance with professional standards for food service safety. The deficient practice could place residents at risk for foodborne illnesses. Findings include: During a dining observation conducted on (MONTH) 23, 2019 at 11:27 a.m., a Certified Nursing Assistant (staff #47) was observed assisting a resident with eating lunch. At this time, the resident dropped a piece of chicken on his clothing protector, and staff #47 picked the chicken up with bare hands and handed it to the resident. During the observation, the resident continued to drop food onto his clothing protector, and the CNA repeatedly used bare hands to pick the food up and give it back to the resident to eat. The resident was also observed trying to give food to staff #47 and staff #47 would then grasp the food with bare hands and give it back to the resident to eat. Staff #47 was also observed placing her bare thumb directly on the rim of a cup, as she guided the cup to the resident's mouth. An interview was conducted with the kitchen manager (staff #45) on (MONTH) 24, 2019 at 2:14 p.m. He said food should be served so that bare hands do not come in contact with food or the eating surfaces of plates and utensils. He stated staff should use utensils when assisting residents to eat, and should not touch food with bare hands. Review of the facility's Food Handling policy revealed that some of the critical factors implicated in foodborne illness were poor personal hygiene of food service employees and contaminated equipment. The policy stated that all employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to serving food to residents.",2020-09-01
316,"HAVEN OF SIERRA VISTA, LLC",35086,660 SOUTH CORONADO DRIVE,SIERRA VISTA,AZ,85635,2019-03-14,552,D,1,1,GDVT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on closed clinical record review, staff interviews and policy and procedures, the facility failed to have evidence that one (#267) of six sampled residents/representative was informed of the risks and benefits of a [MEDICAL CONDITION] medication prior to administration. The deficient practice could result in the resident's representative not being aware of the benefits and the potential adverse side effects of taking psychoactive medications. Findings include: Resident #267 was admitted to the facility on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. The resident was discharged on (MONTH) 21, (YEAR). Review of the care plan dated (MONTH) 10, (YEAR), revealed the resident had impaired cognitive function/impaired thought processes related to dementia. Interventions included keeping the resident's routine consistent and providing consistent care givers as much as possible in order to decrease confusion. The admission Minimum Data Set assessment dated (MONTH) 16, (YEAR), revealed a Brief Interview for Mental Status (BIMS) score of 7 which indicated the resident had severe cognitive impairment. An interdisciplinary team note dated (MONTH) 25, (YEAR), included the resident had become more confused. A nurse's note dated (MONTH) 1, (YEAR), revealed the resident was alert and oriented to self and had poor appetite. The note included orders were obtained for [MEDICATION NAME] to stimulate the resident's appetite and for an urinalysis. The note also included the resident's spouse was at the bedside and was notified of the new orders. Review of the clinical record revealed a physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. However, review of the [MEDICAL CONDITION] medication informed consent for [MEDICATION NAME] revealed the consent was signed by the resident who was cognitively impaired. The consent did not contain a date and the boxes for yes I consent and no I do not consent were blank. An interview was conducted on (MONTH) 13, 2019 at 1:18 p.m. with the Director of Nursing (DON/staff #76). She stated that it was not normal for the resident to sign his own medication consent. She stated that if a resident was alert and oriented to self, she would expect the nurse to obtained informed consent from a family member or responsible party. The DON also stated that they had identified an issue with obtaining informed consents for medications. She said that in (MONTH) 2019, it was identified through an audit that was conducted that there were medication consents that had not been completed or were not in the residents' charts. She said that since then weekly audits had been performed to ensure consents were collected, completed, and uploaded into the clinical record. However, review of the facility's audit documentation revealed the facility had not identified the issue of residents with severe cognitive impairment signing informed consents for [MEDICAL CONDITION] medications. The facility's policy for behavior management revealed the Assistant Director of Nursing is to ensure the required informed consent is obtained from the resident and/or responsible party for all [MEDICAL CONDITION] medications.",2020-09-01
317,"HAVEN OF SIERRA VISTA, LLC",35086,660 SOUTH CORONADO DRIVE,SIERRA VISTA,AZ,85635,2019-03-14,600,D,1,1,GDVT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews, facility documentation and policy review, the failed to ensure one resident (#59) was free from abuse by another resident (#3). The sampled residents for abuse were four. The resident census was 77. This deficient practice could potentially allow for further abuse. Findings include: -Resident #59 was admitted on (MONTH) 6, (YEAR) with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated (MONTH) 1, (YEAR) revealed a score of 4 on the Brief Interview for Mental Status (BIMS) which indicated the resident had severe cognitive impairment. Review of a nursing progress note dated (MONTH) 25, (YEAR), revealed a resident (#3) struck resident #59 on the right forearm with a brush which caused immediate swelling. The note revealed there were no open areas or bleeding observed and that resident #59 denied pain. -Resident #3 was admitted on (MONTH) 3, (YEAR) with [DIAGNOSES REDACTED]. A care plan initiated (MONTH) 3, (YEAR) revealed the resident had the potential to demonstrate physical and/or verbal aggression. The goal was that the resident would not harm others. Interventions included intervening as needed to protect the rights and safety of others, approaching the resident in a calm manner, diverting the resident's attention, and removing the resident from the situation. The quarterly MDS assessment dated (MONTH) 23, (YEAR) revealed a score of 7 on the BIMS which indicated the resident had severe cognitive impairment. A nursing progress note dated (MONTH) 25, (YEAR) revealed an off duty Certified Nursing Assistant (CNA) witnessed resident #3 strike resident #59 with a hairbrush. The note also included the writer observed resident #3 standing with a hairbrush in her hand near another resident who was seated at a dining room table. Review of the facility's documentation revealed that on (MONTH) 25, (YEAR) at 11:35 a.m., resident #3 struck resident #59 with a hair brush on the right wrist causing a bruise. The incident occurred in the dining room and was witnessed by a CNA (staff #68). The documentation included a written statement by staff #68 that revealed resident #3 was attempting to take a chair that resident #59 was saving for her spouse. Resident #3 became angry when resident #59 would not let go of the chair and hit resident #59 with a brush. The facility's documentation included the residents were redirected and separated immediately. The Director of Nursing (DON/staff #76) conducted an initial interview with resident #3 who stated resident #59 had gotten too close to her. The DON conducted an initial interview with resident #59 who stated that resident #3 had struck her. An interview was conducted with the CNA (staff #68) on (MONTH) 13, 2019 at 12:47 PM. She stated that resident #59 was seated at the dining table and was saving a chair for her family member. She stated that resident #3 walked up to the table and attempted to grab the chair that resident #59 had been saving. The CNA stated that as resident #3 began pulling the chair away, resident #59 grabbed resident #3's hand. She said resident #3 said, Let go! Staff #68 stated that resident #59 would not let go of the chair and that is when resident #3 hit resident #59 with the hair brush she was holding in her other hand. The CNA stated that she intervened and separated the residents. During an interview conducted with the Registered Nurse (RN/#66) on (MONTH) 13, 2019 at 1:01 PM, she stated that she heard a commotion, stood up from her desk, and saw resident #3 hit at resident #59. The RN stated that she did not realize contact had been made until she saw the hematoma. On (MONTH) 13, 2019 at 1:06 PM, an interview was conducted with the DON (staff #76). She stated that her first priority regarding resident-to-resident abuse is to make sure the residents are ok, and separated. The DON stated that she obtains statements from staff and if possible, from the residents involved, to identify the cause of the incident. The facility's policy on abuse, dated (YEAR), revealed the facility's objective is to provide a safe haven for residents through preventative measures that protect every resident's right to freedom from abuse. The policy also included .Instances of abuse of all resident, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, neglect, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . The policy further included that due to the proximity of our residents one to another and an individual's freedom of choice, that situations may arise where it is not possible to completely prevent all incidents of abuse.",2020-09-01
318,"HAVEN OF SIERRA VISTA, LLC",35086,660 SOUTH CORONADO DRIVE,SIERRA VISTA,AZ,85635,2019-03-14,609,D,1,1,GDVT11,"> Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to report an allegation of misappropriation of resident funds to the State Agency within the required timeframe for one of four sampled residents (#217). The resident census was 77. Findings include: Resident #217 was admitted on (MONTH) 31, (YEAR) with diagnoses, which included fractured right clavicle, dementia, and repeated falls. The admission Minimum Data Set assessment dated (MONTH) 5, (YEAR) revealed a score of 15 on the Brief Interview for Mental Status which indicated the resident had intact cognition. Review of a hand written note revealed on (MONTH) 3, (YEAR), the resident (#217) stated that he was missing money. The note also included the State Agency was notified on (MONTH) 6, (YEAR) at 2:00 p.m. Review of the facility's investigation report revealed the resident notified a Certified Nursing Assistant (CNA) on (MONTH) 4, (YEAR), that he was missing money. The report included the CNA had seen money under the resident's pillow. The CNA reported the missing money to the resident relations manager (staff #1). On (MONTH) 5, 2019, staff #1 confirmed with the resident's emergency contact, that the resident was missing $300.00. The report did not include notification of this allegation to the State Agency. However, review of the State Agency data base revealed the facility's first notification to the State Agency regarding this allegation was on (MONTH) 12, (YEAR) when they submitted their investigation report. During an interview conducted with the Director of Nursing (DON/staff #76) on (MONTH) 13, 2019, the DON stated that she reported the allegation to the State Agency on (MONTH) 6, (YEAR) at 2:00 p.m. The DON was aware that allegations of misappropriation of resident property are to be reported to the State Agency within 24 hours. An interview was conducted with the Resident Relations Manager (staff #1) on (MONTH) 13, 2019 at 12:10 p.m. Staff #1 stated that she notified Adult Protective Services and the Ombudsman of the allegation, but did not recall notifying the State Agency. The facility's policy titled Abuse Investigation and Reporting, (Revised July, (YEAR)), revealed an alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown sources and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse or has resulted in serious bodily injury; or Twenty-four (24) hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury.",2020-09-01
319,"HAVEN OF SIERRA VISTA, LLC",35086,660 SOUTH CORONADO DRIVE,SIERRA VISTA,AZ,85635,2019-03-14,641,D,0,1,GDVT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure a Minimum Data Set (MDS) assessment for one resident (#68) was accurate. The resident census was 77. This deficient practice has the potential to affect continuity of care. Findings include: Resident #68 was admitted to the facility on (MONTH) 9, 2019 with [DIAGNOSES REDACTED]. Review of the clinical record revealed a physician's orders [REDACTED]. A Health Status note dated (MONTH) 7, 2019 revealed the resident was discharged home at 1:30 p.m. However, review of the discharge MDS assessment dated (MONTH) 7, 2019 revealed the resident was discharged to an acute care hospital. During an interview conducted with the MDS coordinator (staff #95) on (MONTH) 14, 2019 at 9:52 a.m., staff #95 stated that if a resident is discharged home, it would be coded on the discharge MDS assessment as discharged to the community. After reviewing resident #68 discharge MDS assessment, she stated that the assessment was coded incorrectly because the resident was discharged home. The RAI manual instructs to review the clinical record including the discharge plan and discharge orders for documentation of a resident's discharge location. The manual also included .the importance of accurately completing and submitting the MDS cannot be over-emphasized . and that Federal regulations require the assessment accurately reflects the resident's status.",2020-09-01
320,"HAVEN OF SIERRA VISTA, LLC",35086,660 SOUTH CORONADO DRIVE,SIERRA VISTA,AZ,85635,2019-03-14,695,D,0,1,GDVT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and policy review, the facility failed to ensure that oxygen was administered per the physician's orders [REDACTED].#15). This deficient practice could result in respiratory complications. Findings include: Resident #15 was readmitted on (MONTH) 4, 2019, with [DIAGNOSES REDACTED]. Review of the clinical record revealed physician's orders [REDACTED]. The 5-day Minimum Data Set assessment dated (MONTH) 11, 2019 revealed a Brief Interview for Mental Status score of 2, which indicated that the resident had severe cognitive impaired. The assessment also included the resident was receiving oxygen therapy. Review of the oxygen saturation report for (MONTH) 2019 revealed the resident's oxygen saturations were between 92 - 99% on 5 LPM of oxygen. During an observation conducted of the resident on (MONTH) 11, 2019 at 1:37 p.m., the resident was observed sitting in a wheelchair in the dining room with oxygen via nasal cannula at 5 LPM. Further observation of the portable oxygen tank revealed the oxygen tank pounds per square inch (PSI) level was reading in the red, which indicated the tank was empty or OFF. Another observation was conducted of the resident with the nasal cannula in place on (MONTH) 11, 2019 at 2:10 p.m. The portable oxygen tank was observed with the oxygen tank PSI level in the red. The resident was observed moving about restlessly and appeared to have difficulty breathing. Immediately following this observation, an interview was conducted with the Registered Nurse (RN/staff #66). The RN stated that the resident is receiving oxygen continuously at 5 LPM and that the resident's heavy breathing pattern was normal because it was behavioral. When the RN checked the resident's oxygen saturation, the oxygen saturation was 87 - 88%. The RN then instructed the resident to take some deep breaths. After being alerted to the fact that the oxygen tank needle was in the red area, the RN used a key to turn the oxygen tank on. Once the oxygen tank was turned on, the resident's oxygen saturation went up to 98%. The RN then stated that a Certified Nursing Assistant (CNA) had changed the portable oxygen tank and must have forgotten to turn the oxygen back on. During an interview conducted with a CNA (staff# 68) on (MONTH) 14 at 10:21 a.m., she stated that for a resident who is receiving oxygen via a portable oxygen tank, she checks the tank every time she walks by the resident to ensure the tank is turned on and is full. The CNA stated that the CNAs are responsible for changing the oxygen tank. She further stated the nurses are responsible for turning on the oxygen and setting the rate. An interview was conducted with the Director of Nursing (DON/staff# 76) on (MONTH) 14, 2019 at 1:15 p.m. The DON stated that CNAs can set up oxygen but cannot turn the oxygen on. The DON stated that the nurses are responsible for turning on a resident's oxygen. She stated that the staff are encouraged to monitor oxygen tanks as they walk by to ensure the tanks are full and working. She also stated that if a resident is having difficulty breathing, the nurse is supposed to assess the resident and check the oxygen and titrate the oxygen accordingly. Review of the facility's policy regarding Oxygen Administration (revised (MONTH) 2010) revealed the purpose is to provide guidelines for safe oxygen administration. The policy instructs to review the physician's orders [REDACTED]. The policy included checking the oxygen tank to ensure that it is in good working order.",2020-09-01
321,"HAVEN OF SIERRA VISTA, LLC",35086,660 SOUTH CORONADO DRIVE,SIERRA VISTA,AZ,85635,2019-03-14,757,E,0,1,GDVT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy review, the facility failed to ensure that one residents (#36) drug regimen was free from unnecessary drugs, by failing to administer pain medication according to the physician ordered parameters. Findings include: Resident #36 was admitted to the facility on (MONTH) 30, (YEAR), with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated (MONTH) 11, (YEAR), revealed the resident scored a 14 on the Brief Interview for Mental Status (BIMS) assessment, indicating intact cognition. The MDS included that the resident frequently experienced severe pain. A physician's orders [REDACTED]. This order was discontinued on (MONTH) 23, 2019. Review of the medication administration record (MAR) for (MONTH) 2019 revealed the resident received [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg outside of the physician ordered parameters as follows: (MONTH) 3 for a pain level of 3, (MONTH) 4 for a pain level of 1, (MONTH) 10 for a pain level of 2, twice on (MONTH) 11 for a pain level of 2, and twice on (MONTH) 17 for a pain level of 2. A physician's orders [REDACTED]. The (MONTH) 2019 MAR included documentation that the resident was administered [MEDICATION NAME] HCl concentrate outside of the physician ordered parameters as follows: twice on (MONTH) 25 for pain levels of 2 and 3, and twice on (MONTH) 31 for a pain level of 2. Review of a pain care plan dated (MONTH) 27, 2019 revealed the use of [MEDICATION NAME]-[MEDICATION NAME], and [MEDICATION NAME] HCl concentrate for chronic pai[DIAGNOSES REDACTED], [MEDICAL CONDITIONS] and restless leg syndrome. A goal included the resident would verbalize adequate pain relief and would not have problems related to side effects of opioid [MEDICATION NAME]. Interventions included for the administration of pain medications as ordered, anticipation of the resident's need for pain relief and responding as soon as possible to any complaint of pain, evaluation of the effectiveness of pain interventions, monitoring and documenting side effects of pain medication and informing the resident of the risks and benefits of pain medication. Review of the MAR for (MONTH) 2019 revealed the resident was administered [MEDICATION NAME] HCl concentrate below the physician ordered parameters of 6-10, over 20 times. An interview was conducted on (MONTH) 14, 2019 at 9:35 AM with a Licensed Practical Nurse (LPN/staff #73). She acknowledged her initials on resident #36's MAR and stated she guessed she hasn't been paying attention to the pain scale on the physician's orders [REDACTED]. On (MONTH) 14, 2019 at 10:07 AM an interview was conducted with a Registered Nurse (RN/staff #90). She said she would assess the resident's pain prior to administering a pain medication. She said she would then check the physician's orders [REDACTED]. On (MONTH) 14, 2019 at 10:11 AM an interview was conducted with the Director of Nursing (DON/staff #76). She stated that her expectation for nurses administering pain medications was for the nurse to assess the resident's pain level and to follow the ordered parameters. The medication administration policy dated (MONTH) 2012 stated medications must be administered in accordance with the orders, including any required timeframe. Additionally, the policy states the individual administering the medication must check the label three (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.",2020-09-01
322,"HAVEN OF SIERRA VISTA, LLC",35086,660 SOUTH CORONADO DRIVE,SIERRA VISTA,AZ,85635,2019-03-14,842,D,1,1,GDVT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interview and policy review, the facility failed to ensure that the protected health information for one resident (#27) was kept confidential and failed to ensure that one resident's (#267) medical record accurately reflected their status. The deficient practice resulted in private medical information being exposed to the public, and the deficient practice had the potential for inaccurate care and treatment being provided. The sample size was 20 and the resident census was 77. Findings include: -Resident #267 was admitted to the facility on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. Review of a care plan dated (MONTH) 10, (YEAR) revealed a potential for skin integrity impairment, related to having a cast to the left lower extremity (instead of the right lower extremity) for a right tibia fracture (instead of a right fibula fracture). A care plan dated (MONTH) 10, (YEAR), included the resident was at risk for experiencing pain, related to a left tibia fracture (instead of a right fibula fracture). Another care plan dated (MONTH) 10, (YEAR) for Activities of Daily Living (ADL) included the resident had self care performance deficits, related to a left tibia fracture (instead of a right fibula fracture). According to a physician's progress note dated (MONTH) 12, (YEAR), the resident's right leg was in a short cast. However, review of the nurse's notes dated (MONTH) 11, 12 and 13, (YEAR), revealed documentation that the resident had a cast in place to his left lower extremity (instead of the right lower extremity). -Resident #27 was admitted to the facility on (MONTH) 11, 2012, with [DIAGNOSES REDACTED]. The State Agency received information that another resident's representative had requested copies of that resident's medical record. Included in the copies that they received was a copy of the laboratory results, which belonged to resident #27. Review of the clinical record for resident #27 revealed diagnostic laboratory results dated (MONTH) 6, (YEAR). The resident's name, date and laboratory values were identical to the copy that the other resident's representative had received. An interview was conducted on (MONTH) 12, 2019 at 9:25 a.m., with the Medical Records Director (staff #12). She stated that the request for medical records had been handled by the legal department. She stated she was not aware that the laboratory results for resident #27 were included in the copies for another resident's records. Review of the facility's policy on Confidentiality of Information revealed the facility would treat all resident information confidentially and would access protected health information only as necessary. Access to resident medical records would be limited to authorized staff and business associates. Release of resident information would be handled in accordance with resident rights and privacy policies.",2020-09-01
323,"HAVEN OF SIERRA VISTA, LLC",35086,660 SOUTH CORONADO DRIVE,SIERRA VISTA,AZ,85635,2016-10-27,154,D,0,1,ZCFO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure one resident (#74) was informed of the risks and benefits of a [MEDICAL CONDITION] medication prior to it being administered. Findings include: Resident #74 was admitted to the facility on (MONTH) 23, (YEAR) with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. However, no documentation that the risks and benefits had been explained to the resident and no signed risk and benefit consent form was able to be located in the resident's clinical record. In an interview with a Licensed Practical Nurse (LPN/staff #99) on (MONTH) 27, (YEAR) at 11:41 a.m. she stated a consent form explaining the risks and benefits of a [MEDICAL CONDITION] medication would need to be signed by the resident or their responsible party prior to administering the medication. In an interview with a Registered Nurse (RN/staff #94) on (MONTH) 27, (YEAR) at 11:45 a.m., she stated that before a [MEDICAL CONDITION] medication is administered, such as [MEDICATION NAME], a consent form would need to be signed by the resident or responsible party after explaining what the medication is being administered for. In an interview with the Director of Nursing (DON/staff #53) on (MONTH) 27, (YEAR) at 12:41 p.m., she stated that the nurses are responsible for presenting the risks and benefits form of a [MEDICAL CONDITION] medication to either the resident or their responsible party before the medication is administered. The nurses are responsible for explaining what the mediation is and what it is used for. The form should be signed before the medication is administered. In an interview with a Cooperate RN (staff #94) on (MONTH) 27, (YEAR) at 12:58 p.m. she stated that the facility was unable to locate a signed risk/benefit form for the medication [MEDICATION NAME] for this resident. A facility policy titled Antipsychotic/Psychoactive Medication included informed that consent must be obtained prior to administering the medication and an Acknowledgement of Psychoactive Medication Use form obtained from the patient or responsible party.",2020-09-01
324,"HAVEN OF SIERRA VISTA, LLC",35086,660 SOUTH CORONADO DRIVE,SIERRA VISTA,AZ,85635,2016-10-27,241,D,0,1,ZCFO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interviews, and review of facility policies and procedures, the facility failed to provide one resident (#46) with assistance during mealtime to promote dignity. Findings include: Resident #46 was admitted to the facility on (MONTH) 22, (YEAR) with [DIAGNOSES REDACTED]. A review of the resident's admission MDS (Minimum Data Set) assessment, Section G Functional Status dated (MONTH) 29, (YEAR) revealed the resident required set up help only with eating. A review of the resident's clinical record revealed a care plan with a problem the resident has a potential for altered nutritional status related to being overweight, dementia. A goal documented the resident will consume an average of 75% food/beverage at meals. Interventions documented were Prefers to have food in bowls when able .Provide feeding/dining assistance as needed . An observation was made of the resident during breakfast on (MONTH) 26, (YEAR) at 7:25 a.m. The resident was observed to have three separate bowls in front of her. A spoon was observed in the center of the table approximately two feet away from the resident. The resident was observed to feed herself a bowl of mechanical soft pancakes with syrup and a bowl of mechanical soft bacon and sausage with her left hand. Once the resident finished the two bowls of food with her left hand, she began to feed herself cream of wheat with her left hand. A fork was observed on the resident's lap. A CNA (certified nursing assistant) was observed seated at a table next to the resident. An immediate interview was conducted with the resident on (MONTH) 26, (YEAR). When asked if she enjoyed her breakfast, the resident stated It's ok. I need spoons and forks. An interview was conducted with a CNA, staff #79 on (MONTH) 26, (YEAR) at 7:35 a.m. The CNA stated that the resident was able to use silverware if she wanted to. The CNA stated I gave her a fork, I don't know what she did with it. The CNA was then observed to place a spoon in the resident's left hand without wiping the resident's hand of the food that was on it. The resident was then observed to begin feeding herself cream of wheat with her spoon while the CNA went to another table. At 7:40 a.m., the CNA returned to the resident's table, wiped the resident's left hand and fed the resident the rest of the cream of wheat. An interview was conducted with the DON, (director of nursing) staff #53 on (MONTH) 26, (YEAR) at 8:29 a.m. The DON stated that the resident required assistance with cueing and the CNA should have put the resident's silverware in her hand so that she could feed herself her food with her silverware. A review of the facility's policy Dining Standards included The dining environment enhances the patient's quality of life .Patients are provided with special eating equipment and utensils, as needed .Staff is available to provide supervision and assistance to the patient, as needed .",2020-09-01
325,"HAVEN OF SIERRA VISTA, LLC",35086,660 SOUTH CORONADO DRIVE,SIERRA VISTA,AZ,85635,2016-10-27,323,D,0,1,ZCFO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, and staff interviews, the facility failed to ensure that the armrests of three (#'s 12, 36, and 199) resident's wheelchairs were maintained in good repair to prevent possible injury to the resident. Findings include: -Resident #12 was readmitted to the facility on (MONTH) 2, 2012 with [DIAGNOSES REDACTED]. An observation was made of the resident on (MONTH) 26, (YEAR) at 7:15 a.m. during breakfast in the dining room. The right armrest to the resident's wheelchair was extremely worn with sharp edges. The back of the left arm rest was also worn with sharp edges. An immediate interview was conducted with the resident on (MONTH) 26, (YEAR). When the resident was asked how long his wheelchair had been in disrepair, the resident stated I don't know. -Resident #36 was readmitted to the facility on (MONTH) 16, (YEAR) with [DIAGNOSES REDACTED]. An observation was made of the resident during breakfast on (MONTH) 26, (YEAR) at 7:18 a.m. The right arm rest to the resident's wheelchair was observed to be extremely worn with sharp edges. An immediate interview was conducted with the resident on (MONTH) 26, (YEAR). The resident stated that his wheelchair had been in disrepair for a long time. -Resident #199 was admitted to the facility on (MONTH) 29, (YEAR) with [DIAGNOSES REDACTED]. An observation was made of the resident's wheelchair in her room on (MONTH) 27, (YEAR) at 11:00 a.m. There was no arm rest on the left side of the resident's wheelchair and two screw holes to the arm of the wheelchair were exposed. An environmental tour was conducted on (MONTH) 27, (YEAR) at 12:30 p.m. with the maintenance director, staff #83, the therapy director, staff #89, and the interim administrator, staff #95. An interview was conducted with the therapy director, staff #89 on (MONTH) 27, (YEAR) at 12:45 p.m. The therapy director stated that wheelchairs are repaired when it is brought to the therapy department's attention or the therapy department notices it. An interview was conducted with the maintenance director, staff #83 on (MONTH) 27, (YEAR) at 12:45 p.m. The maintenance director stated that staff let him know when a wheelchair needs repair but that he does not routinely inspect wheelchairs to ensure that they are in good repair. An interview was conducted with the interim administrator, staff #95 on (MONTH) 27, (YEAR) at 1:00 p.m. The interim administrator stated that the facility needed to create a maintenance checklist for the routine inspection of wheelchairs to ensure that they are in good repair. The facility did not have a policy for the routine and preventative maintenance of resident equipment.",2020-09-01
326,"HAVEN OF SIERRA VISTA, LLC",35086,660 SOUTH CORONADO DRIVE,SIERRA VISTA,AZ,85635,2016-10-27,364,D,0,1,ZCFO11,"Based on observation, staff interviews, and policy review, the facility failed to ensure one resident (#18) was assisted with her meal in a timely manner, in order to maintain food at preferable temperatures. Findings include: A dining observation was conducted on (MONTH) 26, (YEAR) at 7:20 a.m., in the assisted section of the main dining room. Resident #18 was observed to receive an uncovered breakfast plate at 7:22 a.m., which consisted of pancakes and bacon. The resident was seated at a table with another resident who was being by assisted to eat their breakfast by a Certified Nursing Assistant (CNA/staff #75). Resident #18 was not observed attempting to eat her food or to be assisted to eat her food until 7:47 a.m. At this time the CNA (staff #75) who had been feeding another resident at the same table asked resident #18 if she was ready to eat. However the resident's plate had been sitting uncovered for 25 minutes. The CNA (staff #75) was asked if the resident's food was still warm and she stated probably not and that she would speak with the dietitian regarding the food. In an interview conducted with the Director of Nursing (DON/staff #53) on (MONTH) 26, (YEAR) at 8:29 a.m., she stated that her expectation of the CNAs in the assisted dining room is to either assist the resident with eating or to cue the resident to eat. Additionally, she stated that resident #18 is capable of feeding herself, but needs cueing. Further, the DON stated that the resident should have been cued by the CNA to eat. Review of facility policy regarding meal services included, at the point of service to the patient, the food temperature should be such that the food is palatable. Additionally, Nursing personnel should see that the patients are ready to eat when the trays arrive.",2020-09-01
327,"HAVEN OF SIERRA VISTA, LLC",35086,660 SOUTH CORONADO DRIVE,SIERRA VISTA,AZ,85635,2016-10-27,502,E,0,1,ZCFO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of policy, the facility failed to ensure physician ordered laboratory tests were provided for one resident (#13). Findings include: Resident #13 was admitted to the facility on (MONTH) 14, (YEAR) with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The tests included specific tests regarding glucose, cholesterol, and [MEDICAL CONDITION] levels. In a review of the clinical record there was documentation dated (MONTH) 2, (YEAR), from the pharmacist that the laboratory test results from the (MONTH) 6, (YEAR) orders were not available in the clinical record. A further review of the clinical record now revealed that the three laboratory results were re-ordered by the physician on (MONTH) 2, (YEAR) and the laboratory tests were provided. An interview was conducted with a Licensed Practical Nurse/staff #99 on (MONTH) 27, (YEAR) at 12:25 p.m. She stated that all physician orders [REDACTED]. She stated the laboratory tests were not completed as ordered on (MONTH) 6, (YEAR). An interview was conducted with the Director of Nursing/staff #53 on (MONTH) 27, (YEAR) at 12:45 p.m. She stated all nurses are responsible to make sure all physician orders [REDACTED]. She further stated that the laboratory tests ordered on (MONTH) 6, (YEAR) for resident #13 were not completed. In a review of a facility policy regarding laboratory testing the following was included: The laboratory services are provided to detect risk or disease and to monitor a condition. Procedure: Services are timely. The facility is responsible to obtain laboratory tests when ordered by the physician.",2020-09-01
328,"HAVEN OF SIERRA VISTA, LLC",35086,660 SOUTH CORONADO DRIVE,SIERRA VISTA,AZ,85635,2016-10-27,505,D,0,1,ZCFO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of policy, the facility failed to ensure that the physician was promptly notified of the laboratory results for one resident (#61). Findings include: Resident #61 was admitted to the facility on (MONTH) 3, (YEAR), with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The tests included a complete blood count, a lipid panel, comprehensive metabolic panel, [MEDICAL CONDITION] stimulating hormone, and a ferritin level. A review of the clinical record revealed the laboratory test had been obtained and the results reported to the facility on (MONTH) 10, (YEAR). However, the clinical record did not include any documented evidence that the laboratory test results had been reported to the physician for further review and recommendations, including the test results that were outside of the reference ranges. An interview was conducted with a Licensed Practical Nurse/staff #99 on (MONTH) 27, (YEAR) at 12:25 p.m. She stated the routine practice included when laboratory results were received at the facility the nurse signs and dates the results form when the physician was notified. In addition, the pending laboratory results are discussed in the 24 hour facility report so that all nursing staff are aware and alerted to pending results. She stated that for resident #61 there was no documentation of physician notification when the results were received on (MONTH) 10, (YEAR). An interview was conducted with the Director of Nursing/staff #53 on (MONTH) 27, (YEAR) at 12:45 p.m. She stated the routine process is for the licensed staff to notify the physician when the results are received and then sign and document the physician notification. She stated this was not done for resident #61. A facility policy regarding laboratory services included the following: Laboratory services are provided to detect risk or disease, and to monitor a condition. Procedure: Services are both accurate and timely and to promptly notify the physician of the findings.",2020-09-01
329,"HAVEN OF SIERRA VISTA, LLC",35086,660 SOUTH CORONADO DRIVE,SIERRA VISTA,AZ,85635,2017-12-16,553,D,0,1,VDR111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff and family interviews, and facility policy and procedures, the facility failed to inform one resident's (#36) family regarding the right to participate in the care planning process. Findings include: Resident #36 was admitted on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment dated (MONTH) 11, (YEAR) included a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. Review of the clinical record revealed there was no documentation that the facility had invited the resident's family member to attend any care plan conferences or that any conferences had been conducted. An interview was conducted with the resident's family member on (MONTH) 13, (YEAR) at 1:08 p.m. He stated that he had never been invited or given notice of a care plan meeting. He further stated that he had attended care plan meetings in the past at another facility. An interview was conducted on (MONTH) 15, (YEAR) at 9:43 a.m., with the Director of Social Services (staff #59). She stated that she was responsible for mailing out the invitations; however the previous nurse case manager would conduct the meetings. She stated that invitations to attend the meetings are mailed to the family or Power of Attorney and they are also contacted by telephone for a follow up reminder. Staff #59 stated that the meetings are usually scheduled on Thursdays. Staff #59 was unable to explain why there was no record of the care plan meeting invitations or why there was no documentation that the meetings had occurred. An interview was conducted with the Director of Nursing (DON/staff #46) on (MONTH) 15, (YEAR) at 1:53 p.m. She stated that she does not attend the care conferences and was unaware that they were not being conducted. Review of a policy regarding care plans revealed the resident, the resident's family, and or the resident's legal representative are encouraged to participate in the development of and revisions to the resident's care plan. Every effort will be made to schedule care plan meetings at the best time of day for the resident and family.",2020-09-01
330,"HAVEN OF SIERRA VISTA, LLC",35086,660 SOUTH CORONADO DRIVE,SIERRA VISTA,AZ,85635,2017-12-16,558,D,0,1,VDR111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, resident and staff interviews, and facility policy and procedure, the facility failed to ensure that one resident (#43) had a call light in his room. Findings include: Resident #43 was admitted to the facility on (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. Review of a nursing note dated (MONTH) 14, (YEAR), revealed the resident fell from the bed to the floor while attempting to retrieve the call light from the other bed. The note further included the resident stated he hit his back on his bed frame. Review of interdisciplinary team fall documentation dated (MONTH) 15, (YEAR), revealed the resident sustained [REDACTED]. The resident was reoriented how to use his call light to request assistance. The new intervention was to place bolsters for safety and to remind the resident of the bed edges. A nursing note dated (MONTH) 17, (YEAR), revealed resident #43 had an unwitnessed fall trying to get to the bathroom because he had soiled his pants. The resident started crying and stated I just don't understand why this is happening; my body is just not working anymore. Review of the admission Minimum Data Set assessment dated (MONTH) 21, (YEAR), revealed the resident had a Basic Interview for Mental Status score of 7, which indicated the resident had severe cognitive impairment. Continued review of the clinical record revealed a nursing note dated (MONTH) 26, (YEAR) that the resident was found beside his bed with his head against the closet because he was trying to get up, he denied pain or discomfort, and no bumps or bruises were noted. An interview was conducted on (MONTH) 12, (YEAR) at 9:00 a.m. with resident #43. The resident stated that he does not have a call light and has not had a call light since admission. An observation was made and it was observed resident #43 did not have a call light. During an interview conducted on (MONTH) 12, (YEAR) at 9:15 a.m. with a registered nurse (staff #44), staff #44 stated after observing resident #43's room that the resident did not a call light. She stated the resident was alert and oriented enough to use a call light and should have a call light. An interview was conducted on (MONTH) 16, (YEAR) at 8:30 a.m. with the resident. Resident #43 stated he felt better having a call light in case he needed help. The policy Answering the Call Light included to explain the call light to the new resident; demonstrate the use of the call light and have the resident return the demonstration. The policy also included to ensure the call light is plugged in at all times and within easy reach of the resident.",2020-09-01
331,"HAVEN OF SIERRA VISTA, LLC",35086,660 SOUTH CORONADO DRIVE,SIERRA VISTA,AZ,85635,2017-12-16,641,D,0,1,VDR111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, resident and staff interviews, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure an admission Minimum Data Set (MDS) assessment was accurate regarding oral/dental status for one resident (#364). Findings include: Resident #364 was admitted on (MONTH) 7, (YEAR), with [DIAGNOSES REDACTED]. The Admission Nursing Evaluation dated (MONTH) 7, (YEAR), revealed the resident had either an obvious or likely cavity or broken natural teeth. A nurse progress note dated (MONTH) 7, (YEAR), revealed the resident had poor dentition and did not wear dentures. A physician's orders [REDACTED].>Review of a care plan dated (MONTH) 7, (YEAR), revealed the resident had oral/dental health problems. Review of the admission MDS assessment dated (MONTH) 12, (YEAR), revealed the resident had a Brief Interview for Mental Status score of 12, which indicated the resident had moderate cognitive impairment. The resident was also assessed to have no broken or loosely fitting dentures and no mouth pain. An observation of resident #364 was conducted on (MONTH) 13, (YEAR) at 2:19 p.m. The resident was observed grimacing with pain, while holding the right side of his face. At this time, an interview was conducted with the resident. The resident stated that he had a broken tooth, which was cutting the inside of his mouth when he tried to talk and eat. The resident further stated he has an appointment to see his dentist on (MONTH) 15. In an interview conducted with a Licensed Practical Nurse (MDS Coordinator/staff #24) on (MONTH) 16, (YEAR) at 10:50 a.m., staff #24 stated she obtains information for the MDS dental assessment from the clinical record and from staff and resident interviews. Staff #24 stated the MDS dental assessment was incorrect. The RAI manual for the MDS assessments instructs to ask the resident about the presence of chewing problems or mouth or facial pain/discomfort and that if the resident is unable to answer to observe the resident while eating. The manual also instructs to conduct an exam of the resident's lips and oral cavity. The RAI manual also included that the importance of accurately completing and submitting the MDS assessment cannot be over emphasized.",2020-09-01
332,"HAVEN OF SIERRA VISTA, LLC",35086,660 SOUTH CORONADO DRIVE,SIERRA VISTA,AZ,85635,2017-12-16,655,D,0,1,VDR111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to ensure one resident's (#160) care plan regarding the monitoring of pedal pulses was implemented. Findings include: Resident #160 was admitted on (MONTH) 12, (YEAR), with [DIAGNOSES REDACTED]. Review of a care plan dated (MONTH) 13, (YEAR), revealed the resident had [MEDICAL CONDITION] related to limited mobility. A goal included that the resident would remain free of complications related to [MEDICAL CONDITION]. An intervention was to .Check for presence of pedal pulses and record findings every 8 hours . However, review of the clinical record revealed there was no evidence that the resident's pedal pulses were checked every 8 hours as care planned. Clinical record documentation included that the resident was transferred to the hospital on (MONTH) 25, (YEAR) for an elevated blood glucose level. An interview was conducted with a Licensed Practical Nurse (staff #26) on (MONTH) 15, (YEAR) at 12:30 p.m. Staff #26 stated that if a specific intervention was on the care plan that an order should be written, and then it should be documented on the TAR (treatment administration record), so the nurses would be aware. An interview was conducted with the MDS (Minimum Data Set) coordinator (staff #24) on (MONTH) 15, (YEAR) at 12:40 p.m. Staff #24 stated that if specific interventions are on the care plan, orders should be written so that they can be transferred to the TAR. An interview was conducted with the Director of Nursing (staff #46) on (MONTH) 15, (YEAR) at 12:55 p.m. Staff #45 stated that an order should have been written for the care plan intervention.",2020-09-01
333,"HAVEN OF SIERRA VISTA, LLC",35086,660 SOUTH CORONADO DRIVE,SIERRA VISTA,AZ,85635,2017-12-16,657,D,0,1,VDR111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and facility policy, the facility failed to ensure that a [MEDICAL TREATMENT] care plan was revised for one resident (#49). Findings include: Resident #49 was readmitted on (MONTH) 17, (YEAR), following a discharge to the hospital on (MONTH) 15, (YEAR), for a non-functioning arteriovenous fistula (a [MEDICAL TREATMENT]). [DIAGNOSES REDACTED]. A nursing note dated (MONTH) 17, (YEAR), revealed the resident returned to the facility with a CVC (central venous catheter) in the left chest. Although a [MEDICAL TREATMENT] care plan was initially developed, it was not revised to reflect that the resident now had a CVC, instead of a AV fistula for [MEDICAL TREATMENT] treatments. An interview was conducted on (MONTH) 15, (YEAR) at 11:30 a.m. with the Minimum Data Set nurse (staff #24). She stated that she was responsible for the review and revision of care plans. Following a review of the clinical record, staff #24 stated that the [MEDICAL TREATMENT] care plan was not accurate, because the resident did not have a functional AV fistula. The policy Comprehensive Care Plans included the following: 8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change.",2020-09-01
334,"HAVEN OF SIERRA VISTA, LLC",35086,660 SOUTH CORONADO DRIVE,SIERRA VISTA,AZ,85635,2017-12-16,684,D,0,1,VDR111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, staff interviews, and facilities policies and procedures, the facility failed to ensure that one resident (#8) was provided an appropriate sized wheelchair and failed to ensure that physician orders [REDACTED].#59). Findings include: -Resident #8 was admitted on (MONTH) 27, 2012, with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A Health Status Note dated (MONTH) 5, (YEAR), revealed Reviewed/screened patient post fall. Patient with multiple falls as she pushes herself out of chair, dycem placed under cushion and on cushion to prevent patient slipping. Patient aware she is pushing herself out of chair. A Health Status Note dated (MONTH) 16, (YEAR), revealed .patient remains fall risk as she pushes herself out of chair. Patient education to decrease fall risk, patient with soft pommel in chair. Patient continues with RNA (restorative nursing assistant) therapy . A Health Status Note dated (MONTH) 14, (YEAR), revealed .resident out of bed in wheelchair, able to unlock brakes and propel self forward throughout facility . Review of the (MONTH) (YEAR) physician orders [REDACTED]. Review of an annual Minimum Data Set (MDS) assessment dated (MONTH) 11, (YEAR), revealed a Brief Interview for Mental Status score of 9, which indicated the resident had moderate cognitive impairment. The resident was also assessed to require extensive assistance with bed mobility, transfers, and locomotion off the unit. The MDS assessment also included the resident utilized a wheelchair. According to a fall care plan, the resident had a history of [REDACTED]. Another care plan included the resident had behaviors of scooting out of the wheelchair. One of the interventions was to assess and anticipate needs, which included comfort level and body positioning. An observation was conducted on (MONTH) 13, (YEAR) at 12:22 p.m., of resident #8 seated in her wheelchair at a table in the assisted dining room eating lunch. The resident's feet did not touch the floor. The resident's toes were pointed toward the floor and were approximately two inches off the floor. There were no foot pedals on the resident's wheelchair. An observation was conducted of the resident on (MONTH) 14, (YEAR) at 8:30 a.m. The resident was seated in her wheelchair at the dining room table. The resident's toes were pointed toward the floor, and were approximately two inches off the floor, with no support. Another observation was conducted of the resident on (MONTH) 15, (YEAR) at 12:20 p.m. The resident was observed in her wheelchair and the resident's feet did not reach the floor. An interview was conducted with a Licensed Practical Nurse (staff #48) on (MONTH) 15, (YEAR) at 12:30 p.m. Staff #48 stated that therapy decides how high or low the wheelchair should be for the residents. Staff #48 also stated that the reason why the resident's wheelchair was so high was because the wheelchair had a 4 inch pommel cushion in it. An interview was conducted with an Occupational Therapist (staff #85) on (MONTH) 15, (YEAR) at 2:00 p.m. Staff #85 stated the resident's wheelchair was not ideal based on the resident's height, but that the resident had been standing up and falling. Staff #85 stated that he had not worked with the resident in over 1 1/2 months. An interview was conducted with a Restorative Nursing Assistant (staff #58) on (MONTH) 15, (YEAR) at 2:30 p.m. Staff #58 stated that they were going to try a different wheelchair with a lower seat for the resident. Review of a policy regarding Assistive Devices and Equipment revealed Our facility provides, maintains, trains, and supervises the use of assistive devices and equipment for residents .the equipment or device will be used only according to its intended purpose and will be measured to fit the resident's size and weight . -Resident #59 was admitted on (MONTH) 30, (YEAR), with [DIAGNOSES REDACTED]. The admission orders [REDACTED] -Pain evaluation every shift. -Oxygen at 2 liters per minute to keep oxygen saturation above 90% every shift. -Monitor for signs of bleeding/hemorrhaging/bruising every shift and notify physician if present. Review of the (MONTH) (YEAR) TARs (Treatment Administration Records) included the above orders. However, there was no documentation that the resident's pain was evaluated each shift, that oxygen saturations were done each shift, and that the resident was monitored for signs of bleeding on (MONTH) 5, 6, and 7. An interview was conducted on (MONTH) 15, (YEAR) at 2:40 p.m., with a Registered Nurse (staff #31). Following a review of the physician's orders [REDACTED]. Staff #31 also stated that licensed staff should have documented the evaluation and assessments if the orders were followed. An interview was conducted on (MONTH) 15, (YEAR), with the Director of Nursing (staff #46). Following a review of the physician's orders [REDACTED]. Staff #46 stated that licensed staff had not followed the physician's orders [REDACTED]. A policy Charting and Documentation included All services provided to the resident, or changes in the resident's medical or mental condition, shall be documented in the resident's medical record. The policy also included the following: 1. All observations, medications administered, services performed, etc., must be documented in the resident's clinical record.",2020-09-01
335,"HAVEN OF SIERRA VISTA, LLC",35086,660 SOUTH CORONADO DRIVE,SIERRA VISTA,AZ,85635,2017-12-16,687,E,0,1,VDR111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff, resident, and family interviews, and review of facility policies and procedures, the facility failed to ensure that one resident (#15) was provided routine podiatry care. Findings include: Resident #15 was admitted on (MONTH) 22, (YEAR) with [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed a physician's orders [REDACTED].as needed. An interview was conducted with a family member of the resident on (MONTH) 14, (YEAR) at 8:43 a.m. The resident's family member stated that the resident's toenails had not been trimmed since she was admitted to the facility. The resident's family member then took the resident's socks off. The resident's toenails were observed to be yellow, thick, and at least 1/4 inch long. The resident's family member then stated that the resident's toenails were yellow and that she thought that meant that the resident had an infection. An interview was conducted with the resident on (MONTH) 14, (YEAR) at 8:43 a.m. The resident stated that there was no one in the facility to trim her toenails. An interview was conducted with a Registered Nurse (staff #76) on (MONTH) 16, (YEAR) at 9:50 a.m. Staff #76 stated that licensed nurses provide routine toenail care for residents as long as there are no contraindications. Staff #76 further stated that she usually trim the residents' toenails some but prefers to wait for the residents to go to a podiatrist to have their toenails trimmed. She stated that she would write a progress note in the resident's clinical record if she had trimmed their toenails. Staff #76 stated that a family member of resident #15 had asked a couple weeks ago for a podiatrist appointment for the resident. Another observation was made of the resident's toenails on (MONTH) 16, (YEAR) at 10:00 a.m. with staff #76. Staff #76 stated that the resident's toenails were pretty long and thick and not something she would attempt to trim. An interview was conducted with the Director of Nursing (staff #46) on (MONTH) 16, (YEAR) at 10:30 a.m. Staff #46 stated that CNAs (certified nursing assistants) should trim the residents' toenails if there are no special podiatry needs but that there was no place for the CNAs to document this. Staff #46 further stated she would have to review the clinical record determine the last time resident #15 had her toenails trimmed. Another interview was conducted with staff #46 on (MONTH) 16, (YEAR) at 12:35 p.m. Staff #46 stated she reviewed the clinical record but was unable to find documentation to determine the last time the resident had her toenails trimmed. Review of the facility's policy Care of Fingernails/Toenails revealed The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infection .Nail care includes daily cleaning and regular trimming .The following information should be recorded in the resident's medical record: 1. The date and time that nails care was given .",2020-09-01
336,"HAVEN OF SIERRA VISTA, LLC",35086,660 SOUTH CORONADO DRIVE,SIERRA VISTA,AZ,85635,2017-12-16,689,E,0,1,VDR111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, staff and resident interviews, and facility policies and procedure, the facility failed to assess and monitor one resident (#20) for accident hazards. Findings include: Resident #20 was admitted on (MONTH) 30, (YEAR), with [DIAGNOSES REDACTED]. The admission nursing assessment dated (MONTH) 2, (YEAR), revealed the resident was not exhibiting wandering and was not at risk for elopement. Review of the nursing notes dated (MONTH) 4, (YEAR), revealed a therapist observed the resident wandering toward the exits. On (MONTH) 4, (YEAR), the resident was moved from one unit of the facility into the secured dementia unit. Review of the nursing notes revealed multiple elopement attempts by the resident. These included: -[DATE], (YEAR), the resident attempted to climb the fence out in the patio at 4:00 p.m. and then again at 5:00 p.m. The resident was easily redirected and returned inside the facility. -[DATE], (YEAR), the resident did not attend activities because she had exit seeking behavior. -[DATE], (YEAR), the resident was exit seeking and was found by a Certified Nursing Assistant (CNA) behind a tree tying to climb the wall. When asked to come down, the resident continued to try to climb the wall. The CNA had to guide the resident off the wall and back inside. -[DATE], (YEAR), the resident went out on the patio and attempted to look over the fence. Later, she went out with a peer and was trying to grab the fence when staff redirected her inside. -[DATE], (YEAR), the resident was found outside in the courtyard attempting to jump the fence. She was able to be redirected without any difficulty. -[DATE], (YEAR), the resident was exit seeking throughout the day. Staff was able to redirect the resident. -[DATE], (YEAR), the resident was found in the courtyard by the back gate trying to get out two times. She was redirected away from the gate. The resident stated that she was trying to leave. Later, she was attempting to enter the code on the keypad to exit through one of the secured doors of the unit. She was redirected with success. -[DATE], (YEAR), the resident was attempting to exit the facility via the courtyard gate. She was also exit seeking at both secured unit doors along with a second resident. She was redirected each time. -[DATE], (YEAR), the resident was found standing on a chair in the television room. A CNA assisted her down and reported the event to the nurse. The resident was educated on safety and danger prevention. -[DATE], (YEAR), the resident was caught exit seeking in the courtyard of the secured unit and was behind a tree attempting to climb the wall. She was redirected back inside and was told to not go outside on her own. The annual Minimum Data Set (MDS) assessment dated (MONTH) 8, (YEAR), revealed the resident scored a 10 on the Brief Interview for Mental Status (BIMS) which indicated the resident had moderate cognitive impairment. The resident was coded to be able to walk in her room and the corridor independently. Review of the resident's care plan revealed the resident was at risk for falls related to her diminished safety awareness. An intervention for this care plan included that the resident needs a safe environment. Further review of the care plan revealed no information regarding the resident's wandering or elopement risk. Review of the (MONTH) (YEAR), recapitulation of the physician's orders [REDACTED]. The clinical record was reviewed and there was no evidence that an assessment had been completed regarding the resident's elopement/wandering status. Review of facility documentation dated (MONTH) 17, (YEAR), revealed a work order for the alarm on the back door to the patio and that new batteries were placed in the alarm. During an interview conducted on (MONTH) 16, (YEAR) at 9:30 a.m. with resident #20, the resident stated that she tries to get out of the facility at times and that she is still trying to get out. She stated she would go outside from time to time to the patio and that there is no alarm on the door. During an interview conducted (MONTH) 16, (YEAR) at 9:40 a.m. with a Licensed Practical Nurse (staff #64), staff #64 stated that she knew about resident #20's attempts to leave the facility, but that she had never witnessed any attempts. She stated that staff monitors the resident and that the resident has a wander guard that would sound if she attempted to exit the unit's main doors but not the door leading to the patio. Staff #64 stated the resident had tried to learn the main door's code but that the door code has been changed from time to time. She stated the door that leads to the patio used to have an alarm that would sound however, the door alarm has not worked for a few months. Staff #64 further stated that although the resident is independent with ambulation, she did not believe the resident would be able to climb the wall. An interview was conducted (MONTH) 16, (YEAR) at 10:00 a.m. with a CNA (staff #38). Staff #38 stated she knew about resident #20's attempts to elope from the facility, but that she had not witnessed any elopement attempts. She stated the resident keeps her eyes on the door, but that the resident is easily redirected. Staff #38 stated she did not know about the resident's care plan, but that she is informed about the resident's needs through communication with other staff. Staff #38 further stated that she knew the patio door was no longer alarming when opened but could not state how long the door had not been alarming. An observation was conducted on (MONTH) 16, (YEAR) at 10:30 a.m., of the patio outside of the secured dementia unit. There was a door that lead from inside to the patio. On the door was a motion alarm but when the door was opened, the alarm did not sound even though it was set to alarm. When the alarm was reset, it still did not alarm. Out on the patio, multiple chairs were noted. Two large trees were noted on the patio and there was an area behind one of them that was not visible from the inside. The patio extended around the side of the building and lead to a gate. The area around the gate was not visible from the inside of the building. During an interview with the maintenance director (staff #81) at 11:00 a.m. on (MONTH) 16, (YEAR), he stated that he checks all exit doors to the facility at least weekly, but that he does not check the alarm on the door to the patio in the secured unit because it leads to a secured area and is not considered an exit. Staff #81 stated he had replaced the batteries on this alarm and that staff are good about notifying him when the batteries have died . Staff #81 further stated that he did not have a current work order for the alarm. An observation of the resident was conducted on (MONTH) 16, (YEAR) at 1:20 p.m. The resident was ambulating in the unit on her own. She was noted to have a wander guard anklet on her left ankle. The resident's room was directly next to a second exit that leads to the patio by a gate that is not visible from the inside. The door's sign revealed the door must be pushed for 15 seconds and then an alarm would go off. An interview was conducted (MONTH) 16, (YEAR) at 2:00 p.m. with the Director of Nursing (staff #46). Staff #46 stated when a resident is assessed to be at risk for elopement, an elopement risk assessment is completed. She stated that if a resident has had episodes of elopement or is at risk for elopement, it should be on the care plan with interventions. Staff #46 stated some staff are not reviewing the care plans which is an ongoing educational topic. Staff #46 further stated there should be an order for [REDACTED].#46 further stated there was no documentation regarding the placement of the wander guard. She stated they have no specific policy regarding wander guards. The policy Wandering, Unsafe Resident included the facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. The policy also included the staff will assess at-risk residents for potentially correctable risk factors related to unsafe wandering. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. The policy Safety and Supervision of Residents included the interdisciplinary team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. The policy further included the effectiveness of the interventions will be monitored to ensure they are implemented correctly and consistently.",2020-09-01
337,CAMELBACK POST ACUTE AND REHABILITATION,35088,4635 NORTH 14TH STREET,PHOENIX,AZ,85014,2017-03-10,250,D,0,1,MBR211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, and policy review, the facility failed to provide medically related social services timely in assisting one resident (#46) with obtaining a new motorized scooter. Findings include: Resident #46 was admitted on (MONTH) 21, 2013, with [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment dated (MONTH) 28, (YEAR), documented the resident had been assessed with [REDACTED]. The MDS further documented that the resident was totally dependent on two or more staff for transfers and needed supervision of one person with locomotion on the unit and two persons with locomotion off the unit. The MDS also noted that the resident used a wheelchair (manual or electric) for mobility. On (MONTH) 8, (YEAR) at 8:00 a.m., an interview was conducted with resident #46. The resident stated that her power scooter has been broken and needed to be replaced. She stated that she had asked the facility to assist her in getting the paperwork completed and submitting it to the medical equipment provider. The resident stated that she had spoken to the facility case manager, who told her that the paperwork had gotten lost. The resident stated she felt like the facility was not doing anything to help her get her power scooter replaced. An interview was conducted on (MONTH) 8, (YEAR) at 8:30 a.m., with the case manager (LPN/licensed practical nurse/staff #75). Staff #75 stated that the social worker came to her for assistance with the paperwork regarding resident #46's power scooter and the social worker asked her to obtain an order from the resident's physician and obtain additional paperwork required by the medical equipment provider. Staff #75 stated she gave the physician the paperwork, but the physician did not complete the letter of medical justification. Staff #75 thinks this occurred sometime in (MONTH) (YEAR). After not getting a response from the resident's physician, staff #75 stated she forwarded the request to the resident's Nurse Practitioner (NP) about two or more weeks ago. Staff #75 was not sure of the current status of the situation and stated the social worker may have additional information. On (MONTH) 8, (YEAR) at 8:40 a.m., an interview was conducted with the Social Services Director (staff #105). Staff #105 stated that she had received the paperwork from the medical equipment provider. Staff #105 provided a copy of a fax from the medical provider dated (MONTH) 16, (YEAR), requesting supporting documentation from the resident's physician. Staff #105 stated that she understood the resident's physician had signed the order for the power scooter, but did not complete the requested information, so she gave the paperwork to the NP. Staff #105 had no further information regarding where the paperwork was. An interview was conducted with the Administrator (staff #112) on (MONTH) 8, (YEAR) at 10:00 a.m. Staff #112 stated that he understood the resident had independently initiated the replacement of her power scooter sometime in (MONTH) (YEAR). He said that on (MONTH) 11, (YEAR), while the resident was out in the community in her old power scooter, the facility got a call from the resident stating that her power scooter had died and she was stuck. Staff #112 stated that he and maintenance staff picked up the resident and her broken power scooter. Staff #112 stated the resident told him that she was working on getting a new scooter and was waiting for a letter from her physician. He said on (MONTH) 31, (YEAR), the resident filed a grievance. At this time, the grievance dated (MONTH) 31, (YEAR) was reviewed. Per the documentation, the resident's concern was regarding a delay in the process of getting her power scooter. The documentation included that staff #112 had spoken to staff #75 and that a letter still needed to be obtained from the physician, and that on (MONTH) 15, (YEAR), the paperwork had been given to the NP. Staff #112 provided a copy of an email dated (MONTH) 24, (YEAR), between the facility and the NP. The email documented that the NP had just gotten back from out of town and would get to the paperwork sometime in (MONTH) (YEAR). Staff #112 stated that nothing more had been done since (MONTH) 24, (YEAR). When asked if he had contacted the facility's Medical Director for assistance, staff #112 stated he had not thought about doing that. According to the Social Worker job description, the social worker is to participate in community planning related to the services and needs of the resident. A review of the Social Services policy revealed to provide all medically related social services functions, as defined by State, Federal, and local regulatory agencies. The policy included the purpose of the Social Services Department is to promote the optimal psychological well-being of each resident. The department staff develops and provides services targeted at assisting residents.",2020-09-01
338,CAMELBACK POST ACUTE AND REHABILITATION,35088,4635 NORTH 14TH STREET,PHOENIX,AZ,85014,2017-03-10,252,B,0,1,MBR211,"Based on observations, staff interviews and policy review, the facility failed to maintain a homelike environment, by storing mechanical lifts in the northeast dining room and by having dining room tables, without any table coverings. Findings include: Observations were conducted of the facility's main dining room on (MONTH) 6, (YEAR) at approximately 11:15 a.m. At this time, there were multiple resident's who were seated at the dining room tables. Further observations revealed that the dining room tables had cloth table coverings on them. It was also observed that there were no mechanical lifts being stored in this dining room. At 11:30 a.m. on (MONTH) 6, (YEAR), an observation was conducted of the dining room on the long term care unit (northeast dining room) and multiple residents were seated at the tables. Additional observations revealed that the dining room tables were bare of any table coverings and there were two mechanical lifts stored in the northwest corner of the dining area. Another observation was conducted on the long term care dining room on (MONTH) 7, (YEAR) at 11:30 a.m., during the noon meal and multiple residents were observed to be seated at tables. Again, the tables were bare of any table coverings. Also, there were two mechanical lifts which were being stored in the northwest corner of the dining area. An interview was conducted with a LPN (licensed practical nurse/staff #61) on (MONTH) 7, (YEAR) at 11:35 a.m. Staff #61 stated that the mechanical lifts were usually stored in the dining room and didn't know why. Staff #61 stated she did not recall ever seeing table cloths on the tables in the northeast dining room. Following this, an interview was conducted with the Director of Nursing (DON/staff #113), who stated that she thought the mechanical lifts were usually stored in the hallways. Staff #113 stated the dining room with no table coverings and having mechanical lifts stored in the dining room was not a very homelike environment for the residents, while eating their meals. A review of the facility policy regarding provision of a homelike environment revealed to encourage and provide areas that reflect a homelike environment.",2020-09-01
339,CAMELBACK POST ACUTE AND REHABILITATION,35088,4635 NORTH 14TH STREET,PHOENIX,AZ,85014,2017-03-10,253,E,0,1,MBR211,"Based on observations, staff interviews, facility documentation and policy review, the facility failed to ensure resident equipment was maintained in a sanitary manner. Findings include: During the initial facility tour conducted on (MONTH) 6, (YEAR) at 10:00 a.m., the Hoyer lift in the 200 hall was observed to have a black dirt like substance and dried liquids on the base of the lift. A second observation of the same Hoyer lift was conducted on (MONTH) 7, (YEAR) at 11:30 a.m. The lift was observed to be in the northeast dining room. The black dirt and dried liquids were still present on the base of the lift. A third observation of the same Hoyer lift was conducted on (MONTH) 8, (YEAR) at 1:34 p.m., as the lift was being removed from a resident room. The lift continued to have black dirt and dried liquids at the base. During this observation, the Director of Nursing (DON/staff #113) was also present. The DON stated she was not sure who was supposed to clean the lifts and with what frequency the equipment is cleaned. She stated she thought housekeeping might be responsible for cleaning. In an interview conducted with the Director of Facilities/Housekeeping (staff #77) on (MONTH) 9, (YEAR) at 12:35 p.m., the Director stated that he saw how dirty the Hoyer lifts were yesterday and that the lifts are on a monthly cleaning schedule. He further stated that after seeing how dirty the lifts were, the monthly cleaning was not enough and the lifts should be cleaned at least weekly. Review of the Hoyer cleaning schedules for (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR), revealed the Hoyer lifts were inspected for safety, oiled/lubricated and were cleaned once each month. Review of the facility policy titled, General Cleaning and Maintenance of Equipment revealed that all resident care equipment will be cleaned and decontaminated after use and will be prepared for reuse.",2020-09-01
340,CAMELBACK POST ACUTE AND REHABILITATION,35088,4635 NORTH 14TH STREET,PHOENIX,AZ,85014,2017-03-10,278,D,0,1,MBR211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interviews and policy review, the facility failed to ensure a Minimum Data Set (MDS) assessment accurately reflected one resident's (#136) status. Findings include: Resident #136 was admitted to the facility on (MONTH) 6, (YEAR), with a readmitted (MONTH) 21, (YEAR). [DIAGNOSES REDACTED]. Review of the clinical record revealed that the resident has been a quadriplegic for [AGE] years. Review of the annual MDS assessment dated (MONTH) 9, (YEAR) revealed in Section [NAME] Functional Assessment, that the resident required extensive assistance with transfers. Per the MDS, extensive assistance included that the resident is involved in the activity and staff provide weight-bearing support. Review of the Activities of Daily Living (ADLs) documentation completed by the CNA's for the 7-day look back period of the MDS, revealed that on one occasion on (MONTH) 5, and on two occasions on (MONTH) 6, the resident required extensive assistance with transfers. Review of the quarterly MDS assessment dated (MONTH) 9, (YEAR) revealed in Section [NAME] Functional Assessment, that the resident required total dependence with transfers, which included full staff performance every time during the entire 7-day period. Review of the ADL documentation during the 7-day look back period for the quarterly MDS, revealed that on four occasions, the resident required extensive assistance with transfers. On multiple occasions during the survey, resident #136 was observed being provided care and having individual activities in his room. The resident was not able to lift his body or move his lower extremities. In an interview conducted with a CNA (staff #38) on (MONTH) 8, (YEAR) at 8:25 a.m., the CNA stated that resident #136 required the use of a Hoyer lift for transfers every time, so he is considered to be totally dependent. She further stated that she had never known him to be extensive assistance for transfers, because of having [MEDICAL CONDITION]. In an interview conducted with a CNA (staff #22) on (MONTH) 8, (YEAR) at 8:31 a.m., staff #22 stated that resident #136 requires total dependence and would never be considered extensive assistance, due to his condition. In an interview conducted with the MDS nurse (licensed practical nurse/staff #78) on (MONTH) 8, (YEAR) at 8:33 a.m., staff #78 stated when she completes an MDS assessment she looks at the data over the past 7 days from the therapy notes, nurses notes, ADL documentation and interviews the residents and staff. Staff #78 stated that if there is a discrepancy, she talks with the CNA's and if documentation is not correct, she will bring it to the attention of the Director of Nursing for a determination on whether or not it should be changed. The MDS nurse stated she would never consider this resident to be extensive assistance with transfers. She stated the information from the MDS is then used to formulate topics for the care plan. An interview was conducted on (MONTH) 8, (YEAR) at 10:19 a.m., with the Director of Nursing (DON/staff #113) and the Corporate Resource Nurse (registered nurse/staff #111). The DON and RN stated the MDS nurse's work with the corporate MDS resource and discuss the MDS assessments to ensure they are correct. They stated that if there is incorrect documentation in an area, the MDS nurse can observe and/or assess the resident and interview staff and if a correction is needed, the MDS nurse will write a note and code the MDS differently than the documentation indicated. The facility policy titled, Accuracy of Assessment (MDS 3.0) included to ensure that the assessment accurately reflects the resident's status. The policy also indicated the physical, mental and psychosocial condition of the resident determines the appropriate level of involvement of care givers.",2020-09-01
341,CAMELBACK POST ACUTE AND REHABILITATION,35088,4635 NORTH 14TH STREET,PHOENIX,AZ,85014,2017-03-10,281,D,0,1,MBR211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff and resident interviews, and policy and procedures, the facility failed to ensure that a [MEDICAL CONDITION] medication was administered timely for one resident (#265), and failed to ensure that treatments were administered as ordered for one resident (#263). Findings include: -Resident #265 was admitted on (MONTH) 1, (YEAR) for surgical aftercare. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A care plan to address the resident's [MEDICAL CONDITION] was developed on (MONTH) 3, (YEAR) and included as an intervention to administer the [MEDICAL CONDITION] medication, as ordered by the physician. Review of the (MONTH) (YEAR) MAR (Medication Administration Record) revealed the [MEDICATION NAME] was scheduled to be administered at 8:00 a.m. and at 4:00 p.m. According to the documentation, the [MEDICATION NAME] was administered on (MONTH) 8, at 8:00 a.m. However, during an interview with resident #265 conducted on (MONTH) 8, (YEAR) at 11:00 a.m., the resident stated that he had not received his [MEDICAL CONDITION] medication ([MEDICATION NAME]) until almost 11:00 a.m. today. Resident #265 stated that he was suppose to have his [MEDICAL CONDITION] medication at 8:00 a.m. and at 4:00 p.m., and that his medications were sometimes administered late. Immediately following, an interview was conducted with a LPN (Licensed Practical Nurse/staff #70), who confirmed that the [MEDICATION NAME] was suppose to be administered at 8:00 a.m. and at 4:00 p.m. Although the MAR indicated [REDACTED]. According to staff #70, she had not informed any other staff that she needed help to ensure the resident's medications were administered timely. An interview was conducted with Clinical Resource staff (staff #114), who stated that the LPN (staff #70) could have requested assistance, so that the medications were not administered late. Staff #114 confirmed that medications were to be administered one hour prior or one hour after their scheduled times. A facility policy titled, Medication Administration included the following: 5. Scheduled medications must be administered within the facility time frame. (The specific time frame was not documented.) 7. If a medication is withheld, refused or given other than at the scheduled time, the documentation will be reflected in the clinical record. -Resident #263 was admitted on (MONTH) 17, (YEAR), and discharged on (MONTH) 25, (YEAR), against medical advice. [DIAGNOSES REDACTED]. The admission nursing note and the initial admission assessment dated (MONTH) 17, (YEAR), included that the resident had wounds to the left lower leg. The admission nursing note also included that per the hospital, the resident's wounds were caused by Silvadine cream which the resident had a reaction to, causing blisters to form. A continued review of the clinical record revealed that the resident had venous stasis and arterial ulcers on the left lower leg. On (MONTH) 26, (YEAR), a physician's orders [REDACTED]. The treatment was to be administered daily and prn (as needed). However, a review of the (MONTH) (YEAR) wound team administration record revealed no documented evidence that the prescribed treatment had been administered on (MONTH) 28. On (MONTH) 14, (YEAR), a physician's orders [REDACTED]. Change the dressing daily and prn. However, a review of the (MONTH) (YEAR) wound team administration record revealed that the prescribed treatment had not been administered until (MONTH) 16, which was two days after the physician's orders [REDACTED].>An interview was conducted on (MONTH) 8, (YEAR) at 8:15 a.m., with Corporate Resource staff (staff #114). Following a review and comparison of the physician's orders [REDACTED]. An interview was conducted on (MONTH) 8, (YEAR) at 9:20 a.m., with the wound nurse (registered nurse/staff #110). She stated that she worked Monday through Friday and that she was responsible to administer the prescribed treatments during that time frame. Staff #110 also stated that either the admission nurse or the floor nurses were responsible to administer the physician ordered treatments on the weekends and whenever she was not in the facility. Following a review of the (YEAR) calendar, staff #110 was unable to explain why the prescribed treatment was not administered on (MONTH) 15, which was a Tuesday. A facility policy titled, Medication Administration included It is the policy of this facility that medications shall be administered as prescribed by the attending physician.",2020-09-01
342,CAMELBACK POST ACUTE AND REHABILITATION,35088,4635 NORTH 14TH STREET,PHOENIX,AZ,85014,2017-03-10,312,D,0,1,MBR211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews and policy review, the facility failed to ensure one resident (#1) received adequate showers. Findings include: Resident #1 was admitted on (MONTH) 1, 2000, with [DIAGNOSES REDACTED]. An annual MDS (Minimum Data Set) assessment dated (MONTH) 8, (YEAR), assessed the resident to have a BIMS (brief interview for mental status) score of 15, which indicated the resident was cognitively intact. The MDS further documented that the resident required total assistance of two or more staff with transfers and total assistance of one staff for bathing. On (MONTH) 7, (YEAR) at 2:40 p.m., resident #1 stated that in (MONTH) (YEAR), he was not receiving two showers per week as scheduled on the p.m. shift. Resident #1 stated that the facility was short-staffed and he just didn't get his showers. A review of the resident's clinical record revealed documentation of the resident's showers. The documentation showed that from (MONTH) 10 through 21, (YEAR) (12 days), the resident had only received two showers. On (MONTH) 7, (YEAR) at 2:45 p.m., an interview was conducted with a CNA (Certified Nursing Assistant/staff #8), who provided cares to resident #1, including showers. Staff #8 stated that the resident is scheduled for two showers per week, on Tuesdays and Fridays during the p.m. shift. Staff #8 stated that resident #1 needs two staff for the mechanical lift transfers, and that there just wasn't enough staff. Staff #8 stated that they try to give the resident at least one shower per week. A review of the facility's policy regarding the provision of ADL (activities of daily living) care revealed that residents would be offered bathing at least twice per week, and as requested.",2020-09-01
343,CAMELBACK POST ACUTE AND REHABILITATION,35088,4635 NORTH 14TH STREET,PHOENIX,AZ,85014,2017-03-10,314,G,0,1,MBR211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record reviews, staff interviews and policy review, the facility failed to ensure that pressure ulcer care and services were provided for two residents (#'s 236 and 251). Findings include: -Resident #236 was admitted to the facility on (MONTH) 10, (YEAR), with [DIAGNOSES REDACTED]. The resident was discharged on (MONTH) 3, (YEAR). The initial admission assessment documentation dated (MONTH) 10, (YEAR) indicated the resident had a Stage 1 pressure ulcer on/off to the sacrum. No measurements or a description of the area was documented. There was no documentation of any other pressure ulcers present on admission. The initial Braden Pressure Ulcer Risk assessment dated (MONTH) 10, (YEAR) indicated the resident was at moderate risk for the development of pressure ulcers. Review of the clinical record revealed there were no treatment orders for the Stage 1 pressure ulcer to the sacrum at this time. A pressure ulcer care plan developed on (MONTH) 11, (YEAR) included the resident had pressure ulcers, due to immobility. Interventions included to administer medications as ordered and to monitor for side effects and effectiveness, and to administer treatments as ordered and monitor for effectiveness. However, the care plan did not include any interventions related to the prevention of pressure ulcer development. A physician's order was obtained on (MONTH) 13, (YEAR), which was three days after admission. The order included to cleanse the resident's bilateral buttocks area with soap and water each shift and as needed and apply barrier cream, as a preventative measure. The admission Minimum Data Set (MDS) assessment dated (MONTH) 17, (YEAR) revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS included that the resident required extensive assistance of one person for all activities of daily living, except eating for which she required supervision. The MDS further included that the resident had only one Stage 1 pressure ulcer and was receiving pressure ulcer care. A physician's order dated (MONTH) 17, (YEAR) included for a Braden Scale risk assessment to be completed weekly for 4 weeks. A Braden Pressure Ulcer Risk assessment completed on (MONTH) 17, (YEAR) identified the resident was at low risk for the development of pressure ulcers. A wound physician's note dated (MONTH) 17, (YEAR) indicated that in addition to wounds #1, #2, and #3 which were surgical wounds, the resident had a wound to the left ischial area (wound #4). The wound was described as a Stage 3 pressure ulcer which measured 2.5 cm x 1.5 cm x 0.2 cm, with a scant amount of drainage. The wound was identified as having 1-25% [MEDICATION NAME], 51-75% pink granulation and was improving. The note further included the resident had a medial sacral Stage 3 pressure ulcer (wound #5), which measured 7.5 cm x 3 cm x 0.2 cm. The wound was described as having 1-25% [MEDICATION NAME] and 51-75% pink granulation tissue, with a small amount of serosanguinous drainage The plan included to apply calcium alginate to wounds #4 and #5 and cover with a dry protective dressing daily, to reposition the resident per facility protocol, and for an offloading mattress. The note included that the plan of care was discussed with the nursing staff and resident. However, further review of the clinical record revealed there was no physician's order for the calcium alginate to be applied to wounds #4 and #5, as per the physician's note. Review of the initial Skin Pressure Ulcer Weekly documentation dated (MONTH) 19, (YEAR) revealed the resident had two pressure ulcers. One wound was noted to be on the left gluteal fold (wound #4) and was identified as a Stage 3 which was present on admission, with an unknown date of onset and measured 2.5 cm x 1.5 cm x 0.2 cm. The wound was described as having 25% [MEDICATION NAME] and 75% granulation tissue, with scant serosanguinous drainage. The second wound was described as a Stage 3 pressure ulcer to the sacrum (wound #5) which was present on admission, with an unknown date of onset and measured 7.5 cm x 3 cm. The wound was described as having 25% [MEDICATION NAME] and 75% granulation tissue, with a small amount of serosanguinous drainage. However, per the initial admission assessment and the MDS dated (MONTH) 17, the resident only had one Stage 1 pressure ulcer present upon admission. A physician's treatment order was obtained on (MONTH) 19, (YEAR), which was two days after the resident was identified to have two Stage 3 pressure ulcers. The order included to cleanse the sacrum and ischial wounds with wound cleanser or normal saline, pat dry, apply calcium alginate, cover with a dressing daily and as needed for soilage or dislodgment. Further review of the pressure ulcer care plan revealed it had not been revised to include the physician's recommendations (from the (MONTH) 17 physician's note) for an off-loading mattress and to reposition the resident per facility protocol. A wound physician's note dated (MONTH) 24, (YEAR) indicated wound #4 was described as a left ischial Stage 3 pressure ulcer which measured 2.2 cm x 0.8 cm x 0.1 cm, with a small amount of drainage. The wound was identified as having 1-25% [MEDICATION NAME], 51-75% pink granulation tissue and was described as improving. Wound #5 was described as a medial sacral Stage 3 pressure ulcer which measured 4.2 cm x 3 cm x 0.1 cm. The wound was described as having 1-25% [MEDICATION NAME], 51-75% pink granulation tissue, with a small amount of serosanguinous drainage and was improving. The plan included the following: apply calcium alginate to wounds #4 and #5 and cover with a dry protective dressing daily; reposition the resident per facility protocol; and use an offloading mattress. The note further included that the plan of care was discussed with the nursing staff and resident. A Braden Pressure Ulcer Risk assessment completed on (MONTH) 25, (YEAR) identified the resident was at low risk for the development of pressure ulcers. A physician's order dated (MONTH) 25, (YEAR) included to cleanse the sacral wound and the left ischial wound, pat dry and apply calcium alginate and cover with a dressing every Tuesday, Thursday and Saturday and as needed. Review of a wound physician's note dated (MONTH) 26, (YEAR) revealed that wound #4 to the left ischial area was a Stage 3 pressure ulcer which measured 7 cm x 1.7 cm x 0.1 cm. The wound was described as having 1-25% [MEDICATION NAME] and 51-75% pink granulation tissue, with a small amount of drainage and was improving. Wound #5 was described as a Stage 3 pressure ulcer to the medial sacral area, which measured 4.5 cm x 3.5 cm. The wound was described as having 1-25% [MEDICATION NAME] and 51-75% pink granulation tissue, with a small amount of serosanguinous drainage. The plan included to reposition the resident per facility protocol and use an offloading mattress. No change was noted and the plan remained unchanged. A Braden Pressure Ulcer Risk assessment completed on (MONTH) 31, (YEAR) identified the resident was at low risk for the development of pressure ulcers. A wound physician's note dated (MONTH) 31, (YEAR) indicated wound #4 to the left ischial area was a Stage 3 pressure ulcer which measured 0.6 cm x 1.5 cm x 0.1 cm. The wound was described as having 1-25% [MEDICATION NAME], 51-75% pink granulation tissue, with a small amount of drainage and was improving. Wound #5 was described as a Stage 3 pressure ulcer to the medial sacral area which measured 4.7 cm x 4 cm 0.1 cm. The wound was described as having 1-25% [MEDICATION NAME] and 51-75% pink granulation tissue, with a moderate amount of serosanguinous drainage. The plan included to reposition the resident per facility protocol and use an offloading mattress. No change was noted and the plan remained unchanged. Review of the Skin Pressure Ulcer Weekly documentation dated (MONTH) 1, (YEAR) revealed the Stage 3 pressure ulcer to the left gluteal fold (wound #4) measured 0.6 cm x 1.5 cm x 0.3 cm and was described as having 25% [MEDICATION NAME] and 75% granulation tissue, with a small amount of serosanguinous drainage. The pressure ulcer to the sacrum area (wound #5) was described as a Stage 3 and measured 4.7 cm x 4 cm x 0.1 cm and had 25% [MEDICATION NAME] and 75% granulation tissue, with a moderate amount of serous drainage. A physician's order dated (MONTH) 2, (YEAR) included to cleanse the bilateral buttocks with warm, soapy water and pat dry, and apply barrier cream for prevention measures and after incontinent episodes. A physician's order dated (MONTH) 3, (YEAR) included to cleanse the sacral wound and the left ischial wound, pat dry, apply calcium alginate and a dressing every day and as needed. A Braden Pressure Ulcer Risk assessment completed on (MONTH) 7, (YEAR) identified the resident was at low risk for the development of pressure ulcers. Review of the Skin Pressure Ulcer Weekly documentation dated (MONTH) 7, (YEAR) revealed the left gluteal fold Stage 3 pressure ulcer (wound #4) measured 0.7 cm x 1.2 cm x 0.3 cm. The wound was described as having 25% [MEDICATION NAME] and 75% granulation tissue, with a small amount of serous drainage. The Stage 3 pressure ulcer to the sacrum (wound #5) measured 5.0 cm x 5.3 cm and was described as having 50% [MEDICATION NAME] and 50% granulation tissue, with a small amount of serous drainage. A Braden Pressure Ulcer Risk assessment completed on (MONTH) 14, (YEAR) identified the resident was at low risk for the development of pressure ulcers. Review of the Skin Pressure Ulcer Weekly documentation dated (MONTH) 14, (YEAR) indicated the left gluteal fold wound (#4) was resolved. The Stage 3 pressure ulcer to the sacrum (wound #5) measured 3.6 cm x 4.2 cm and had 50% [MEDICATION NAME] and 50% granulation tissue, with a small amount of serous drainage. Review of the Skin Pressure Ulcer Weekly documentation dated (MONTH) 21, (YEAR) revealed the Stage 3 pressure ulcer to the sacrum (wound #5) measured 2 cm x 3.1 cm x 0.1 cm and had 50% [MEDICATION NAME] and 50% granulation tissue, with a small amount of serous drainage. Review of the Skin Pressure Ulcer Weekly documentation dated (MONTH) 28, (YEAR) revealed the sacrum pressure ulcer (wound #5) was a Stage 3 and measured 2 cm x 3.1 cm x 0.1 cm. The wound was described as having 50% [MEDICATION NAME] and 50% granulation tissue, with a small amount of serous drainage. Continued review of the pressure ulcer care plan revealed it was not revised to reflect the ongoing recommendations from the wound physician notes regarding the need for an off-loading mattress and repositioning the resident per facility protocol. The care plan was also not revised to reflect any additional interventions related to the resident having two Stage 3 pressure ulcers. In an interview with a Certified Nursing Assistant (CNA/staff #36) on (MONTH) 10, (YEAR) at 9:21 a.m., the CNA stated that the information about a resident's positioning needs and how to transfer a resident, are included on the Kardex and the care plan. Staff #36 stated that they also receive this information in report during shift change. An interview was conducted on (MONTH) 10, (YEAR) at 10:59 a.m., with the Licensed Practical Nurse (previous wound nurse during resident #236's stay and who is currently in another position/staff #78). Staff #78 stated when a resident is admitted to the facility with a wound, the wound nurse will see the resident within 72 hours. However, staff #78 further stated that they did not see this resident on admission so she cannot speak to what the resident's wounds were like on admission. Staff #78 stated she did not know if the policy included how frequently a wound should be assessed. Staff #78 stated that wound care and preventive interventions needed are to be added to the care plan and if there are changes or new interventions, the care plan should be revised. An interview was conducted on (MONTH) 10, (YEAR) at 11:03 a.m., with a Corporate Resource Nurse/Registered Nurse (RN/staff #111) and the Director of Nursing (staff #113). The Corporate Nurse stated that the care plan should include all interventions for the prevention of pressure ulcers, but there was nothing added to this one. The Corporate Nurse also stated that the care plan should have been revised when the resident pressure ulcers worsened and the new one developed. She also stated that all the mattresses in the facility are off-loading mattresses. -Resident #251 was admitted on (MONTH) 10, (YEAR), with [DIAGNOSES REDACTED]. The initial admission record documentation dated (MONTH) 10, (YEAR), included the resident had a stage 1 pressure ulcer on the left heel, which measured 1 by 1 cm (centimeter). This record did not include any documentation of a pressure ulcer on the resident's right buttocks. Review of a Skin Pressure Ulcer Weekly report dated (MONTH) 10, (YEAR) revealed the resident had a SDTI (Suspected Deep Tissue Injury) on the right buttock, which measured 5 by 3 cm (centimeters). Per the report, the wound bed was beefy red, edges were well defined and had no exudate or odor. However, the comment section of this report included that the SDTI was on the left buttock. The documentation also included that a treatment had been completed. The assessment did not include any documentation regarding the stage 1 pressure ulcer on the resident's left heel. A pressure ulcer care plan was developed on (MONTH) 13, (YEAR), which identified that a SDTI was present on the resident's right buttock. The care plan included as an intervention to administer treatments as ordered. The care plan did not include the resident had a pressure ulcer to the left heel. Review of the clinical record revealed there were no wound treatment orders upon admission for the stage 1 pressure ulcer to the left heel, nor for the SDTI to the buttocks. The initial Braden Risk assessment dated (MONTH) 17, (YEAR), identified the resident was at moderate risk for the development of pressure ulcers. The admission MDS (Minimum Data Set) assessment dated (MONTH) 17, (YEAR), included the resident had a BIMS (Brief Interview for Mental Status) score of 6, which indicated severe cognitive impairment. The MDS included that the resident required extensive assistance for activities of daily living, except for eating, for which he only required supervision. The MDS also included that a stage 2 pressure ulcer was present. Review of the Skin Pressure Ulcer Weekly report dated (MONTH) 17, (YEAR), revealed the resident had a SDTI to the right buttocks, which measured 5 by 3 cm, no odor or exudate was present, and the wound edges were well defined. The assessment did not include any documentation regarding the status of the wound bed. The documentation also included that a treatment was completed. However, further review of the clinical record revealed there were no physician ordered treatments for the buttocks pressure ulcer at this time. Another Skin Pressure Ulcer Weekly report dated (MONTH) 20, (YEAR), included the right buttocks was a stage 2, which measured 3.5 by 1 by 0.1 cm. The wound was described as having 100% granulation tissue with well defined edges, and a scant amount of serous exudate with no odor. The comment section of this report included that the resident had a SDTI upon admission, which had opened and was now a stage 2 pressure ulcer. The documentation further included that a treatment was completed. There was no documentation regarding the condition of the resident's left heel. Continued review of the clinical record revealed that a treatment order was not obtained until (MONTH) 23, (YEAR), which was 13 days after the SDTI was first identified upon admission. The prescribed treatment included to cleanse the bilateral buttocks with warm, soapy water, pat dry and apply Barrier cream every shift. The orders also included for a low air mattress. According to the (MONTH) (YEAR) TAR (Treatment Administration Record), there was no documentation that the treatment to the buttock area had been administered on (MONTH) 3. Review of the Skin Pressure Ulcer Weekly report dated (MONTH) 3, (YEAR), revealed a stage 2 on the resident's right buttock. A pressure ulcer treatment observation was conducted on (MONTH) 8, (YEAR) at 12:58 p.m., with the wound nurse (staff #74). At this time, a stage 2 pressure ulcer was observed on the resident's right buttock. The wound measured 0.7 by 0.4 cm, with a small scab in the center, with no odor or drainage present. An interview was conducted on (MONTH) 8, (YEAR) at 10:58 a.m., with Corporate Resource staff (staff #115), who stated that the stage 1 pressure ulcer on the left heel may have been resolved and therefore, no treatment would have been required. Staff #115 acknowledged that the clinical record lacked documentation regarding the stage 1 pressure ulcer on the resident's left heel. Staff #115 also stated the documentation that the treatment was completed could refer to the CNA's (Certified Nursing Assistant) having applied Barrier cream after an incontinent episode, but the documentation was not clear or specific as to what treatment had been administered. Staff #111 further stated that pressure ulcer treatment orders should have been obtained and that there was a delay in treatment. Staff #111 stated that prescribed treatments should have been administered and documented. An interview was conducted on (MONTH) 9, (YEAR) at 11:35 a.m., with the DON (Director of Nursing/staff #113). She stated the facility did not utilize standing orders for pressure ulcers and that resident specific physician orders needed to be obtained. Staff #113 stated that based on the documentation, the physician was not promptly notified of a change in the resident's pressure ulcer status from a SDTI to a stage 2 pressure ulcer. Staff #113 stated that treatments should have been implemented and documented. She also acknowledged that there had been a delay in treatment. Review of the Wound Management policy revealed that a resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the individual's clinical condition or other factors demonstrate that a developed pressure ulcer was unavoidable and that a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection and prevent new, avoidable sores from developing. The policy included to promote the prevention of pressure ulcer development, promote the healing of pressure ulcers that are present and prevent the development of additional pressure ulcers. The nurse responsible for assessing and evaluating the resident's condition on admission and readmission is expected to take the following actions: complete the comprehensive admission assessment and Braden Scale to identify risk and to identify any alterations in skin integrity noted at that time; develop a comprehensive care plan following the assessment, and that care plans must be individualized and designed to meet the needs of the resident. The policy further noted that once a wound has been identified, assessed and documented, nursing shall administer treatment to each affected area as per the physician's order; and that all wound treatments should be documented in the resident's clinical record at the time they are administered. The policy further included that in order to prevent the development of skin breakdown or prevent existing pressure ulcers from worsening, nursing staff shall implement the following approaches as appropriate and consistent with the resident's plan of care: stabilize, reduce or remove any existing underlying risks, monitor impact of interventions and modify interventions as appropriate based on changes in condition; reposition the resident; use pressure relieving/reducing and redistributing devices (including but not limited to low air loss mattresses, wedges, pillows etc.); and use transfer techniques which minimize friction and skin tears. The policy also stated to Review and/or re-evaluate existing treatment regimen in connection with the resident's clinical presentation, to include current interventions and care plan considerations, if any wound is non-healing or not showing signs of improvement after a given time or any time a wound is worsening. Review of the Care Planning policy revealed that the resident's plan of care - focus, goals, and interventions are communicated and implemented. The resident's plan of care is reviewed and revised on an ongoing basis, quarterly at a minimum and/or as needed with changes in condition.",2020-09-01
344,CAMELBACK POST ACUTE AND REHABILITATION,35088,4635 NORTH 14TH STREET,PHOENIX,AZ,85014,2017-03-10,323,E,0,1,MBR211,"Based on observations and staff interviews, the facility failed to ensure the resident environment was free of accident hazards, by failing to ensure multiple wooden handrails were free from splintering. Findings include: During the initial facility tour conducted on (MONTH) 6, (YEAR) at 10:00 a.m., the wooden handrails in all of the halls were noted to have multiple gouges in the wood, with areas of splintering. An observation was conducted on (MONTH) 10, (YEAR) at 12:25 p.m., near room #262. A resident was observed to be holding onto the handrail while propelling himself in a wheelchair. The resident was observed to pull himself past the splintered gouges in the handrail by room #262 and missed the splintered area by approximately 0.5 inches. In an interview at the time of the second observation with the Corporate Resource Nurse/Registered Nurse (RN/staff #111), staff #111 stated she wasn't aware that some of the rails were that bad and she would let maintenance know right away. In an interview conducted with the Director of Facilities/Housekeeping (staff #77) on (MONTH) 10, (YEAR) at 12:35 p.m., the Director stated he wasn't aware that the rails were that bad in some areas. He stated he tries to keep up on them when he sees they are getting bad.",2020-09-01
345,CAMELBACK POST ACUTE AND REHABILITATION,35088,4635 NORTH 14TH STREET,PHOENIX,AZ,85014,2017-03-10,371,E,0,1,MBR211,"Based on observations, staff interviews, and policy review, the facility failed to ensure that the dishwasher sanitizing mechanism was functioning, failed to ensure that ready to use dishware was free of dried substances, failed to ensure that the juice dispenser was clean, failed to ensure clean utensils were stored in containers/shelving which were free of debris and dried food particles, and failed to ensure that food stored in the cooler was covered, labeled and/or dated. Findings include: -During the initial kitchen tour conducted on (MONTH) 6, (YEAR) at 7:45 a.m., a dietary aide (staff #44) was asked to complete a sanitizer test of the low temperature dishwasher. There were no test strips available near the dishwasher, so staff #44 was provided a container of test strips labeled as TP-104. Staff #44 made three attempts to test the sanitizer cycle, with no results. Another dietary aide (staff #43) was asked to complete a sanitizer test of the low temperature dishwasher. The same container of test strips were used twice, with no result. The test strips were then identified as the wrong test strips and the instructions on the dishmachine directed staff to use test strips TP-101. The Dietary Supervisor (staff #47) then provided a new package of the correct test strips and tested the sanitizer cycle, again with no results. Staff #47 then identified that the sanitizer line was not primed to draw sanitizer into the dishmachine and was unable to get it to work. In addition, the dishmachine log was reviewed and revealed documentation that the sanitizer was checked on (MONTH) 5, (YEAR), however, staff #47 was unable to determine how long the sanitizer had not been working. -During the same kitchen tour, a tall rack of dishes was observed near the dishwasher. Staff #43 identified these dishes as clean and ready to use for food service. Further observations revealed the bottom rack contained a tray of small bowls. One of the bowls was heavily coated in a dried yellowish substance around part of the rim and in the bowl. Another bowl had black loose particles inside of the bowl. -During the same kitchen tour, a juice concentrate dispenser containing apple, cranberry, orange juice and lemonade was partially opened, as the duct tape holding it closed had come loose. The lower frame of the machine had a build-up of a dark black substance. Staff #47 stated the build-up looked like mold. -During the same kitchen tour, a shelving unit contained two large plastic bins used to store clean scoops, ladles, and other kitchen utensils. The bottom of the bins were lined with paper towels, which were 75% stained with an oily like substance and there were food particles and debris observed on the bottom of the bins. The shelving unit that held the bins was also used as storage for pots, pans, and serve ware. All of the shelves contained debris, food particles and a dried liquid substance which was stuck to the shelves. -During the same kitchen tour, the cooler was observed to have a tray containing six pieces of pie and eleven dishes of a dessert, which were uncovered and unlabeled. At this time, a cook (staff #38) stated they were probably sitting there since (MONTH) 5, but she was not sure. In addition, there were four large trays of rolls which were undated, and there was a plate with a sandwich which was covered with plastic and dated (MONTH) 5, (YEAR). The sandwich was also labeled with a resident's name. However, staff #47 stated he didn't know if that date was the date it was made or the date when it expired. There was also a tray on a rack which was filled with desert cups and a tray which was half filled with cups of salsa, and only half of the dessert cups and the salsa cups were dated. In an interview with staff #47, the Supervisor stated that the kitchen is usually a lot cleaner than this and that staff have cleaning schedules for each shift to complete different things in the department. Staff #47 stated he had not had ongoing problems with the dishwasher. Review of the facility policy titled, Food Storage revealed that .foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their use by dates, or frozen, or discarded. Review of the facility policy titled, Sanitation of Dishes/Dish Machine indicated that the low temperature dishwasher should have a sanitizer test of 50 parts per million (PPM) of Hypochlorite to properly sanitize dishes.",2020-09-01
346,CAMELBACK POST ACUTE AND REHABILITATION,35088,4635 NORTH 14TH STREET,PHOENIX,AZ,85014,2017-03-10,431,D,0,1,MBR211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interviews, and policy review, the facility failed to ensure that a medication was properly stored for one resident (#251). Findings include: Resident #251 was admitted on (MONTH) 10, (YEAR), with [DIAGNOSES REDACTED]. A review of the clinical record revealed the resident had a stage 2 pressure ulcer on the right buttock. Physician orders [REDACTED]. A pressure ulcer treatment observation was conducted on (MONTH) 8, (YEAR) at 12:58 p.m. During this observation, the LPN (Licensed Practical Nurse/Wound Nurse/staff #74) was observed to administer the prescribed treatment of [REDACTED]. However, at the conclusion of the treatment staff #74 was observed to place the tube of Barrier cream inside the top drawer of the resident's nightstand, instead of placing the tube of Barrier cream back in the treatment cart. An interview was immediately conducted and staff #74 stated that she put the Barrier cream in the nightstand, so the CNAs (Certified Nursing Assistants) could also apply it. Following this interview, an interview was conducted with the DON (Director of Nursing/staff #113). According to the DON, no medications including treatment supplies were to be kept at the bedside or stored in the resident's nightstand. A facility policy titled, Medication Access and Storage included It is the policy of this facility to store all drugs and biologicals in locked compartments .",2020-09-01
347,CAMELBACK POST ACUTE AND REHABILITATION,35088,4635 NORTH 14TH STREET,PHOENIX,AZ,85014,2017-03-10,514,E,0,1,MBR211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record reviews, and resident and staff interviews, the facility failed to ensure medical records were complete and/or accurate for four residents (#'s 96, 136, 263 and 265). Findings include: -Resident #96 was admitted on (MONTH) 7, 2013, with [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed a copy of a PASRR (preadmission screening and resident review) dated (MONTH) 19, (YEAR), which documented the resident needed a referral for a PASRR level 2 evaluation. However, the clinical record did not include any documentation of the PASRR level 2 evaluation. On (MONTH) 10, (YEAR) at 8:54 a.m., an interview was conducted with a case manager (staff #75), who stated she did not have a copy of the resident's level 2 PASRR evaluation. After calling the social services director (staff #105), staff #75 stated that the social services director told her that she had called someone about the PASRR level 2 evaluation and was told one was done, however, a copy of the evaluation was not requested or placed in the resident's clinical record. -Resident #265 was admitted on (MONTH) 1, (YEAR) for surgical aftercare. The resident's [DIAGNOSES REDACTED]. The initial admission record dated (MONTH) 1, (YEAR) included the following in Section 3. Oral assessment: Natural teeth [NAME] Present: not applicable B. Carious: not applicable C. No Loose: not applicable D. Missing: not applicable E. Artificial: not applicable Artificial teeth F. Present: no [NAME] Upper: yes H. Lower: yes I. Bridge: no [NAME] Partial: no K. Dentures/Partial dentures broken or loose fitting: no L. Dentures/Partial plates present on admission: no However, during a resident observation conducted on (MONTH) 7, (YEAR) at 1:32 p.m., the resident was observed to have several missing lower and upper teeth. A resident interview was conducted on (MONTH) 8, (YEAR) at 11:00 a.m. At this time, the resident stated that he does not have dentures and has several missing upper and lower teeth. An interview was conducted on (MONTH) 8, (YEAR) at 11:20 a.m., with the LPN (Licensed Practical Nurse/staff #70), who confirmed that the resident did not have dentures. On (MONTH) 9, (YEAR), a second oral assessment was completed. The documentation included the resident had natural teeth, with several missing and broken teeth. On (MONTH) 9, (YEAR) at 1:10 p.m., an interview was conducted with the RN (Registered Nurse/staff #96), who had conducted the initial oral assessment. Staff #96 stated that she did not observe that the resident had several missing upper and lower teeth. Staff #96 confirmed that the initial oral assessment was inaccurate. -Resident #263 was admitted on (MONTH) 17, (YEAR) and discharged on (MONTH) 25, (YEAR). [DIAGNOSES REDACTED]. Regarding the physician orders: The nursing admission note dated (MONTH) 17, (YEAR), included that the resident had wounds to the left lower leg. A review of the nursing weekly non-pressure ulcer reports and the wound care physician notes also included documentation that the resident had wounds on the left lower leg. However, review of the physician's telephone orders dated (MONTH) 18 and 22, (YEAR) revealed treatment orders for the right lower leg, instead of the left lower leg. Review of the clinical record revealed there was no documentation that the resident had any wounds on the right leg. An interview was conducted on (MONTH) 8, (YEAR) at 8:15 a.m., with the Corporate Resource staff (staff #111). Following a review of the clinical record, staff #111 stated that there were discrepancies in the clinical record documentation regarding the site of the resident's wounds. Staff #111 also stated that it must have been an error in documentation. An interview was conducted on (MONTH) 8, (YEAR) at 9:20 a.m., with the Registered Nurse/Wound Nurse (staff #110). Following a review of the physician's telephone orders, she stated it must be a mistake. Regarding the care plan: The admission nursing note dated (MONTH) 17, (YEAR), included that the resident had wounds to the left lower leg. A review of the physician's orders [REDACTED]. However, a skin impairment care plan which was developed on (MONTH) 17, (YEAR), included that the wounds/ulcers were on the resident's right lower leg. An interview was conducted on (MONTH) 8, (YEAR) at 8:15 a.m., with staff #111. She stated that the care plan should have been revised to indicate the resident's wounds were on the left lower leg and not the right lower leg. Another interview was conducted on (MONTH) 8, (YEAR) at 9:20 a.m., with staff #110. Following a review of the clinical record and care plan, she stated it must be an error in documentation. -Resident #136 was admitted to the facility on (MONTH) 6, (YEAR), with a readmitted (MONTH) 21, (YEAR). [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident has been a quadriplegic for [AGE] years. Review of the Braden Scale for Predicting Pressure Sore Risk dated (MONTH) 21, (YEAR), (MONTH) 28, (YEAR), (MONTH) 4, (YEAR), (MONTH) 27, (YEAR), (MONTH) 3, (YEAR) and (MONTH) 10, (YEAR), revealed that all of these assessments included that the resident had no sensory impairment, which would limit his ability to feel pain or discomfort. In an interview conducted with a Registered Nurse (RN/staff #96) on (MONTH) 9, (YEAR) at 1:42 p.m., the RN stated that upon admission the Braden Scale assessment is done every week for 4 weeks. Staff #96 stated the Braden Scale assessments which indicated that the resident had no deficits were incorrect, and that he must have completed them to fast. In an interview with the Director of Nursing (DON/staff #113) and the Corporate Resource RN (staff #111) on (MONTH) 8, (YEAR) at 10:19 a.m., they stated this resident has been a quadriplegic and the documentation that the resident had no impairment is incorrect. The facility was unable to provide a policy regarding ensuring that clinical records are complete and accurate.",2020-09-01
348,CAMELBACK POST ACUTE AND REHABILITATION,35088,4635 NORTH 14TH STREET,PHOENIX,AZ,85014,2018-03-23,550,E,0,1,73KO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, clinical record review, and policy review, the facility failed to ensure that dignity and privacy was maintained for one resident (#40) Findings include: Resident #40 was admitted on (MONTH) 5, (YEAR) with [DIAGNOSES REDACTED]. The comprehensive care plan dated (MONTH) 9, (YEAR), included that the resident was resistive to care related to dressing. It included that the resident choose to remain undressed with the room door open and just a sheet over her body. Interventions included educating the resident on possibility of exposure to people that pass by. The care plan also included that the resident understood but still preferred to remain unclothed. During an observation conducted on (MONTH) 19, (YEAR) from 12:23 p.m. to 1:02 p.m., the resident's room door was observed wide open. From the door, the resident was observed sitting in bed eating her lunch with her incontinent brief and her legs (from her thighs to her feet) uncovered. At 12:43 p.m., a female visitor passed by and looked inside the resident's room. At 12:46 p.m., a Certified Nursing Assistant (CNA/staff #48) stood in the resident's room door and asked whether the resident was finished with lunch. The resident replied no. Staff #48 then left without attempting to cover the resident with a blanket, without pulling the privacy curtain, and/or without closing the door. At 12:55 p.m., a male resident in a wheelchair passed by resident #40's room. The resident looked inside the room and did not stop looking until he was passed the resident's door. Also during this period of observation, multiple male and female nurses and CNAs passed by and looked inside the resident's room. However, none of these nurses and CNAs attempted to cover the resident, pull the privacy curtain, or shut the room door. During an observation conducted on (MONTH) 19, (YEAR) at 2:11 p.m. and 2:21 p.m., the door was wide open. From the door, the resident's brief and her uncovered legs were visible. On (MONTH) 21, (YEAR) at 10:38 a.m., the resident was again found lying in her bed with her brief and her uncovered legs visible from the opened door. On (MONTH) 21, (YEAR) at 2:26 p.m., the resident was observed sitting in bed with her brief and her uncovered legs visible from the door. An electric fan was blowing directly at the resident's legs. An interview was conducted with the resident immediately following the observation. She stated that the electric fan was provided to help her cool off. She further stated that she did not want her privacy curtain pulled or her door shut. During an interview conducted with a licensed practical nurse (LPN/staff #45) on (MONTH) 22, (YEAR) at 9:14 a.m., she stated that a resident's dignity is maintained by knocking on the resident's room door prior to entering and by maintaining the resident's privacy at all times. She stated that if she observed a resident from the room door without clothes and/or a blanket, she would pull the privacy curtain and shut the door. Staff #45 stated that she will offer to cover the resident or offer to provide the resident some clothes to wear. She further stated that if the resident refused these options, she would offer to pull the privacy curtain or to shut the door. Staff #45 stated she would educate the resident that being uncovered and exposed from the door is not appropriate. She further stated that this is a dignity issue. During an interview conducted with a CNA (staff #48) on (MONTH) 22, (YEAR) at 10:42 a.m., she stated that if she observed a resident with no clothes or with his/her incontinent brief visible from the resident's room door, she would pull the privacy curtain and/or close the resident's room door. Staff #48 stated that if the resident refused these options, she would cover the resident with a blanket and report the incident to the nurse. An interview was conducted with the Director of Nursing (DON/staff #98) on (MONTH) 23, (YEAR) at 8:59 a.m. She stated resident #40 was claustrophobic and that when the staff tried to pull the privacy curtains, the resident would start yelling. Staff #98 stated that the resident was care planned for resisting care related to her refusal to dress. She also stated that they respected the resident's wishes to not dress. However, staff #98 did not provide a response to how this exposure affected other residents' rights. The facility's policy Dignity included that all residents shall be treated with kindness, dignity, and respect. It also included that residents will be appropriately dressed in clean clothes. The policy further included residents shall be treated in a manner that maintains the privacy of their bodies by a closed door or drawn curtain that shields the residents from passers-by.",2020-09-01
349,CAMELBACK POST ACUTE AND REHABILITATION,35088,4635 NORTH 14TH STREET,PHOENIX,AZ,85014,2018-03-23,585,D,0,1,73KO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, facility documentation, and policy review, the facility failed to ensure prompt efforts were made to resolve one resident's (#9) grievance. Findings include: Resident #9 was admitted on (MONTH) 19, (YEAR) with a [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set assessment dated (MONTH) 26, (YEAR), revealed a BIMS (Brief Interview for Mental Status) score of 15 which indicated the resident was cognitively intact. A physician progress notes [REDACTED]. During an interview conducted with the resident on (MONTH) 19, (YEAR) at 10:54 a.m., she stated that 3 weeks ago, her gown was sent to the laundry and that she did not receive it back. Resident #9 stated that she reported the missing gown to a staff member but has not heard anything back from staff. She stated the gown is still missing. An interview was conducted with the social services director (staff #99) on (MONTH) 22, (YEAR) at 10:25 a.m. She stated that reports of missing items including clothing will be investigated. Staff #99 stated that if the missing item is listed on the inventory sheet, the facility will reimburse the resident for the item. She stated that if the item is not listed on the inventory sheet, then the item will be reimbursed on a case to case basis. Staff #99 further stated that during a mock survey conducted last month, it was identified that there were grievances from residents that were not documented. She stated that there was no paper trail related to whether a grievance was reported or resolved. During an interview conducted with the resident on (MONTH) 22, (YEAR) at 2:25 p.m., she stated that she reported the incident to a female CNA (certified nursing assistant) and that she was unable to remember the CNA's name. During an interview conducted with a licensed practical nurse (LPN/staff #74) on (MONTH) 22, (YEAR) at 2:00 p.m., he stated that when he receives a report from any resident regarding a missing item, he will try to locate the item, file a grievance for the resident with social services, and inform the administrator and the resident's family. He stated that the administrator and social services will then conduct an investigation. In a later interview with staff #99 conducted on (MONTH) 22, (YEAR) at 2:01 p.m., she stated that resident #9 had not reported any missing personal item to her. Review of the Grievance Binder was conducted with staff #99 immediately following the interview. Staff #99 stated that she could not find any record of a grievance related to resident #9's missing gown. During an interview conducted with the Director of Nursing (DON/staff #98) and the Resource person (staff #112) on (MONTH) 23, (YEAR) at 8:59 a.m., the DON stated that if a resident reports a missing item, staff will look for the item and start a grievance process. She stated that if the family brings in items, the family should notify the staff to ensure the items are transcribed onto the resident's inventory list. The DON also stated that staff will continue to follow through with the report either by finding or replacing the item. She further stated that she was not sure if there was any issues/grievance reported by resident #9. An interview was conducted with staff #112 on (MONTH) 23, (YEAR) at 10:05 a.m. She stated that she reviewed the social services notes and was unable to find documentation regarding the resident's missing gown. During an interview conducted with a laundry staff (staff #43) and the dietary supervisor (staff #31) on (MONTH) 23, (YEAR) at 10:54 a.m., staff #43 stated that the CNA, other staff, or the resident will report missing clothing to the laundry staff. She stated that the laundry staff keeps a list of residents who reported missing clothing on the board in the laundry room. Staff #43 further stated that she was not aware of any missing clothing for resident #9. The facility's policy Resident's Personal Property included that the facility will provide space and safety for resident's personal property. It also included that the facility will promptly investigate any complaints of misappropriation or mistreatment of [REDACTED].",2020-09-01
350,CAMELBACK POST ACUTE AND REHABILITATION,35088,4635 NORTH 14TH STREET,PHOENIX,AZ,85014,2018-03-23,623,E,0,1,73KO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, closed clinical record review, facility documentation, and policy, the facility failed to ensure that the State LTC (Long Term Care) Ombudsman received a copy of the resident's (#59) notice of transfer to the hospital as close as possible to the actual time of the facility-initiated transfer/discharge. Findings include: Resident #59 was admitted on (MONTH) 13, (YEAR) with [DIAGNOSES REDACTED]. Review of a nursing progress note dated (MONTH) 20, (YEAR), revealed the hospital physician requested for the resident to be sent back to the hospital. The note further revealed the resident was transported to the hospital at approximately 12:45 p.m. A physician order [REDACTED]. The Discharge MDS (Minimum Data Set) assessment dated (MONTH) 20, (YEAR), revealed a planned discharge to an acute hospital with return not anticipated. Review of the facility's List of Facility Discharges from (MONTH) 1, (YEAR) through (MONTH) 31, (YEAR), revealed resident #59 was discharged to an acute hospital on (MONTH) 20, (YEAR). However, further review of the facility's List of Facility Discharges revealed the List was not faxed to the Ombudsman until (MONTH) 8, (YEAR). There was no documented evidence found in the clinical record that the Ombudsman was notified of the resident's discharge before (MONTH) 8, (YEAR). During an interview conducted with resource staffs #112 and #102 on (MONTH) 23, (YEAR) at 11:17 a.m., staff #112 stated that the List of Facility Discharges was faxed to the Ombudsman on (MONTH) 8, (YEAR). She stated that the current social worker is current with notifying the Ombudsman every month. The facility's policy Criteria for Transfer and Discharge included that the facility will notify the Ombudsman per CMS (Centers for Medicare and Medicaid Services) regulations and guidelines.",2020-09-01
351,CAMELBACK POST ACUTE AND REHABILITATION,35088,4635 NORTH 14TH STREET,PHOENIX,AZ,85014,2018-03-23,641,D,0,1,73KO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one MDS (Minimum Data Set) assessment was accurate for one resident (#35) regarding hospice care and for one resident (#6) regarding a pressure ulcer. Findings include: -Resident #6 was admitted (MONTH) 14, 2006 with [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed an annual MDS (Minimum Data Set) assessment dated (MONTH) 8, (YEAR), that the resident had a stage two pressure that was present at admission or re-entry. Further review of the assessment revealed the on-set date of the pressure ulcer was (MONTH) 8, (YEAR). Additional review of the resident's clinical record did not reveal any documentation that the resident had been out to the hospital or readmitted (MONTH) 8, (YEAR). An interview was conducted with a RN (Registered Nurse/staff #111) who had completed the (MONTH) 8, (YEAR) annual MDS assessment. Staff #111 stated that the documentation of the resident having a pressure ulcer at admission/re-entry was incorrect, that the resident had not been readmitted or had a new admission. -Resident #35 was admitted on (MONTH) 29, (YEAR) with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A care plan dated (MONTH) 16, (YEAR), included that the resident had a terminal prognosis and was admitted to hospice care on (MONTH) 15, (YEAR). Interventions included the nursing staff were to provide maximum comfort for the resident and to work cooperatively with the hospice team to ensure his needs were met. Review of a binder which included hospice information specifically for resident #35 revealed the resident was admitted to hospice on (MONTH) 15, (YEAR) and was receiving hospice services. However, an MDS significant change assessment dated (MONTH) 9, (YEAR), did not include the resident was receiving hospice care. During an interview conducted with the resource nurse (staff #102) on (MONTH) 23, (YEAR) at 9:07 a.m., he stated the MDS assessment was an error and should have reflected the resident was receiving hospice services. The facility's policy titled Accuracy of Assessment (MDS 3.0) revealed It is the policy of this facility to ensure that the assessment accurately reflect the resident's status.",2020-09-01
352,CAMELBACK POST ACUTE AND REHABILITATION,35088,4635 NORTH 14TH STREET,PHOENIX,AZ,85014,2018-03-23,655,D,0,1,73KO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, clinical record review, facility documentation, and policy review, the facility failed to ensure that a summary of the baseline care plan for two residents (#9 and #31) was provided to the residents by the completion of the comprehensive care plan. Findings include: -Resident #9 was admitted on (MONTH) 19, (YEAR) with [DIAGNOSES REDACTED]. The Admission note dated (MONTH) 19, (YEAR), revealed the resident was admitted s/p (status [REDACTED]. It also revealed the resident was alert and oriented x 3. Review of the baseline care plan revealed it was developed on (MONTH) 19, (YEAR). The care plan included the following focus areas: cognition, ADLs (activities of daily living), skin, nutrition, pain, and falls. However, the baseline care plan and summary acknowledgement form signed by the resident revealed the resident was not provided a summary of the baseline care plan until (MONTH) 23, (YEAR) at 12:35 (a.m. or p.m. was not indicated). During an interview conducted with Resource staff (staff #112) on (MONTH) 23, (YEAR) at 10:30 a.m., she stated that the summary of the baseline care plan was provided late to resident #9. -Resident #31 was admitted on (MONTH) 23, (YEAR) with [DIAGNOSES REDACTED]. Review of the admission progress note dated (MONTH) 23, (YEAR), revealed the resident was alert to self and was able to verbalize needs and followed commands. Continued review of the clinical record revealed an admission Minimum Data Set assessment dated (MONTH) 30, (YEAR). Review of care plans that were developed on (MONTH) 30, (YEAR), revealed the following focus areas: cognition, ADLs (activities of daily living), incontinence, falls, nutrition, [MEDICAL CONDITION] medications and pain. Review of The Baseline Care Plan and Acknowledgement Form revealed the form was not signed by the resident until (MONTH) 22, (YEAR). An interview was conducted with the DON (director of nursing/staff #98) on (MONTH) 21, (YEAR) at 11:55 a.m. The DON stated that the baseline care plan should be completed by all department heads and reviewed with the resident within 48 hours of admission. The DON further stated that residents acknowledge the baseline care plan was reviewed with them by a signature and that a copy is kept in the electronic clinical record. An interview was conducted with an RN (Registered Nurse) consultant (staff #102) on (MONTH) 21, (YEAR) at 1:00 p.m. The RN consultant stated that the baseline care plan is completed within 48 hours of admission and the resident signs the form prior to the completion of the comprehensive care plan. The comprehensive care plan was developed on (MONTH) 30, (YEAR). The RN consultant further stated that we are out on this one. An interview was conducted with an LPN (licensed practical nurse/staff #95) on (MONTH) 22, (YEAR) at 9:19 a.m. The LPN stated that the admitting nurse usually have the resident sign the code status and consent to treat. The LPN stated the next day the unit manager will review the baseline care plan with the resident and have the resident sign it. An interview was conducted with the DON/staff #98 on (MONTH) 22, (YEAR) at 9:25 a.m. The DON stated that up until two weeks ago the case manager was responsible for reviewing the baseline care plan with the resident or their responsible party but that it was not being done. Review of the facility's policy Comprehensive Person-Centered Care Planning included .The IDT (interdisciplinary team) will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care .The facility team will provide a written summary of the baseline care plan to the resident or resident representative by completion of the comprehensive care plan .",2020-09-01
353,CAMELBACK POST ACUTE AND REHABILITATION,35088,4635 NORTH 14TH STREET,PHOENIX,AZ,85014,2018-03-23,657,D,0,1,73KO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a clinical record review, staff interviews, and policy, the facility failed to ensure one resident (#13) was provided the opportunity to participate in his care planning process. Findings include: Resident #13 was readmitted on (MONTH) 22, (YEAR) with [DIAGNOSES REDACTED]. Review of the progress notes from (MONTH) 5, (YEAR) to (MONTH) 22, (YEAR), revealed no evidence the resident was invited to participate and/or participated in his care planning process. Review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 28, (YEAR), revealed the resident scored a fifteen on the Brief Interview for Mental Status (BIMS) which indicated the resident was cognitively intact. An interview was conducted on (MONTH) 20, (YEAR) at 8:15 a.m. with the resident. He stated that he is unsure of the care plan meetings conducted at the facility. During a follow up interview conducted on (MONTH) 21, (YEAR) at 12:53 p.m. with the resident. He stated the care plan meetings are not conducted at the facility. Resident #13 stated that neither he nor his power of attorney have been invited to participate in the care plan meetings. An interview was conducted on (MONTH) 22, (YEAR) at 12:16 p.m. with a licensed practical nurse (staff #74). He stated social services make the arrangements for the care plan meetings. Staff #74 stated all residents are invited to participate in their care plan meeting. He further stated care plan meetings are held quarterly with an interdisciplinary team involving the Director of Nursing, social services, unit manager, wound nurse if necessary, dietary, therapy, and the resident. Staff #74 also stated that resident #13 is alert and oriented. During an interview conducted with the Director of Social Services (staff #99) on (MONTH) 23, (YEAR) at 9:38 a.m., she stated social services is responsible for organizing care plan meetings but that she has not been trained. She stated care plan meetings are set up quarterly in conjunction with the MDS assessment schedule. Staff #99 stated residents and family members are invited to participate in the care plan meetings prior to the completion of the MDS assessments. She stated if a resident is alert and oriented, information regarding care plan meetings is communicated with the resident. Staff #99 stated care plan conferences involves the therapy department, the Director of Social Services, the case manager, the Activities Director, the dietary department, and the MDS assessment nurse. An interview was conducted on (MONTH) 23, (YEAR) at 10:16 a.m. with a registered nurse (RN) consultant (staff #102). He stated no documentation was found that resident #13 was invited to participate in his care plan conference. During an interview conducted with the Director of Nursing (staff #98/DON) and a RN consultant (staff #101) on (MONTH) 23, (YEAR) at 12:02 p.m., she stated social services are responsible for implementing care plan conferences. She stated residents and family members are invited to care plan conferences via phone, mail, or verbally. Staff #98 stated a resident's involvement in the care plan conference is documented in the progress notes. She also stated the expectation is that residents and family members are invited to participate in their care planning conference. Staff #101 stated care plan conferences are based on the MDS assessment schedule or as needed. He further stated residents and family members are invited two weeks to thirty days prior to the care plan conference. The facility's policy and procedure titled Care Planning included that the interdisciplinary team shall develop a comprehensive care plan for each resident. The policy also included to the extent possible, the resident, the resident's family and/or responsible party should participate in the development of the care plan and will be notified of the date and time of the care plan conference prior to the meeting.",2020-09-01
354,CAMELBACK POST ACUTE AND REHABILITATION,35088,4635 NORTH 14TH STREET,PHOENIX,AZ,85014,2018-03-23,658,E,0,1,73KO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, staff interviews, and policy and procedure, the facility failed to ensure professional standards of quality were met for one resident (#4) during a medication administration. Findings include: Resident #4 was admitted on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set assessment (MDS) dated (MONTH) 7, (YEAR), revealed the resident scored a fifteen on the Brief Interview for Mental Status (BIMS) which indicated the resident was cognitively intact. Review of the physician's orders revealed the following medications: [REDACTED] -[MEDICATION NAME] 150 milligram (mg) by mouth (PO) one time a day for gout dated (MONTH) 28, (YEAR), -Sodium [MEDICATION NAME] 650 mg one tablet by mouth every twelve hours for supplement dated (MONTH) 7, (YEAR), -Vitamin B Complex one tablet by mouth one time a day dated (MONTH) 7, (YEAR), -[MEDICATION NAME] HCL 50 mg tablet by mouth every eight hours for hypertension dated (MONTH) 5, (YEAR), -[MEDICATION NAME] 5 mg by mouth two times a day for muscle spasms dated (MONTH) 29, (YEAR), -[MEDICATION NAME] extended release (ER) 60 mg tablet one time a day for hypertension dated (MONTH) 20, (YEAR). Further review of the physician's orders revealed no physician's order to crush medications. Review of the resident's care plan for hypertension and [MEDICAL CONDITION] revealed that all cardiac medications and anti-hypertensive medications are to be administered as ordered by the physician. During a medication administration observation conducted on (MONTH) 21, (YEAR) at 8:09 a.m. with a licensed practical nurse (LPN/staff #95); the nurse prepared the following medications: [REDACTED] . [MEDICATION NAME] 150 mg by PO . Vitamin B Complex 1 tablet PO . [MEDICATION NAME] 5 mg PO . [MEDICATION NAME] 60 mg extended release (ER) PO . Sodium [MEDICATION NAME] 650 mg PO . [MEDICATION NAME] 50 mg PO When the nurse attempted to administer the medications to the resident, the resident requested the medications be crushed. Staff #95 returned to the medication cart and crushed all the medications together and placed the medications in a medicine cup. At 8:15 a.m., the nurse handed the crushed medications to the resident and would have administered the crushed [MEDICATION NAME] ER if not for intervention. Staff #95 then left the room with the medications. He stated that he should not administer the crushed [MEDICATION NAME] ER medication because the extended release medication should not be crushed. At 8:17 a.m., staff #95 prepared the medications again excluding the [MEDICATION NAME] ER, crushed all the medications together, and administered the medications to the resident. A follow up interview was conducted on (MONTH) 21, (YEAR) at 2:08 p.m. with staff #95. He stated nurses have a list of medications that can and cannot be crushed. Staff #95 stated extended release medications take longer to dissolve in the body and cannot be crushed. He stated a physician's order is required to crush medications. At this time, he reviewed the resident's physician's orders and stated there was an order to crush medications that was obtained today at 9:47 a.m. An interview was conducted on (MONTH) 21, (YEAR) at 2:42 p.m. with the Director of Nursing (DON/staff #98). She stated extended release medications should not be crushed. Staff #98 stated that if a nurse is unsure if a medication can be crushed, the nurse should contact the DON or the pharmacy. She stated the pharmacy phone number is located at the nursing station. Staff #98 also stated she will need to verify if a physician's order for crushing medications is required. During an interview conducted on (MONTH) 22, (YEAR) at 9:23 a.m. with a licensed pharmacist (staff #106), she stated [MEDICATION NAME], Sodium [MEDICATION NAME], and Vitamin B complex medications can be crushed without a negative outcome. Staff #106 stated that crushing [MEDICATION NAME] ER would compromise the medication and would administer the resident a burst of the medication. She stated that there is a possibility the crushed medication could lower the heart rate more than desired. An interview was conducted on (MONTH) 22, (YEAR) at 12:32 p.m. with a LPN (staff #74). He stated a physician's order is required for nurses to crush medications. Staff #74 stated crushing and administering medications without a physician's order is a medication error. He stated crushing and administering an extended release blood pressure medication could potentially result in a negative outcome for a resident. Staff #74 stated the resident's blood pressure could drop. He stated administering a crushed extended release medication is also a medication error. Staff #74 further stated the nurses are able to call the pharmacy, the DON, or the unit manager to determine if a medication can be crushed. A follow up interview was conducted on (MONTH) 22, (YEAR) at 10:20 a.m. with the DON. She stated a physician's order to crushed medications is not needed. She stated the need for a physician's order to crush medications was removed from the facility's policies. Later that day at 1:47 p.m., she stated the facility does not have a policy for crushing medications. An interview was conducted on (MONTH) 23, (YEAR) at 9:13 a.m. with resident #4. She stated her medications have been administered crushed for about a month because she has trouble swallowing. The resident stated all her medications are crushed except for one medication and that she does not remember which medication. She then stated she typically receives all the medications crushed together. The facility's policy titled Administration of Drugs included that medications shall be administered as prescribed by the attending physician.",2020-09-01
355,CAMELBACK POST ACUTE AND REHABILITATION,35088,4635 NORTH 14TH STREET,PHOENIX,AZ,85014,2018-03-23,686,D,0,1,73KO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, resident and staff interviews, and policy review, the facility failed to identify that one resident (#43) had a stage II pressure ulcer on the right buttock and failed to ensure a pressure ulcer treatment was consistently provided to one resident (#6). Findings include: Resident #43 was admitted on (MONTH) 14, (YEAR) and readmitted on (MONTH) 2, (YEAR). [DIAGNOSES REDACTED]. Review of a care plan revealed that the resident was at risk for pressure sore development related to decreased mobility, deconditioning and co-morbid health condition. The goal included the resident's skin would be intact, free of redness, blisters or discoloration. Approaches included the following: administer treatment as ordered and monitor for effectiveness, follow facility policy/protocols for prevention/treatment of [REDACTED]. Review of the quarterly MDS (Minimum Data Set) assessment dated (MONTH) 20, (YEAR), revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15, which indicated the resident was cognitively intact. The MDS assessed the resident to require extensive assistance of one to two staff with bed mobility, transfers, dressing, toilet use and personal hygiene. Per the MDS, the resident was incontinent of bowel and bladder and was at risk for developing pressure sores and had one unhealed unstageable pressure sore. Review of the weekly evaluation note dated (MONTH) 26, (YEAR) revealed resident #43's buttocks was pink, but blanchable. A physician's order dated (MONTH) 2, (YEAR), included to cleanse the resident's buttocks with warm soapy water, pat dry, apply barrier cream to buttocks, coccyx and sacrum, every shift. Review of the weekly evaluation note dated (MONTH) 9 and 12, (YEAR) revealed the resident had a red area to the coccyx, which measured 2.0 cm x 1.5 cm and that the wound nurse was continuing with treatments. Review of the weekly evaluation note dated (MONTH) 21, (YEAR), revealed a late entry for (MONTH) 19, (YEAR). The note included that the resident had a red area on the bottom and was being turned frequently as tolerated. On (MONTH) 21, (YEAR) at 1:31 p.m., an interview was conducted with resident #43. She stated that she had an open sore on her bottom. On (MONTH) 21, (YEAR) at 2:37 p.m., an interview was conducted with the wound care nurse (Licensed Practical Nurse/staff #28). She stated that resident #43 did not have an open area on her buttocks. Following this interview, a wound care observation was conducted with staff #28. The resident was observed to have an open area to the right buttock. The wound bed was beefy red, with a small area of yellow tissue and had a small amount of reddish/brownish drainage. The wound measured 0.9 cm x 0.8 cm x 0.1 cm, with no undermining. The outer edges of the wound were thick, pink and macerated. At this time, staff #28 stated that the resident had a stage III wound on the right buttock, which had not been reported to her. Staff #28 stated that there was no documentation of this wound, and there were no physician orders to care for it. On (MONTH) 21, (YEAR) at 3:00 p.m., another interview was conducted with staff #28. Staff #28 stated that she expected the floor nurses to document in the clinical record any new skin breakdown and notify her right away. She stated after being notified of any skin breakdown, she would assess the wound, notify the physician and obtain treatment orders. She said that the certified nursing assistants (CNAs) or nurses usually alert her if a new area has opened. Staff #28 further stated the nurses had documented that the resident had redness on her buttocks on (MONTH) 9 and 12, but they did not notify her. She stated that nursing staff are supposed to let her know of any changes in the resident's skin, so she can obtain timely treatment orders. She stated that she was unaware that the resident had a stage III pressure sore on her right buttock. The clinical record was reviewed on (MONTH) 21, (YEAR) at 3:28 p.m. An initial nurses' note dated (MONTH) 21, (YEAR) at 3:15 p.m. included documentation that during a wound care observation, the resident's buttocks was noted to have a stage III pressure injury, with 100% granulation tissue present to the wound bed and the wound edges were macerated. The note included that the physician was notified, and new treatment orders were obtained to cleanse the wound with normal saline, pat dry, apply silver alginate to the wound bed and cover with a dry dressing. The note included the care plan was updated and weekly wound assessments were initiated. The note was signed by staff #28 (the wound care nurse). The care plan was also updated to reflect that the resident had a pressure ulcer on the right upper buttock. The goal included the pressure ulcer will show signs of healing and remain free from infection through (MONTH) 12, (YEAR). Approaches included the following: assess, record, monitor the wound for healing, measure length, width and depth, document the status of wound perimeter, wound bed and healing progress, and to use lifting devices and draw sheet to reduce friction. On (MONTH) 21, (YEAR) at 3:55 p.m., an interview was conducted with the Director of Nursing (DON/staff #98), who stated that the process was to initiate assessments of any new skin breakdown and document it. Review of the weekly pressure ulcer assessment dated (MONTH) 21, (YEAR) at 4:19 p.m., revealed an initial wound evaluation for an acquired stage II pressure ulcer which measured 0.9 cm x 0.8 cm x 0.1 cm, had serosanguinus drainage, and the wound bed was described as beefy red, with surrounding macerated tissue. The clinical record was again reviewed on (MONTH) 22, (YEAR) at 3:22 p.m. The initial nurse's note dated (MONTH) 21, (YEAR) at 3:15 p.m., regarding the right buttock wound had been stricken out, using black lines through the entire entry, and was noted as an incorrect entry. A new note which was identified as a late entry with an effective date of (MONTH) 21, (YEAR) at 3:21 p.m., included that the resident was turned to her right side and a new wound was found on the right buttock region, and the resident's briefs were wet with urine. Per the note, the physician was notified and ordered silver alginate treatments. The note included the wound measured 0.9 cm x 0.8 cm x 0.1 cm and was pink with macerated edges. The note further included that the resident was encouraged to reposition in bed and offload pressure to the buttocks. The note did not include the stage of the pressure ulcer. This note was signed by staff #28. On March, 23, (YEAR) at 8:56 a.m., an interview was conducted with staff #28. She stated that she had miss-staged resident #43's right buttock wound during the wound care observation. She stated that the wound bed was red and there was no granular tissue in the wound bed. She stated that the tissue on the edges of the wound was thick, pink and macerated. Staff #28 stated that at first, during the wound care observation she thought it was a stage III wound, but it was not. Staff #28 stated that she changed her mind, as the DON (staff #98) re-assessed the wound and determined that the wound was moisture associated skin breakdown. Another interview was conducted with staff #98 on (MONTH) 23, (YEAR) at 10:00 a.m. Staff #98 stated that the wound was moisture associated. Staff #98 stated that when she saw the wound last night it was flat with no depth and according to her knowledge, the wound was not a pressure sore, as it had no depth to it. She stated it was her expectation that when a CNA or a nurse observe a wound, the wound care nurse and herself should be notified immediately. Further review of the clinical record revealed there was no documentation of the wound assessment which was completed by staff #98 on (MONTH) 22 or 23, (YEAR). Another wound care observation was conducted on (MONTH) 23, (YEAR) at 10:48 a.m., with staff #28 and the Assistant Director of Nursing (ADON). The buttocks wound bed was pink and the wound edges were thick, pink and macerated. The wound measured 1.0 cm x 1.0 cm x 0.2 cm. Review of a nurses note dated (MONTH) 23, (YEAR) at 11:13 a.m., revealed the ADON assisted with standby wound care. The note included that wound care was done as ordered. The buttock wound had no signs or symptoms of infection and the wound had pink tissue, with red tissue in the depth of the wound, and the edges of the wound were thick, pink and macerated. The wound measured 1 cm x 1 cm x 0.2 cm. Review of a facility policy titled, Pressure Ulcer Management indicated the following: Chart the presence of the pressure ulcer in the nurses progress notes and indicate the location and stage. Specifics of the pressure ulcer assessment should be charted on the pressure ulcer site sheet. The wound care nurse should be notified of the presence of any pressure sores. -Resident #6 was admitted on (MONTH) 14, 2007, with [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed a weekly Skin/Pressure evaluation dated (MONTH) 27, (YEAR), that revealed the resident had a stage 2 pressure ulcer on the left medial heel. The wound measured 2 cm (centimeters) by 1.5 cm, with depth assessed at 0.1 cm and tunneling and undermining at 0.1 cm. The wound appeared as a serous filled blister with serous drainage with no signs or symptoms of infection. The evaluation included that the resident refused dressings and to continue with the current treatment. Continued review of the clinical record revealed a physician's order dated (MONTH) 5, (YEAR) to cleanse the left medial heel with normal saline solution, pat dry, paint the wound with [MEDICATION NAME], and leave open to air every shift. The clinical record revealed an annual MDS (Minimum Data Set) assessment dated (MONTH) 8, (YEAR), that the resident had a BIMS (Brief Interview for Mental Status) score of 7 which indicated the resident had severe cognitive impairment. The assessment included the resident was at risk of developing a pressure ulcer, and had a stage 1 or greater pressure ulcer. A weekly skin/pressure ulcer evaluation dated (MONTH) 13, (YEAR), revealed documentation that the resident had a stage 2 pressure ulcer on the left medial heel that measured 2 cm by 1.5 cm with a depth of 0.2 cm with no tunneling or undermining, no drainage, and no odor. The wound appeared as a serous filled blister starting to callous over. The treatment continued to be provided daily with an occasional refusal and behaviors from the resident. The evaluation included there were no complaints of pain from the resident and that the resident refused to off-load pressure. Review of the resident's TAR (Treatment Administration Record) dated (MONTH) (YEAR), revealed missing documentation for the wound care of the left medial heel on the night shift for (MONTH) 17, 18, and 19, (YEAR). A review of nursing progress notes did not reveal any documentation for the wound care on (MONTH) 17, 18, and 19, (YEAR). On (MONTH) 21, (YEAR) at 1:30 p.m., an interview was conducted with the LPN (Licensed Practical Nurse/staff #95) who was responsible for the resident's wound care on (MONTH) 17 and 18, (YEAR). Staff #95 stated that he provided the resident's wound care on (MONTH) 17 and 18, (YEAR), but that he must have forgotten to document the care. He further stated if the care was not documented then it was not considered done. An interview was conducted on (MONTH) 21, (YEAR) at 1:45 p.m. with the DON (Director of Nursing/staff #48) who stated that the residents' TARs were audited weekly, but was unsure if there had been an audit of this resident's TAR. A telephone interview was conducted with LPN (staff #15) on (MONTH) 21, (YEAR) at 2:47 p.m. Staff #15 stated that she would have documented the wound care for resident #6 on the wound TAR. She stated that she remembered providing the wound care on (MONTH) 19, (YEAR). Staff #15 further stated if the care was not documented, then it was not done. The facility's policy regarding wound care included that upon completion of treatment; the staff should document the treatment given, the wound appearance, and changes in the nurses' notes and elsewhere as indicated.",2020-09-01
356,CAMELBACK POST ACUTE AND REHABILITATION,35088,4635 NORTH 14TH STREET,PHOENIX,AZ,85014,2018-03-23,689,D,0,1,73KO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, resident interview, staff interviews, and policies and procedures, the facility failed to ensure that one resident (#31) who was assessed to require supervision while smoking, received staff supervision while he smoked outdoors. Findings include: Resident #31 was admitted on (MONTH) 23, (YEAR) with [DIAGNOSES REDACTED]. Review of the resident's admission MDS (Minimum Data Set) assessment dated (MONTH) 30, (YEAR), revealed the resident's BIMS (brief interview for mental status) score was an 11 which indicated the resident had moderately impaired cognition. The resident's clinical record revealed a smoking care plan dated (MONTH) 30, (YEAR). A problem included was the resident has potential for injury related to smoking. A goal included was Will have no injuries related to smoking. Will be compliant with smoking protocols and individual smoking plan until next review. Interventions included were Complete smoking assessment. Explain smoking policy. Maintain smoking materials at nurse's station or other designated area. Monitor to assess compliance with facility smoking policy/individual plan. Observe smoking while in designated area. Report non-compliance or unsafe smoking habits to MD and responsible party. The resident's clinical record revealed a Smoking Evaluation dated (MONTH) 31, (YEAR). The Smoking Evaluation revealed the resident had cognitive loss, dexterity problem, was unable to light his own cigarette, and required adaptive clothing while smoking. The Smoking Evaluation included the resident has no cigarettes but will need a smoking apron when he smokes and will be assessed for a cigarette holder. He has the policy and facility lights resident cigarettes. Review of the facility documentation dated (MONTH) 19, (YEAR), revealed a list of residents who smoked. Resident #31's name was on the list and also included that the resident required a smoking apron while smoking. Further review of facility documentation revealed the supervised smoking times on the main patio were 9:00 a.m., 1:00 p.m., 4:00 p.m., and 8:00 p.m. An observation was made of the resident on (MONTH) 21, (YEAR) at 7:25 a.m. The resident was observed to wheel himself in his wheelchair outdoors to the main patio. Another observation was made of the resident on (MONTH) 21, (YEAR) at 7:28 a.m. The resident was observed seated in his wheelchair against the southeast wall of the main patio. The resident was observed to hold a cigarette with his thumb and forefinger of his right hand. The resident was observed smoking the cigarette as smoke was exhaled from his mouth. An interview was conducted with the resident at 7:30 a.m. The resident stated his name was a name other than his own. The resident was no longer smoking at this time and no cigarette butts were observed on the ground. There was a smell of cigarette smoke near the resident. Cigarette ash was observed on the stomach area of his sweatshirt and the lap area of his sweatpants. The resident stated that he had been smoking. The resident further stated that he retained his own lighter and cigarettes. An interview was conducted with the activity director (staff #47) on (MONTH) 21, (YEAR) at 8:00 a.m. to determine the resident's actual name. Once a description was made of the resident, the activity director stated my little smoker and stated that the resident was resident #31. An interview was conducted with a CNA (certified nursing assistant/staff #27) on (MONTH) 21, (YEAR) at 8:49 a.m. The CNA stated that she did not know the resident but that all of the residents who smoked in the facility needed to be supervised while smoking. The CNA further stated that none of the residents were allowed to keep their smoking materials. An interview was conducted with another CNA (staff #48) on (MONTH) 21, (YEAR) at 8:51 a.m. The CNA stated that she did not know if the resident smoked or not but that all residents needed to smoke during supervised smoking times. An interview was conducted with an RN consultant (staff #101) on (MONTH) 21, (YEAR) at 8:52 a.m. The RN consultant stated that the resident's room was searched and the staff were unable to find any smoking materials. The RN consultant stated that the resident stated that he did not smoke outdoors. An interview was conducted with the DON (director of nursing/staff #98) on (MONTH) 21, (YEAR) at 8:57 a.m. The DON stated that she would check to see if the resident had any more smoking materials in his possession. The DON further stated that a cigarette was found on the resident but that the staff removed it from the resident. An interview was conducted with an LPN (licensed practical nurse/staff #28) on (MONTH) 21, (YEAR) at 8:58 a.m. The LPN stated that all resident smoking materials are kept in a locked box at the nurse's station. An interview was conducted with a CNA (staff #32) on (MONTH) 21, (YEAR) at 9:01 a.m. The CNA stated that all resident smoking materials were kept locked up at the nurse's station. An observation was made of the resident on (MONTH) 21, (YEAR) at 9:05 a.m. The DON asked the resident if she could look under the cushion of his wheelchair to determine if he had any more smoking materials. The resident became angry and stated that he only had two matches and one of them did not light. The resident further stated that he had smoked a cigarette butt and did not have any more smoking materials with him. An interview was conducted with an LPN (staff #95) on (MONTH) 21, (YEAR) at 11:22 a.m. The LPN stated that when a resident is admitted , a smoking assessment is completed and the resident signs it. The LPN stated that there are designated smoking times and that the staff retains the resident's cigarettes and lighters. The LPN further stated that if the resident could not control the ashes on their cigarette that a smoking apron is provided. An interview was conducted with another RN consultant (staff #102) on (MONTH) 21, (YEAR) at 11:30 a.m. The RN consultant stated that residents' smoking times are supervised and the staff retains the residents' cigarettes and lighters. The facility's Smoking Policy included .It is also policy to provide those residents who choose to smoke a means in which to do so that does not jeopardize their safety or the safety of others residing in the facility .No lighting materials, tobacco products, or smoking devices will be allowed to be kept in the possession of the resident either on their person or in the facility .Once evaluated to smoke safely, the resident will be allowed to smoke at the facility scheduled smoking times with staff supervision .All smoking materials will be retained by staff .",2020-09-01
357,CAMELBACK POST ACUTE AND REHABILITATION,35088,4635 NORTH 14TH STREET,PHOENIX,AZ,85014,2018-03-23,725,E,0,1,73KO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident interviews, staff interviews, and policy and procedure, the facility failed to ensure there was sufficient nursing staff to meet the needs of multiple residents (#s 40, 109, 26, 9, 219, 43, 220, and 13). Findings include: -Resident #40 was admitted on (MONTH) 5, (YEAR) with [DIAGNOSES REDACTED]. Review of the resident's quarterly MDS (Minimum Data Set) assessment dated (MONTH) 8, (YEAR), revealed the resident's BIMS (Brief Interview for Mental Status) score was a 15 which indicated the resident was cognitively intact. An interview was conducted with the resident on (MONTH) 19, (YEAR) at 9:22 a.m. The resident stated that on weekends there are not enough CNAs (certified nursing assistants). -Resident #109 was admitted on (MONTH) 27, (YEAR) with [DIAGNOSES REDACTED]. Review of the resident's annual MDS assessment dated (MONTH) 6, (YEAR), revealed the resident's BIMS score was a 15 which indicated the resident was cognitively intact. An interview was conducted with the resident on (MONTH) 19, (YEAR) at 9:38 a.m. The resident stated that sometimes it takes up to six hours for staff to answer her call light and sometimes they never answer it. The resident further stated that this occurred on all shifts. -Resident #26 was admitted on (MONTH) 11, (YEAR) with [DIAGNOSES REDACTED]. Review of the resident's quarterly MDS assessment dated (MONTH) 18, (YEAR), revealed the resident's BIMS score was 12 which indicated the resident had moderately impaired cognition. An interview was conducted with the resident on (MONTH) 19, (YEAR) at 10:14 a.m. The resident stated that he felt the facility needed more help. The resident stated that sometimes staff come right away when he puts his call light on and sometimes they take forever. The resident further stated that when staff take a long time to answer his call light their response is usually that he is not the only resident there. -Resident #9 was admitted on (MONTH) 19, (YEAR) with [DIAGNOSES REDACTED]. Review of the resident's admission MDS assessment dated (MONTH) 26, (YEAR), revealed the resident's BIMS score was a 15 which indicated the resident was cognitively intact. An interview was conducted with the resident on (MONTH) 19, (YEAR) at 10:52 a.m. The resident stated that when she puts her call light on, it can take at least 45 minutes before she receives assistance because the facility is short of staff. -Resident #219 was admitted on (MONTH) 2, (YEAR) with [DIAGNOSES REDACTED]. Review of the resident's admission MDS assessment dated (MONTH) 9, (YEAR), revealed the resident's BIMS score was a 15 which indicated the resident was cognitively intact. An interview was conducted with the resident on (MONTH) 19, (YEAR) at 11:31 a.m. The resident stated that there was not enough staff on the night shift and on the weekends. -Resident #43 was readmitted on (MONTH) 2, (YEAR) with [DIAGNOSES REDACTED]. Review of the resident's quarterly MDS assessment dated (MONTH) 20, (YEAR), revealed the resident's BIMS score was a 15 which indicated the resident was cognitively intact. An interview was conducted with the resident on (MONTH) 19, (YEAR). The resident stated that twice in the past month she waited for over 20 minutes for her call light to be answered. -Resident #220 was admitted on (MONTH) 5, (YEAR) with [DIAGNOSES REDACTED]. Review of the resident's admission MDS assessment dated (MONTH) 12, (YEAR), revealed the resident's BIMS score was a 15 which indicated the resident was cognitively intact. An interview was conducted with the resident on (MONTH) 19, (YEAR) at 1:39 p.m. The resident stated that once in a while it will take staff 20-30 minutes to answer his call lights. -Resident #13 was admitted on (MONTH) 22, (YEAR) with [DIAGNOSES REDACTED]. Review of the resident's quarterly MDS assessment dated (MONTH) 28, (YEAR), revealed the resident's BIMS score was a 15 which indicated the resident was cognitively intact. An interview was conducted with the resident on (MONTH) 20, (YEAR) at 8:18 a.m. The resident stated that he had to wait 30 minutes to an hour at night before staff answered his call light. The resident further stated that sometimes he has had his call light on all night. An interview was conducted with a CNA (staff #48) on (MONTH) 22, (YEAR) at 12:00 p.m. The CNA stated that the staffing person will usually work the floor if they are short. The CNA stated that there is usually 4-5 CNAs on the day shift for 80 residents. An interview was conducted with another CNA (staff #27) on (MONTH) 22, (YEAR) at 12:01 p.m. The CNA stated that staffing is pretty good. The CNA stated that if staff called off from work they were usually replaced with agency or occasional staff. The CNA further stated that there were usually 4-5 CNAs that worked the day shift. An interview was conducted with a CNA (staff #108) on (MONTH) 22, (YEAR) at 12:05 p.m. The CNA stated that she was just helping out at the facility today as she was employed by another facility. The CNA stated that she had never worked at this facility before. An interview was conducted with a CNA (staff #56) on (MONTH) 22, (YEAR) at 12:10 p.m. The CNA stated honestly we do not have enough staff. The CNA stated that the CNAs report at every staff meeting that there is not enough staff and that the reply is the nurses should help out which does not always happen. The CNA stated that the nurses are usually too busy to help. The CNA stated that 4-5 CNAs are usually scheduled on the day shift and rarely is there six CNAs. An interview was conducted with the administrator (staff #109) on (MONTH) 22, (YEAR) at 2:15 p.m. The administrator stated that five CNAs are usually scheduled on the day shift along with a RNA (restorative nursing assistant). The administrator further stated that staffing depended upon the current census and the acuity of the residents. The facility's policy Sufficient Staff included It is the policy of this facility to provide services by sufficient number on a 24 hour basis to provide nursing care to all residents in accordance with resident care plans to meet resident needs for nursing care in a manner and in an environment which promotes each resident's physical, mental and psychosocial well-being.",2020-09-01
358,CAMELBACK POST ACUTE AND REHABILITATION,35088,4635 NORTH 14TH STREET,PHOENIX,AZ,85014,2018-03-23,760,D,0,1,73KO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a clinical record review, observation, staff interviews, and policy and procedure, the facility failed to ensure one resident (#4) was free of a significant medication error. Findings include: Resident #4 was admitted on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. Review of the physician's orders revealed an order for [REDACTED]. Further review of the physician's orders revealed there was no physician's order to crush medications. Review of the resident's care plan for hypertension and [MEDICAL CONDITION] revealed that all cardiac medications and anti-hypertensive medications are to be administered as ordered by the physician. During a medication administration observation conducted on (MONTH) 21, (YEAR) at 8:09 a.m. with a licensed practical nurse (LPN/staff #95); the nurse prepared the following medications: [REDACTED] . [MEDICATION NAME] 150 mg by PO . Vitamin B Complex 1 tablet PO . [MEDICATION NAME] 5 mg PO . [MEDICATION NAME] 60 mg extended release (ER) PO . Sodium [MEDICATION NAME] 650 mg PO . [MEDICATION NAME] 50 mg PO When the nurse attempted to administer the medications to the resident, the resident requested the medications be crushed. Staff #95 returned to the medication cart and crushed all the medications together and placed the medications in a medicine cup. At 8:15 a.m., the nurse handed the crushed medications to the resident and would have administered the crushed [MEDICATION NAME] ER if not for intervention. Staff #95 then left the room with the medications. He stated that he should not administer the crushed [MEDICATION NAME] ER medication because the extended release medication should not be crushed. At 8:17 a.m., staff #95 prepared the medications again excluding the [MEDICATION NAME] ER, crushed all the medications together, and administered the medications to the resident. A follow up interview was conducted on (MONTH) 21, (YEAR) at 2:08 p.m. with staff #95. He stated extended release medications take longer to dissolve in the body and cannot be crushed. An interview was conducted with the Director of Nursing (staff #98/DON) on (MONTH) 21, (YEAR) at 2:42 p.m. She stated extended release medications should not be crushed. Staff #98 stated that if a nurse is unsure if a medication can be crushed, the nurse should contact the DON or the pharmacy. She further stated the pharmacy phone number is located at the nursing station. During an interview conducted on (MONTH) 22, (YEAR) at 9:23 a.m. with a licensed pharmacist (staff #106), she stated that crushing [MEDICATION NAME] ER would compromise the medication and administer the patient a burst of the medication. Staff #106 stated that there is a possibility the crushed medication would lower the heart rate more than desired. An interview was conducted on (MONTH) 22, (YEAR) at 12:32 p.m. with a LPN (staff #74). He stated crushing and administering an extended release blood pressure medication could potentially result in a negative outcome. Staff #74 stated the resident's blood pressure could drop. He also stated administering a crushed extended release medication is a medication error. He further stated the nurses can call the pharmacy, the DON, or the unit manager to determine if a medication can be crushed. The facility's policy titled Administration of Drugs included that medications shall be administered as prescribed by the attending physician.",2020-09-01
359,CAMELBACK POST ACUTE AND REHABILITATION,35088,4635 NORTH 14TH STREET,PHOENIX,AZ,85014,2018-03-23,761,D,0,1,73KO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews, the facility failed to ensure one multi-dose vial of [MEDICATION NAME] was dated when opened and discarded upon discharge for one resident (#22). Findings include: During an a medication cart observation conducted on (MONTH) 21, (YEAR) at 12:56 p.m. with a Licensed Practical Nurse (LPN/staff #103), a vial of [MEDICATION NAME] 100 units/ml (milliliters) for resident #22 was observed open and in a box. Further observation revealed neither the box nor the vial was marked with an open date. Staff #103 stated the resident had been discharged from the facility. During an interview conducted on (MONTH) 21, (YEAR) at 1:15 p.m., a LPN (staff #40) stated that if a nurse opens a new box/bottle of medication, the nurse must put the date it was opened on the box or on the bottle. During an interview conducted on (MONTH) 23, (YEAR) at approximately 8:30 a.m. with the Resource Registered Nurse (staff #102), staff #102 stated they did not have a facility policy regarding dating multi-dose vials upon opening. An interview was conducted on (MONTH) 23, (YEAR) at 8:59 a.m. with the Director of Nursing (DON/staff #98). She stated insulin that is open is stored on the medication cart and that the insulin should be dated when opened. Staff #98 stated that for residents discharged to their home, the insulin may be sent home with them. She also stated that if the residents decline to take the insulin home, the insulin will be sent to the pharmacy for destruction. Staff #98 stated that if the resident is discharged to the hospital, her expectation is that the nurse will give the insulin to the DON for destruction.",2020-09-01
360,CAMELBACK POST ACUTE AND REHABILITATION,35088,4635 NORTH 14TH STREET,PHOENIX,AZ,85014,2018-03-23,812,E,0,1,73KO11,"Based on staff interviews, observation, facility documentation, and policy, the facility failed to ensure food in the nourishment freezer was stored at safe temperature levels in accordance with professional standards for food service safety. Findings include: During an interview conducted on (MONTH) 21, (YEAR) at 11:50 a.m. with the dietary resource staff (staff #105), he stated there was one nourishment refrigerator and freezer. He then reviewed the nourishment refrigerator and freezer temperature log dated (MONTH) (YEAR) and stated the freezer temperature log had not been completed but that the items in the freezer were frozen. Staff #105 further stated there was not a thermometer in the freezer. At this time, an observation was conducted of the freezer. The freezer contained a package of hot dogs, two green packages of spinach, approximately four ice cream cups, and two ice packs. Review of the nourishment temperature log dated (MONTH) (YEAR), revealed no documented freezer temperatures for the entire month. During an interview conducted on (MONTH) 21, (YEAR) at 2:08 p.m. with a licensed practical nurse (staff #95), he stated that the dietary staff check the food in the nourishment refrigerator daily. Staff #95 further stated it was nursing and the dietary staff's responsibility to check and document the nourishment refrigerator temperatures daily in the temperature log. An interview was conducted on (MONTH) 21, (YEAR) at 3:01 p.m. with the Dietary Supervisor (staff #31). She stated that she checks the nourishment refrigerator every morning but that she does not check the freezer temperature. Staff #31 also stated the freezer does not have a thermometer. The facility's policy and procedure titled Nourishment Rooms revealed food and nutrition services are responsible for checking the refrigerators and freezer temperatures in the kitchenettes or pantries and maintaining documentation.",2020-09-01
361,CAMELBACK POST ACUTE AND REHABILITATION,35088,4635 NORTH 14TH STREET,PHOENIX,AZ,85014,2019-05-30,697,D,0,1,RZQF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure one resident (#54) of three sampled residents received pain management consistent with professional standards of practice. The facility census was 80. The deficient practice had the potential to result in residents experiencing unrelieved pain. Findings include: Resident #54 was admitted to the facility on (MONTH) 22, 2019, with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the care plan dated (MONTH) 23, 2019, revealed the resident had acute and/or chronic pain, with a goal that the resident would verbalize adequate relief of pain through the review date. Interventions included assessing the resident for pain each shift, monitoring for non-verbal signs and symptoms of pain, and following the pain scale to administer medications as ordered. The admission Minimum Data Set (MDS) assessment dated (MONTH) 28, 2019 revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. An interview was conducted with the resident on (MONTH) 28, 2019 at 9:08 a.m. She stated she had told the nurse she had a headache, and she was waiting for the nurse to bring her some pain medication. She stated it was not unusual for her to wait over an hour to receive pain medication. In an interview with a Licensed Practical Nurse (LPN/staff #38) on (MONTH) 28, 2019 at 9:20 a.m., she stated she was the resident's nurse, and that the resident had recently reported that she had pain in the form of a stiff neck. She stated that she knew the resident had a physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. This was over an hour after the resident had reported the headache to the nurse. An interview was conducted on (MONTH) 29, 2019 at 11:17 a.m., with a LPN (staff #68). She stated if a resident reported pain, she would assess the resident for the location and intensity of the pain. She said that if a resident reported pain and she was in the middle of taking care of another resident, she would try to assess the resident within fifteen minutes or provide the resident with an estimated wait time if it would take longer than fifteen minutes. She said if the resident had another medication scheduled to be given in an hour, she would ask the resident if they wanted the pain medication immediately or if they felt like they would be able to wait. An interview was conducted on (MONTH) 29, 2019 at 11:21 a.m., with a LPN (staff #37). She stated if a resident reported pain, she would assess the resident using the pain scale. She said she would not wait to give pain medications in conjunction with scheduled medications that were due later. If the resident wanted pain medication, she would give it to them immediately. An interview was conducted on (MONTH) 29, 2019 at 11:32 a.m., with the Director of Nursing (DON/staff #102). He stated that for pain management, he would expect the nurse to prioritize and to follow-up with the resident at the time pain was reported. He said the nurse should go directly to the resident and assess for pain location and intensity using the pain scale. He said he would also like the nurse to offer non-pharmacological interventions to the resident, and if the pain was still present, he would expect the nurse to administer the appropriate medication based on the physician orders. He said if there was a question about waiting to administer pain medication in conjunction with another medication, that question should be asked of the resident so that the resident could state whether or not they wanted to wait. Review of the facility's pain management policy revealed the facility would assist each resident with pain to maintain or achieve the highest practicable level of well-being by screening for pain, comprehensively assessing pain, identifying circumstances when pain can be anticipated, and developing and implementing a plan to manage the pain. Residents would be monitored for pain on a regular basis such as during routine medication pass. The policy included that the care plan will reflect the pharmacological and non-pharmacological interventions to be used for the resident's pain.",2020-09-01
362,PUEBLO NORTE SENIOR LIVING COMMUNITY,35090,7100 EAST MESCAL STREET,SCOTTSDALE,AZ,85254,2020-01-08,658,E,0,1,GTQK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interviews, and policy review, the facility failed to ensure services met professional standards of quality, by failing to ensure physician's orders [REDACTED].#22). The deficient practice could result in complications related to hypoglycemic episodes. Findings include: Resident #22 was admitted to the facility on (MONTH) 22, (YEAR), with [DIAGNOSES REDACTED]. Review of the care plan initiated (MONTH) 23, (YEAR) revealed the resident was at risk for alteration in blood sugar levels, [DIAGNOSES REDACTED] and/or [MEDICAL CONDITION]. The goal was that the resident will have decreased risks for developing any signs or symptoms of [DIAGNOSES REDACTED] and/or [MEDICAL CONDITION]. Interventions included providing the resident medication, blood sugar checks/labs as ordered and notifying the healthcare practitioner as requested of the results and any adverse drug reactions. Review of the current physician orders [REDACTED]. an initial date of (MONTH) 11, (YEAR) that for blood sugars less than 70, give 4 ounces of orange juice, recheck the blood sugar in 15 minutes, and repeat giving 4 ounces of orange juice until the blood sugar was greater than 70. Continued review of the clinical record revealed the orders were transcribed onto the Medication Administration Records (MARs) except for the order to give 4 ounces of orange juice, recheck the blood sugar in 15 minutes, and repeat giving 4 ounces of orange juice until the blood sugar was greater than 70 for blood sugar readings less than 70, which was transcribed onto the Treatment Administration Records (TARs). The quarterly Minimum Data Set assessment dated (MONTH) 25, 2019 revealed a Brief Interview for Mental Status score of 15 which indicated the resident had intact cognition. The assessment included the resident was diabetic and received insulin injections during the look-back period. Review of the MAR for (MONTH) 2019 revealed the resident's blood sugar reading was 44 on (MONTH) 3 at 5:00 a.m., 62 on (MONTH) 3 at 5:30 p.m., 61 on (MONTH) 11 at 7:30 a.m., 52 on (MONTH) 12 at 5:00 a.m., 55 on (MONTH) 12 at 7:30 a.m., and 59 on (MONTH) 25 at 11:30 a.m. The MAR for (MONTH) 2019 revealed the resident's blood sugar reading was 60 on (MONTH) 8 at 11:30 a.m., 47 on (MONTH) 16 at 5:30 p.m., and 58 on (MONTH) 19 at 11:30 a.m. Review of the MAR indicated [REDACTED] The MAR indicated [REDACTED] However, review of the clinical record including the MARs and TARs revealed no evidence the physician orders [REDACTED]. During an observation conducted on (MONTH) 8, 2020 at 08:06 a.m., a Licensed Practical Nurse (LPN/staff #8) was observed telling resident #22 that his blood sugar was 48 and getting orange juice for the resident. An interview was conducted on (MONTH) 8, 2020 at 09:08 a.m. with staff #8 as she was entering the resident's room with an insulin pen. She stated she had just rechecked resident #22's blood sugar and that it was now 149 and she can now administer the resident's morning insulin. During an interview conducted on (MONTH) 8, 2020 at 10:12 a.m. with a Registered Nurse (RN/staff #2), the RN stated orange juice and snacks are offered to a resident who has a low blood sugar and who is alert and oriented. The RN stated that any time the blood sugar is below 70, they notify the physician and that it is not dependent upon whether they are able bring the resident's blood sugar up or not. An interview was conducted with staff #8 and staff #2 on (MONTH) 8, 2020 at 10:32 a.m. Staff #8 stated that when a resident has a low blood sugar, she would check to see what the physician had ordered for low blood sugars. She also stated that they would recheck the blood sugar within an hour. Staff #8 stated that resident #22 had orders to administered orange juice for a low blood sugar and that she had rechecked his blood sugar within an hour. After reviewing the physician order, staff #8 stated that she was unaware of the order to recheck resident #22's blood sugar in 15 minutes. Staff #2 said the order to recheck the blood sugar is on the TAR and that the order should be on the MAR. In an interview conducted with the Director of Nursing (DON/staff #48) on (MONTH) 8, 2020 at 11:13 a.m., the DON stated the expectation is that staff follow their policy regarding residents that are diabetic which includes following physician orders. After reviewing the physician order [REDACTED]. The facility's policy titled Blood Glucose Monitoring with an effective date of (MONTH) 1, 2019, revealed that if the blood sugar is out of established ranges ordered by the health care practitioner, the test should be repeated, the health care practitioner should be promptly notified of the results and treatment should be provided as ordered by the health care practitioner. The policy included the reading from the glucose meter, date and time of the test, and any physician notifications or treatment provided should be documented in the progress/treatment records or the Blood Glucose Monitoring Record.",2020-09-01
363,PUEBLO NORTE SENIOR LIVING COMMUNITY,35090,7100 EAST MESCAL STREET,SCOTTSDALE,AZ,85254,2017-08-17,224,E,1,1,2T9011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, facility documentation, staff interviews and policy review, the facility neglected to identify one resident (#21) who was at risk for abusing other residents (including resident #74) and develop intervention strategies to prevent occurrences. Findings include: -Resident #74 was admitted to the facility on (MONTH) 7, 2013, with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated (MONTH) 1, (YEAR) revealed resident #74 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS also included the resident required extensive assistance of one person for most activities of daily living. -Resident #21 was admitted to the facility on (MONTH) 31, 2013, with [DIAGNOSES REDACTED]. An annual History and Physical note dated (MONTH) 21, (YEAR), documented the resident continued to touch and talk inappropriately. Review of a care plan dated (MONTH) 21, (YEAR), revealed the resident had impaired cognition as evidence by impaired decision making, poor insight and poor impulse control related to dementia. An intervention included to redirect as needed. According to a facility's investigative report, resident #21 approached a female resident on (MONTH) 9, (YEAR) at 10:30 a.m., and shook her right hand, then moved his right hand up the female resident's arm into her arm pit area, and then touched her breast. The report included resident #21 was placed on 15 minute checks for 72 hrs. Per the report, a care plan related to dementia with behavior disturbances with interventions was in place, prior to this event. However, review of the resident's care plan revealed there were no care plans that addressed the resident's behaviors related to inappropriate touching, prior to this incident. Further review of the cognition care plan revealed it was revised on (MONTH) 9, (YEAR) and included that the resident displayed inappropriate behaviors, with a female resident. Interventions included to check resident #21 every 15 minutes for 72 hrs and medication change, but family refused. Other than the 15 minute checks for 72 hrs, there were no other interventions implemented to ensure that female residents were protected from resident #21. Review of a second facility investigative report revealed that on (MONTH) 30, (YEAR) at 12:45 p.m., resident #21 was going to his table and reached out to a female resident as he was passing by, and placed his hand on her chest and attempted to pull her blouse away. The cognition care plan was revised on (MONTH) 30, (YEAR) to reflect that the resident displayed inappropriate behavior, with a female resident. An intervention included to check resident #21 every 15 minutes for 72 hrs. The care plan was again revised again on (MONTH) 1, (YEAR) and included for the physician to notify the family of inappropriate behavior, discuss medication review, discuss the possibility of a psychiatric consult and 15 minute checks. Again, there were no additional interventions implemented to ensure residents were protected from resident #21. Review of a quarterly Minimum Data Set (MDS) assessment dated (MONTH) 15, (YEAR), revealed resident #21 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The functional assessment of the MDS indicated the resident required supervision and set-up help for walking in the room and locomotion in the corridor. The MDS also included that the resident used a walker for a mobility device. The MDS did not include that the resident had any behaviors. Review of a third facility investigative report revealed that two Certified Nursing Assistants (CNA) were assisting a resident to dinner on (MONTH) 31, (YEAR) at 5:45 p.m. The reported indicated as the CNAs approached the great room, they noticed resident #21 was sitting on the sofa next to resident #74, who was in a wheelchair. Resident #21 was observed holding and kissing the right arm of resident #74. Resident #21 was then observed to reach over and grab the breast of resident #74. The report further included that resident #21 did not recall touching resident #74's breast, and resident #74 did not recall having her breast grabbed. The same cognition care plan was revised on (MONTH) 31, (YEAR) and identified that the resident displayed inappropriate behaviors with female residents and staff. A goal included to decrease episodes of inappropriate behaviors. Interventions included to obtain a psychiatric evaluation, which was refused by the daughter, perform checks on the resident every 15 minutes for 72 hours, and monitor the resident's behaviors. This care plan was also revised on (MONTH) 1, (YEAR) and included the following interventions: keep female residents away from resident #21 and activities to encourage participation throughout the day. Review of the behavior monitoring documentation regarding sexually inappropriate behaviors for resident #21, revealed that for (MONTH) (YEAR) revealed, there were approximately 37 times that the behavior was identified as not applicable. A physician's note dated (MONTH) 3, (YEAR) documented the resident continued to have behavioral changes and identified two incidents where resident #21 grabbed staff member's breasts, and one incident when the resident grabbed the breast of another resident. The note also indicated the resident's family member refused a psychiatric consult, but finally agreed to try medication. A physician's orders [REDACTED]. In an interview conducted on (MONTH) 16, (YEAR) at 2:18 p.m. with a CNA (staff #23), staff #23 stated she never heard of resident #21 trying to do anything to female residents, but he does try to grab staff on their butt or chest. Staff #23 stated he has tried to do that to her and she keeps a distance from him. Staff #23 further stated that she has seen him trying to go into other resident rooms, but he is easily diverted. Staff #23 stated she was not aware of any intervention on the resident's care plan to monitor his behavior with female residents or to keep resident #21 away from female residents. In an interview with a Licensed Practical Nurse (LPN/staff #18) conducted on (MONTH) 16, (YEAR) at 2:38 p.m., staff #18 stated that at one point, resident #21 was being monitored for inappropriate behavior with staff, but they are not monitoring him anymore. Staff #18 stated she was not aware of any intervention on the resident's care plan to monitor his behavior with female residents or to keep resident #21 away from female residents. In an interview conducted on (MONTH) 16, (YEAR) at 2:35 p.m. with a CNA (staff #41), staff #41 stated the resident can be inappropriate with touching and if he does that with staff, then he could do that with residents. Staff #41 stated the care plan does have information on it related to his behavior. She stated she tries to keep resident #21 away from female residents, because of what he does with staff. In an interview with a LPN (staff #16) conducted on (MONTH) 16, (YEAR) at 2:37 p.m., staff #16 stated that resident #21 did require behavior monitoring to make sure he was not inappropriate with female residents. Staff #16 further stated she tried to keep a visual eye on resident #21, when he was in the common area. In an interview with the Assistant Director of Nursing (ADON/staff #6) conducted on (MONTH) 16, (YEAR) at 2:56 p.m., the ADON stated staff walk with the resident to the dining room and take him to and from the bathroom. The ADON stated staff do ongoing monitoring of resident #21 for his behavior of touching people inappropriately. Staff #6 also stated that she did not know why the care plan did not include to keep the resident away from female residents, until after the third event of inappropriate sexual touching. Staff #6 stated she did not know why staff documented not applicable when monitoring the resident's behavior during the month of July. Staff #6 further stated staff should be aware that resident #21 needs to be monitored. Review of the abuse policy revealed that every resident has the right to be free from verbal, sexual, physical, and mental abuse, neglect, exploitation and involuntary seclusion. The policy included the facility will take reasonable and appropriated steps to ensure that each resident is free from abuse, neglect, and exploitation by anyone including, but not limited to staff, other residents, family members, friends or other individuals. The policy further included that sexual abuse is non consensual contact of any type with a resident or contact with any person incapable of giving consent. In addition, the policy stated that neglect is the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.",2020-09-01
364,PUEBLO NORTE SENIOR LIVING COMMUNITY,35090,7100 EAST MESCAL STREET,SCOTTSDALE,AZ,85254,2017-08-17,225,D,1,1,2T9011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility documentation, staff interviews, and policies and procedures, the facility failed to ensure an allegation of misappropriation of resident property for one resident (#170) was thoroughly investigated. Findings include: Resident #170 was admitted on (MONTH) 13, (YEAR) and discharged on (MONTH) 18, (YEAR), with a [DIAGNOSES REDACTED]. A review of the resident's inventory of personal property dated (MONTH) 13, (YEAR) and signed by the resident's responsibly party/family member, revealed the resident had two rings. There was no description of the rings on the inventory sheet. Review of a Missing Property Report Form dated (MONTH) 18, (YEAR), revealed the resident had stated that he had lost his ring three minutes ago. The report included a CNA (certified nursing assistant) and the Activity Director assisted in looking for the ring in the resident's room. According to the facility's investigative report, a LPN (licensed practical nurse/staff #12) took a report from the resident's family member regarding a missing ring. A CNA (staff #113) and the Activity Director (staff #133) were assisting with searching for the ring. Further review of the facility's investigative report revealed it was not thorough, as it did not contain statements from staff #113 or staff #133, nor was there documentation that other residents were interviewed in order to determine if other residents were missing any personal property. On (MONTH) 15, (YEAR) at 1:45 p.m., an interview was conducted with the Social Services Director (staff #48). Staff #48 stated that she did not think she had conducted interviews with other residents regarding missing property. Staff #48 also stated that she should have coordinated interviews with the nursing staff. On (MONTH) 16, (YEAR) at 9:23 a.m., an interview was conducted with the Activity Director (staff #133). Staff #133 stated that she was assisting with taking resident #170's belongings out of the facility on the day of discharge, when she overheard the resident's family member telling staff that the resident's ring was missing. Staff #133 stated she went to the resident's room and assisted staff #113 with looking for the ring. Staff #133 stated that no one came to her after the incident to take a statement. An interview was conducted with the corporate Registered Nurse (staff #125) on (MONTH) 16, (YEAR), who stated that an investigation regarding allegations of misappropriation of resident property, should include interviews with residents and staff, but it appeared that this did not happen with this investigation. An interview was conducted on (MONTH) 17, (YEAR) at 11:41 a.m., with a CNA (staff #113). Staff #113 stated he was assisting resident #170 with packing up his belonging to go home. Staff #113 stated that he also assisted in searching the resident's room and belongings to find the missing ring, with no success. Staff #113 stated that no one had spoken to him after this incident regarding what he had witnessed. Review of a policy regarding abuse investigations, including misappropriation of resident property, revealed that an investigation is a formal and systematic collection and review of available evidence and factual information that seeks to describe or explain an event or series of events. The goals of every investigation are to: 1) obtain as much factual information as possible in an effort to reconstruct and evaluate an incident, event or circumstance 2: provide the basis for an analysis of the data collected to be utilized to make a reasoned judgment if possible, as to how and why an incident occurred or whether an allegation can or cannot be substantiated. 3: Determine what remedial and/or corrective action, if any, may be appropriate to protect residents, prevent recurrence and improve quality of care 4: determine whether the incident must be reported to any regulatory body, governmental agency and/or licensing organization. The policy further stated the process for conducting and documenting interviews included the investigator should compile a list of individuals who may have knowledge of the incident or allegation or who had contact with the resident or subject of the incident just prior to, during, or immediately after the incident. This may include the reporting or complaining party, others present during the incident, the individual accused to have committed the particular infraction and others who may not have been an eye witness to the alleged incident, but who may have relevant knowledge.",2020-09-01
365,PUEBLO NORTE SENIOR LIVING COMMUNITY,35090,7100 EAST MESCAL STREET,SCOTTSDALE,AZ,85254,2017-08-17,226,D,1,1,2T9011,"> Based on review of facility documentation, staff interviews and policies and procedures, the facility failed to implement their abuse policy regarding an allegation of misappropriation of resident property. Findings include: According to a facility's investigative report, a LPN (licensed practical nurse/staff #12) took a report from a resident's family member regarding a missing ring. A CNA (staff #113) and the Activity Director (staff #133) were assisting with searching for the ring. Further review of the facility's investigative report revealed it was not thorough, as it did not contain statements from staff #113 or staff #133, nor was there documentation that other residents were interviewed in order to determine if other residents were missing any personal property. On (MONTH) 15, (YEAR) at 1:45 p.m., an interview was conducted with the Social Services Director (staff #48). Staff #48 stated that she did not think she had conducted interviews with other residents regarding missing property. Staff #48 also stated that she should have coordinated interviews with the nursing staff. An interview was conducted with the corporate Registered Nurse (staff #125) on (MONTH) 16, (YEAR), who stated that an investigation regarding allegations of misappropriation of resident property, should include interviews with residents and staff, but it appeared that this did not happen with this investigation. Review of a policy regarding abuse investigations, including misappropriation of resident property, revealed that an investigation is a formal and systematic collection and review of available evidence and factual information that seeks to describe or explain an event or series of events. The goals of every investigation are to: 1) obtain as much factual information as possible in an effort to reconstruct and evaluate an incident, event or circumstance 2: provide the basis for an analysis of the data collected to be utilized to make a reasoned judgment if possible, as to how and why an incident occurred or whether an allegation can or cannot be substantiated. 3: Determine what remedial and/or corrective action, if any, may be appropriate to protect residents, prevent recurrence and improve quality of care 4: determine whether the incident must be reported to any regulatory body, governmental agency and/or licensing organization. The policy further stated the process for conducting and documenting interviews included the investigator should compile a list of individuals who may have knowledge of the incident or allegation or who had contact with the resident or subject of the incident just prior to, during, or immediately after the incident. This may include the reporting or complaining party, others present during the incident, the individual accused to have committed the particular infraction and others who may not have been an eye witness to the alleged incident, but who may have relevant knowledge.",2020-09-01
366,PUEBLO NORTE SENIOR LIVING COMMUNITY,35090,7100 EAST MESCAL STREET,SCOTTSDALE,AZ,85254,2017-08-17,314,D,0,1,2T9011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and policies and procedures, the facility failed to ensure that one resident (#63) was provided thorough and accurate weekly pressure ulcer assessments. Findings include: Resident #63 was admitted on (MONTH) 19. (YEAR), with [DIAGNOSES REDACTED]. A Health Status Note dated (MONTH) 20, (YEAR) documented the resident had a deep tissue injury on the left buttocks, which measured 0.3 cm (centimeters) by 1.8 cm. Review of a physician's orders [REDACTED]. A care plan dated (MONTH) 21, (YEAR) included the resident had non-blanchable redness to the left buttocks area. An intervention included Document wound evaluation weekly and as needed, notify MD of any changes. An admission Minimum Data Set (MDS) assessment dated (MONTH) 26, (YEAR) documented a BIMS (Brief Interview for Mental Status) score of 14, which indicated the resident was cognitively intact. The MDS also assessed the resident to require extensive assistance of two staff members for bed mobility and transfers, and was frequently incontinent of bladder. The MDS further included the resident was admitted with two suspected deep tissue injuries. A Weekly Progress Evaluation dated (MONTH) 27, (YEAR) documented that the deep tissue injury had resolved, and that a pink superficial open abrasion remained, which measured 1.6 cm by 2.0 cm. The evaluation documented that the wound had improved. Despite documentation that the deep tissue injury had resolved, a nutrition note dated (MONTH) 4, (YEAR), included the resident had a deep tissue injury to the left buttocks. Also, a Health Status Note dated (MONTH) 6, (YEAR) included that wound care monitoring was being done, due to a suspected deep tissue injury to the left buttocks. The buttocks area was assessed next eleven days later on (MONTH) 8, (YEAR). Per the Weekly Progress Evaluation, the abrasion on the left buttock had improved. However, the documentation further included that the abrasion had combined with a wound in close proximity to the abrasion and measured 5.0 cm by 2.0 cm. The area was described as having redness. A Weekly Skin check dated (MONTH) 12, (YEAR) documented a red, blanchable area on the left buttock (at the same site as the abrasion). No measurements were included. A weekly skin assessment dated (MONTH) 19, (YEAR) included the resident had redness and a non blanchable area on the left buttocks, and a superficial opening which was non-blanchable. No measurements were included. Further review of the clinical record revealed there were no wound assessments which included any measurements of the left buttock wound until 19 days later on (MONTH) 7. A weekly wound assessment dated (MONTH) 7, (YEAR) included the abrasion on the left buttocks measured 0.7 cm by 0.7 cm. In addition, there was no clinical record documentation of any measurements of the left buttock wound after (MONTH) 7, (YEAR). An observation of wound care for resident #63 was conducted on (MONTH) 16, (YEAR) at 9:30 a.m., with a Registered Nurse (staff #4). The resident was observed to have a superficial round pink area on the left buttocks. The nurse stated that the pink area was the site of an abrasion, and a scab had fallen off. A weekly wound assessment dated (MONTH) 16, (YEAR), documented the left buttocks had a scabbed abrasion site and the surrounding tissues were blanchable pinkish/red skin. The assessment did not include any measurements of the wound. During an interview conducted on (MONTH) 16, (YEAR) at 11:30 a.m. with a Registered Nurse (staff #4), the nurse stated that the abrasion on the left buttock of resident #63 had been found on the site of a deep tissue injury that had heeled. However, she stated that if a deep tissue injury opens up, it reveals (an underlying) pressure ulcer, and that an abrasion is caused by excoriation of the tissue. The nurse was unable to explain how a deep tissue injury can resolve and form an abrasion. Staff #4 stated that different nurses may describe the wound differently, either as an abrasion or a pressure ulcer. An interview was conducted on (MONTH) 17, (YEAR) at 2:40 p.m., with a Registered Nurse (Staff Development Coordinator/staff #45). She stated that wound assessments are done weekly by her, or another nurse and that the weekly wound assessments should include complete measurements of the wounds, and that the wound measurements are documented in the weekly wound assessment. Staff #45 stated that due to the location of the wound on the resident's left buttocks, the wound could have been pressure related. She stated the nurse who had completed the weekly wound assessments for resident #63 was unavailable, and she had not seen the resident's wounds, and was unable to state if the wound had been a pressure wound or an abrasion. Staff #45 was unable to locate any additional wound measurements. Staff #45 was unable to explain how a deep tissue injury wound can resolve to form an abrasion, rather than a pressure sore. A policy titled, General Wound Types defined an abrasion as rubbing away of the top layers of skin caused by friction to the skins surface, and results in a superficial or partial thickness wound. A policy titled, Categories/Staging of Pressure Ulcers included After the skin is visually inspected and determined to be a pressure ulcer, the wound is categorized or staged using the classification system specifically for pressure ulcers. The policy defined various categories of pressure ulcers and included that a deep tissue injury is a localized area of intact skin, due to damage of underlying soft tissue and/or shearing, may further evolve and may expose additional layers of tissue. A policy and procedure titled, Skin and Wound Management Program Overview contained a statement that the goal of the Skin and Wound Management Program is to promote the healing process of pressure ulcers that are present. The policy stated that all wounds were to be monitored at least weekly by a licensed nurse, with documentation to include the measurements of the wound, including length, depth and width.",2020-09-01
367,PUEBLO NORTE SENIOR LIVING COMMUNITY,35090,7100 EAST MESCAL STREET,SCOTTSDALE,AZ,85254,2017-08-17,329,E,0,1,2T9011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of policy and procedures, the facility failed to adequately monitor one resident (#28), who was receiving antidepressant medications. Findings include: Resident #28 was admitted to the facility on (MONTH) 23, 2013, with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. The original order date was (MONTH) 7, (YEAR). The orders also included to document the resident's behavior every night shift and to document the number of episodes, interventions, outcome and side effects of the medication (original order date was (MONTH) 7, (YEAR)). Review of a significant change Minimum Data Set (MDS) assessment dated (MONTH) 6, (YEAR) revealed the resident received antidepressant medication every day of the 7 day look-back period. A care plan addressed the use of the antidepressant medications and noted that the resident had depression related to social isolation, with tearful episodes and sleeplessness. The interventions included to provide medications as ordered; monitor and document side effects and effectiveness of the medication every shift; and to monitor, document and report any adverse reactions. A physician's orders [REDACTED]. According to the Medication Administration Record (MAR) for (MONTH) and (MONTH) 1 through 7, (YEAR), the resident received the Trazadone as ordered. Further review of the MAR, revealed the resident experienced depression as evidence by sleeplessness, and to monitor the number of episodes, any interventions, outcome and side effects every night shift. However, there was no documentation of the number of episodes, if any interventions were implemented, any outcomes or side effects. The MARs only included a check mark on each night shift. Review of the physician orders [REDACTED]. This medication was originally ordered on (MONTH) 14, (YEAR). The orders also included to document signs and symptoms of depression, as evidenced by social isolation/tearful episodes and to document the resident's behavior every day shift, including the number of episodes, interventions, outcome and side effects of the medication (original order date was (MONTH) 7, (YEAR)). Review of the MAR for June, (MONTH) and (MONTH) 1 through 16, (YEAR) revealed the resident received the [MEDICATION NAME] medication as ordered. The MAR included depression as evidenced by social isolation/tearfulness and to monitor the number of episodes, any interventions, outcome and side effects every day shift. However, there was no documentation of the number of episodes, if any interventions were implemented, any outcomes or side effects. The MARs only included a check mark on the shifts. In addition, there was no other clinical record documentation that the resident's behaviors for sleeplessness and self isolation/tearfulness were being consistently monitored as ordered. An interview was conducted with a Registered Nurse (staff #4) at 12:55 p.m. on (MONTH) 16, (YEAR). She said that the resident is receiving two antidepressant medications and that the nurses working with the resident should document if he has any behaviors. She stated that this is done on the MAR and includes how many episodes, the interventions, and if the resident has any side effects. She said that if an antidepressant medication is being used for sleep, the night nurse usually documents how much sleep the resident gets. After reviewing the MARs, staff #4 stated that instead of documenting all the information that should be there, the order is showing a check mark. She said that the order was likely not put into the system the right way. She further stated that this resident does have times, when he is tearful. In an interview with the Assistant Director of Nursing (ADON/staff #6) at 9:00 a.m. on (MONTH) 17, (YEAR). She stated that when a resident is on antidepressant medication, behavior monitoring is completed. She said the behaviors should be documented on the MAR every shift, and this includes the behavior as specified by the order, the number of episodes, interventions and any side effects. She said that this resident receives Trazadone for sleep and she would expect the night shift would have documented the hours of sleep, and that the day shift would have monitored the resident for any hangover effect from the medication and documented this on the behavior sheet. She said the behavior sheets are used when the pharmacist and the physician are determining if the medication is being effective and if the dose needs to be changed. After reviewing the MARs, staff #6 stated the order was put in wrong so the documentation came across as a check mark, instead of including all of the required information for behavior monitoring. An interview was conducted with the corporate nurse consultant (staff #125) at 12:00 p.m. on (MONTH) 17, (YEAR). She stated that the resident's tearfulness was not being directly monitored. She stated the facility has a policy on psychopharmacological medication, however, there was no policy specific to behavior monitoring for antidepressants. Review of the facility's psychopharmacological medication policy revealed that the purpose was to ensure that psychopharmacological medications prescribed for individual residents are evaluated for continued use and monitored for adverse consequences. The policy included that residents who use psychopharmacological medications must be reviewed on a regular basis and there must be monitoring for efficacy of the medications and adverse consequences.",2020-09-01
368,PUEBLO NORTE SENIOR LIVING COMMUNITY,35090,7100 EAST MESCAL STREET,SCOTTSDALE,AZ,85254,2017-08-17,371,D,0,1,2T9011,"Based on observations, staff interviews, and policies and procedures, the facility failed to ensure food was handled in a sanitary manner, as one staff member handled ready to eat food with bare hands. Findings include: During a random observation in the assisted dining room at 12:30 p.m. on (MONTH) 14, (YEAR), a speech therapy staff member (#132) picked up a french fry and a sandwich from the resident's plate, with her bare hands. Staff #132 then offered the food to the resident. Following the observation, an interview was conducted with staff #132, who stated that she was new and had not received training regarding the handling of residents' foods with her bare hands. Staff #132 then asked if she should have been wearing gloves. At 12:30 p.m., an interview was conducted with the regional nurse (Registered Nurse/staff #124), who had also observed staff #132 pick up the resident's food with bare hands. Staff #124 stated that staff should not be handling residents' ready to eat food, with their bare hands. A review of the personnel file for staff #132 revealed documentation that staff #132 was hired on (MONTH) 19, (YEAR) and had signed an acknowledgement of receiving training regarding infection control procedures, which included proper handling of food and utensils on (MONTH) 20. Review of a policy regarding food safety revealed that food was to be handled to minimize contaminate and bacterial growth and that there was to be no bare hand contact, when handling ready to eat food.",2020-09-01
369,PUEBLO NORTE SENIOR LIVING COMMUNITY,35090,7100 EAST MESCAL STREET,SCOTTSDALE,AZ,85254,2017-08-17,431,D,0,1,2T9011,"Based on observation, staff interviews, facility documentation and policy review, the facility failed to ensure that an opened vial of medication was not available for resident use past its use-by date. Findings include: An observation was conducted with a Registered Nurse (staff #1) on (MONTH) 14, (YEAR) at 11:00 a.m., of a medication refrigerator on the 200 unit. Inside of the medication refrigerator was a multi-use 1 ml vial of Aplisol (tuberculin diagnostic agent), with a handwritten open date on the vial of (MONTH) 9, (YEAR). According to a manufacturer's package insert for Aplisol the following was included: Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. An interview was conducted at this time with staff #1, who stated that the vial of Aplisol was dated as opened on (MONTH) 9, (YEAR), and it should be good for thirty days after it was opened, but was not sure. During an interview conducted on (MONTH) 14, (YEAR) at 11:30 a.m. with the Assistant Director of Nursing (staff #6), she stated that she did not know how long the vial of Aplisol could be used after it was first opened, but the vial of Aplisol had been discarded. A policy and procedure titled, Medication Management Guidelines contained the following: No discontinued, outdated or deteriorated drugs may be retained for use.",2020-09-01
370,PUEBLO NORTE SENIOR LIVING COMMUNITY,35090,7100 EAST MESCAL STREET,SCOTTSDALE,AZ,85254,2017-08-17,441,F,0,1,2T9011,"Based on staff interviews, the facility failed to implement a water management program to ensure that the water supply did not contain waterborne pathogens. Findings include: In an interview conducted with the Assistant Director of Nursing (ADON/staff #6) on (MONTH) 16, (YEAR) at 10:01 a.m., the ADON stated she was not aware of any facility risk assessment or program to ensure the water supply was free from communicable organisms, such as Legionella. In an interview conducted with the Resource Nurse (staff #125) on (MONTH) 16, (YEAR) at 10:01 a.m., staff #125 stated that she was not aware of a safe water program. An interview was conducted on (MONTH) 16, (YEAR) at 2:55 p.m., with the Corporate Director of Facilities Management (staff #137). Staff #137 stated that the facility began looking at contractors to provide this service, but did not secure a contract until about 4 weeks ago. Staff #137 stated the facility will be completing the facility assessment of the building water system, within the next 10 days and should have a program implemented by the end of August. Staff #137 also stated that the program is not currently in place. A policy regarding the water system safety was requested, however, the ADON stated the facility does not have one.",2020-09-01
371,PUEBLO NORTE SENIOR LIVING COMMUNITY,35090,7100 EAST MESCAL STREET,SCOTTSDALE,AZ,85254,2017-08-17,520,E,0,1,2T9011,"Based on a review of the Quality Assurance Performance Improvement (QAPI) documentation, staff interviews and policy and procedures, the facility failed to ensure the quality assurance (QA) program identified quality concerns related to pressure ulcer assessments, abuse prevention and completing thorough abuse investigations. Findings include: During the survey, concerns were identified regarding a lack of accurate and thorough pressure ulcer assessments being completed for one resident (#63). The resident was identified to have a deep tissue injury, however, it was also identified as an abrasion. There were also multiple times when the pressure ulcer was assessed, however, the documentation did not include any measurements. In addition, concerns were identified regarding a resident who displayed inappropriate sexual behaviors, and the facility failed to develop intervention strategies to prevent occurrences. Also, the facility failed to conduct a thorough investigation regarding an allegation of misappropriation of resident property. Review of the facility's QAPI documentation revealed they had identified concerns with wounds, including pressure ulcers and abrasions. The documentation included such problems as treatments, location and types of wounds, and conditions of wounds. However, the documentation did not include a concern that wounds/pressure ulcers were not being consistently measured. Further review of the QAPI documentation revealed a report dated (MONTH) 8, (YEAR) which identified that resident (#63) was being monitored for a wound. Review of a QAPI report dated (MONTH) 31, (YEAR), no longer included that resident (#63) was being monitored for a wound. However, current clinical record documentation showed that the resident continued to have a wound. An interview was conducted on (MONTH) 18, (YEAR) 4:00 p.m., with the ADON (Assistant Director of Nursing/staff #6), the Administrator (staff #126), the staff development coordinator (staff #45), and the corporate nurse (staff #125), all of who were identified as members of the QAPI committee. Staff #6 that prior to (MONTH) 31, (YEAR), wound measurements were not part of the QA process. Staff #6 acknowledged responsibility for the audit process, however, could not explain why resident #63 was dropped off the report and was not being monitored, as part of the QAPI process. In addition, staff #6 and staff #126 stated that there was nothing in QAPI regarding abuse prevention or completing thorough abuse investigations. Review of a policy regarding the QAPI program revealed documentation that the purpose of the program was to proactively and continually improve the way we serve and engage with residents, families, staff, and other partners. A goal included to use action-learning strategies to improve the care and services offered. The QAPI program includes setting measurable goals and evaluate the progress and put systems in place to monitor care and services. This may include tracking, investigating and monitoring events/incidents when they occur and that action plans will be developed and implemented to prevent and minimize reoccurrences. The policy further included that the QAPI committee was responsible for the oversight of the QAPI process, data accuracy and outcomes.",2020-09-01
372,PUEBLO NORTE SENIOR LIVING COMMUNITY,35090,7100 EAST MESCAL STREET,SCOTTSDALE,AZ,85254,2018-11-07,578,E,0,1,O3KK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy and procedure, the facility failed to ensure that advance directives for two residents (#33 and #22) were accurate in their clinical record. Findings include: Resident #33 was admitted to the facility on (MONTH) 6, (YEAR) with the [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. Review of the Do Not Resuscitate (DNR) Pre-Hospital Medical Care Directive form revealed the form was dated and signed by the licensed health care provider and the witness to the directive on (MONTH) 7, (YEAR). The space designated for the resident's signature was blank. A review of the advanced directive form dated and signed by the resident, the facility representative, and the physician on (MONTH) 7, (YEAR), revealed the resident was a DNR. Review of the current care plan regarding advance directives revealed the resident was a Cardiopulmonary Resuscitation (CPR)-Full Code. Further review of the clinical record did not reveal evidence that the physician's orders [REDACTED]. An interview was conducted with a Licensed Practical Nurse (LPN/staff #74) on (MONTH) 6, (YEAR) at 8:58 a.m. She stated that the code status for a resident is located in a binder at the nurse's station and is also in the electronic medical record (EMR). The LPN stated that when a resident is admitted , the floor nurse reviews advance directives with the resident. She stated that if a resident's code status changes, is it the floor nurse's responsibility to update the physician's orders [REDACTED]. During an interview conducted with a LPN (staff #75) on (MONTH) 6, (YEAR) at 10:33 a.m., she stated that she usually knows the code status of the residents residing on her hall. The LPN stated that if a resident from another hall was unresponsive, she would review EMR for the resident's code status. After reviewing this resident's code status in the EMR, the LPN state that this resident was a full code and that if the resident was unresponsive, she would initiate CPR, call for stat help on the radio, and get the crash cart. An interview was conducted with the Director of nursing (DON/staff #61) on (MONTH) 6, (YEAR) at 10:39 a.m. The DON stated that if there is a change in a resident's code status, the floor nurse will obtain the resident or family's signature for the paperwork and update the EMR. She also stated that the staff should be reviewing the binder at the nurses' station for a resident's code status. -Resident #22 was admitted to the facility on (MONTH) 14, (YEAR) and readmitted on (MONTH) 18, (YEAR) with [DIAGNOSES REDACTED]. A review of the clinical record revealed an advanced directive dated (MONTH) 14, (YEAR), that the resident was a Do Not Resuscitate (DNR). The form was dated and signed by the resident, the facility representative, and the physician on (MONTH) 14, (YEAR). Review of the advanced directive dated (MONTH) 18, (YEAR), revealed the resident was a DNR. The form was dated and signed by the resident, the facility representative, and the physician on (MONTH) 18, (YEAR). Review of a Prehospital Medical Care Directive dated (MONTH) 26, (YEAR), revealed the resident was a DNR. The form was dated and signed by the resident and the witness to the directive on (MONTH) 26, (YEAR). The form was dated and signed by the licensed health care provider on (MONTH) 20, (YEAR). The current care plan regarding advanced directives initiated on (MONTH) 28, (YEAR), revealed the resident was a DNR. However, review of the current physician's orders [REDACTED]. This order was discontinued (MONTH) 6, (YEAR) and an order was obtained for CPR-DNR dated (MONTH) 6, (YEAR). An interview was conducted on (MONTH) 6, (YEAR) at 12:13 PM with a licensed practical nurse (LPN/staff #74). She stated that CPR-DNR does not make sense. The LPN stated that she would call the doctor to clarify the order before initiating CPR if the resident was unresponsive. During an interview conducted on (MONTH) 6, (YEAR) at 12:15 PM with a LPN (staff #79), she stated that regarding the physician's orders [REDACTED]. An interview was conducted on (MONTH) 7, (YEAR) at 10:36 AM with the Director of Nursing (DON/staff #61). The DON stated that when a resident is admitted , the nurse will discuss the resident's wishes regarding advanced directive with the resident and document the resident's wishes in the resident's clinical record. The DON stated the physician will write the order for the resident's advanced directive. Review of the facility's policy regarding advanced directives revealed the residents' preferences regarding their medical care and treatment will be honored. The policy included the facility respects the right of its residents to make informed decisions regarding their medical care and to appoint a duly authorized agent to make those decisions. The purpose of the policy is to facilitate the process for residents to express the person's wishes with regard to withholding or withdrawing life-sustaining treatment. The policy also included all direct staff are notified of the existence and location of a resident's Advance Health Care Directive.",2020-09-01
373,PUEBLO NORTE SENIOR LIVING COMMUNITY,35090,7100 EAST MESCAL STREET,SCOTTSDALE,AZ,85254,2018-11-07,600,D,1,1,O3KK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, facility documentation, and policy, the facility failed to ensure that one resident (#201) was free from physical abuse by another resident (#202). Findings include: -Resident #202 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the care plan initiated (MONTH) 23, (YEAR), revealed the resident can become agitated around other residents at times when in close proximity. Interventions included frequent ongoing observations/monitoring of the resident's whereabouts and to observe residents within close proximity and redirect/offer to assist. A quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6 which indicated the resident had moderate cognitive impairment. A nursing progress note dated 12/1/2017 revealed that a nurse observed the resident holding and digging his fingers into the skin of another resident's arm. The note included that the nurse immediately instructed the resident to remove his hand and that the resident did. A social service progress note dated 12/1/2018 at 6:35 PM revealed that the resident stated that the incident did occur; that resident #201 was yelling out and he wanted him to stop. He also stated that he only touched his arm and that he did not grab him hard. -Resident #201 was admitted to the facility on (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. A care plan initiated on 06/14/17 regarding the resident's impaired cognitive function included interventions to cue, reorient, and supervise the resident as needed. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS score of 5 which indicated the resident was severely cognitively impaired. A nursing progress note dated 12/1/2017 at 2:45 PM revealed that the resident was a victim of aggression; a witness observed another resident grab resident #201 by the arm. The note include an assessment of the resident's arm revealed 3 small skin tears and a small purple bruise on his left antecubital area. Review of a Reportable Event Record dated 12/6/2017 revealed that a resident to resident incident occurred on 12/1/2017 at 2:45 PM in the activity room. The report states that resident #202 grabbed resident #201 by the left arm. A nurse immediately separated the two residents and provided first aide to resident #201. The report included the activities staff were present in the room at the time and stated that they had just seen resident #202 near them and that when they looked back he was over by resident #201. The report also included resident #201 had three small skin tears to his right antecubital. An interview was conducted on 11/6/2018 at 11:15 AM with a LPN (licensed practical nurse/staff #85). Staff #85 stated that resident #202 has a history of being unkind, but that to her knowledge, he had not displayed aggressive physical contact before. She stated that she saw resident #202 reach up and grab resident #201 and that she immediately yelled for him to let go. She stated that resident #202 did let go of resident #201's arm and that she separated them. The LPN stated that resident #202 stated that he only touched resident #201 and that he did not do anything. The LPN further stated that resident #201 stated that resident #202 had hurt him. An interview was conducted with the activities director (staff #16) on 11/6/2018 at 12:38 PM. She stated that she did not witness the incident but remembers that the residents were at separate tables. She stated that she was decorating the Christmas tree and heard a nurse yell for resident #202 to let go and that the nurse separated the residents. During an interview conducted with the Director of Nursing (staff #61) at 1:37 PM on 11/6/2018, staff #61 stated that she knew resident #201 had sustained an injury from the resident to resident incident when she saw the scratches and the bruise. The facility's policy on abuse prevention revealed the residents have a right to be free from abuse, neglect, and mistreatment. The policy included the facility will take steps to prevent physical abuse by any individual which included residents. The policy further included that physical abuse includes hitting, slapping, pinching, and kicking.",2020-09-01
374,PUEBLO NORTE SENIOR LIVING COMMUNITY,35090,7100 EAST MESCAL STREET,SCOTTSDALE,AZ,85254,2018-11-07,607,D,0,1,O3KK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documentation, and policy, the facility failed to implement their abuse policy, by failing to report an allegation of abuse within the required time for two residents (#201 and #202). Findings include: -Resident #202 was admitted on [DATE], with [DIAGNOSES REDACTED]. -Resident #201 was admitted to the facility on (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. Review of a Reportable Event Record dated 12/6/2017 revealed that a resident to resident incident occurred on 12/1/2017 at 2:45 PM in the activity room. The report states that resident #202 grabbed resident #201 by the left arm. A nurse immediately separated the two residents and provided first aide to resident #201. The report included the activities staff were present in the room at the time and stated that they had just seen resident #202 near them and that when they looked back he was over by resident #201. The report also included resident #201 had three small skin tears to his right antecubital. Further review of the Reportable Event Record dated 12/6/18 revealed that the resident to resident incident was reported to the State Agency on 12/1/2017 at 5:05 PM. During an interview conducted with the activities director (staff #16) on 11/6/2018 at 12:38 PM., she stated that she notified the Director of nursing (DON/staff #61) of the resident to resident incident immediately after it occurred. An interview was conducted with the DON (staff #61) on 11/6/2018 at 12:52 PM. The DON stated that she reported the resident to resident incident immediately to the residents' families, Ombudsman, Adult Protective Services, the Police Department and the State Agency as soon as she realized that an injury had occurred. She stated that when she called the State Agency it was after hours at 5 PM, so she left a message. The DON further stated that she was aware of the required 2 hour reporting time to the State Agency. She later admitted that she was late reporting the incident to the State Agency. The facility's policy on abuse prevention revealed that all alleged violations and verified incidents must be reported to the State Agency as required.",2020-09-01
375,PUEBLO NORTE SENIOR LIVING COMMUNITY,35090,7100 EAST MESCAL STREET,SCOTTSDALE,AZ,85254,2018-11-07,609,D,1,1,O3KK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, facility documentation, and policy and procedure, the facility failed to report an allegation of abuse within the required time for two residents (#201 and #202). Findings include: -Resident #202 was admitted on [DATE], with [DIAGNOSES REDACTED]. -Resident #201 was admitted to the facility on (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. Review of a reportable event record dated 12/6/2017 revealed that a resident to resident incident occurred on 12/1/2017 at 2:45 PM in the activity room. The report states that resident #202 grabbed resident #201 by the left arm. A nurse immediately separated the two residents and provided first aide to resident #201. The report included the activities staff were present in the room at the time and stated that they had just seen resident #202 near them and that when they looked back he was over by resident #201. The report also included resident #201 had three small skin tears to his right antecubital. Further review of the Reportable Event Record dated 12/6/18 revealed that the resident to resident incident was reported to the State Agency on 12/1/2017 at 5:05 PM. During an interview conducted with the activities director (staff #16) on 11/6/2018 at 12:38 PM., she stated that she notified the Director of nursing (DON/staff #61) of the resident to resident incident immediately after it occurred. An interview was conducted with the DON (staff #61) on 11/6/2018 at 12:52 PM. The DON stated that she reported the resident to resident incident immediately to the residents' families, Ombudsman, Adult Protective Services, the Police Department and the State Agency as soon as she realized that an injury had occurred. She stated that when she called the State Agency it was after hours at 5 PM, so she left a message. The DON further stated that she was aware of the required 2 hour reporting time to the State Agency. During an interview conducted with the DON at 1:37 PM on 11/6/2018, the DON stated that her primary concern was the resident's safety and admitted that she was late reporting the incident to the State Agency. The facility's policy on abuse prevention revealed that all alleged violations and verified incidents must be reported to the State Agency as required.",2020-09-01
376,PUEBLO NORTE SENIOR LIVING COMMUNITY,35090,7100 EAST MESCAL STREET,SCOTTSDALE,AZ,85254,2018-11-07,655,D,0,1,O3KK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and policy, the facility failed to ensure that a summary of the baseline care plan was provided to one resident (#15) and their representative. Findings include: Resident #15 was admitted to the facility on (MONTH) 23, (YEAR), with [DIAGNOSES REDACTED]. The care plan initiated (MONTH) 23, (YEAR), revealed the resident was on anti-coagulant therapy, was at risk for miscommunication related to hearing impairment, was at risk for falls, uses an anti-depressant, and was at risk for skin breakdown related to a history of venous stasis ulcers. Review of the Minimum Data Set (MDS) assessment dated (MONTH) 30, (YEAR), revealed a Brief Interview of Mental Status (BIMS) a score of 3 which indicated the resident was severely cognitively impaired. Further review of the clinical record revealed no evidence that a baseline care plan was discussed with the resident and their representative or that a summary of the care plan was provided to them. An interview was conducted on (MONTH) 6, (YEAR) at 11:04 AM with the MDS coordinator (staff #68). She stated that the baseline care plan for this resident was created, but that it was not discussed with the resident or the resident's representative. She further stated that neither the resident nor the resident's representative was provided a summary of the baseline care plan. Staff #68 stated that the facility's policy was to provide baseline care plan summaries to the residents who were admitted for skilled services, but not to the residents who were admitted for respite or long term care. The facility's policy on Care Plan Development revealed the admitting nurse would develop and initiate a baseline care plan for each resident within 48 hours of admission. The policy also revealed the baseline care plan includes the minimum healthcare information necessary to properly care for each resident immediately upon their admission. The policy included the baseline care plan is based on the admission orders [REDACTED]. The policy did not include providing the resident and their representative with a summary of the baseline care plan.",2020-09-01
377,PUEBLO NORTE SENIOR LIVING COMMUNITY,35090,7100 EAST MESCAL STREET,SCOTTSDALE,AZ,85254,2018-11-07,755,D,0,1,O3KK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, clinical record review, and policy, the facility failed to ensure a controlled medication for one resident (#25) was accurately stored and reconciled. Findings include: Resident #25 was readmitted to the facility on (MONTH) 7, (YEAR), with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. A medication storage observation of a medication cart was conducted on (MONTH) 6, (YEAR) at 3:05 PM with a Licensed Practical Nurse (LPN/staff #78). The resident's medication card for [MEDICATION NAME] was observed to contain fourteen sealed bubbles containing white half tablets. The fifteenth bubble contained a white half tablet; however, the seal was broken and a strip of tape had been placed over the back of the seal. An interview was conducted immediately with staff #78. She stated that a nurse probably removed the pill from the bubble by accident, and tried to put it back. When asked if she could verify that the half tablet in the taped bubble was still the same medication indicated on the card, she stated I can't tell. An interview was conducted on (MONTH) 7, (YEAR) at 8:18 AM, with the Director of Nursing (DON/staff #61). She stated that if a controlled substance was removed from a medication card, then it should be wasted in the presence of two nurses. The DON stated there would be no way to verify for certain that the medication in the taped bubble was still the medication that had been ordered. She further stated that her nurses know not to tape the backs of cards. The facility's policies regarding medication management and medication storage revealed that controlled substances would be stored under a double locked system and in a manner that maintained their integrity and security. The policies further included that an inventory would be kept and signed for correctness of count by the nurse reporting on duty and the nurse reporting off duty every shift, and that any discrepancy would be immediately reported to the DON or administrator.",2020-09-01
378,PUEBLO NORTE SENIOR LIVING COMMUNITY,35090,7100 EAST MESCAL STREET,SCOTTSDALE,AZ,85254,2018-11-07,757,D,0,1,O3KK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interviews, and policy and procedure, the facility failed to ensure one resident (#49) drug regimen was free of unnecessary drugs, by failing to follow physician orders [REDACTED]. Findings include: Resident #49 was readmitted on (MONTH) 8, (YEAR), with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. Additional review of the orders did not reveal an order for [REDACTED]. The care plan initiated (MONTH) 9, (YEAR) regarding pain revealed an intervention to administer pain medications according to the physician's orders [REDACTED]. The admission Minimum Data Set (MDS) assessment dated (MONTH) 15, (YEAR) revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. During a medication administration observation conducted on (MONTH) 7, (YEAR) at 8:00 AM with a Licensed Practical Nurse (LPN/staff #72), resident #49 requested pain medication (the resident did not specify a certain pain medication) for a pain level of 2 or 3. The LPN was observed to administer the resident [MEDICATION NAME] 30 mg. Review of the Medication Administration Record (MAR) for (MONTH) (YEAR) revealed [MEDICATION NAME] 30 mg had been administered on (MONTH) 1, (YEAR) at 9:30 a.m. for a pain level of 4 and (MONTH) 7, (YEAR) at 8:13 a.m. for a pain level of 3. Review of the nursing progress notes dated (MONTH) 1, (YEAR), did not reveal documentation that the physician was notified that the resident was administered [MEDICATION NAME] 30 mg for a pain level of 4 which is outside of the ordered pain level parameters of 7-10. An interview was conducted on (MONTH) 7, (YEAR) at 09:50 AM with staff #72. She stated that when a resident requests pain medication, the resident is asked the location of the pain and to rate the pain on a scale of one to ten. The LPN stated that if the resident requests a narcotic pain medication and the resident's pain level is outside of the parameter ordered for the narcotic pain medication, she will administer the narcotic pain medication and then notify the physician. She further stated that the resident requested the narcotic pain medication. Further review of the nursing progress notes revealed a progress note dated (MONTH) 7, (YEAR) at 9:58 a.m., that the resident had requested [MEDICATION NAME] 30 mg for a pain scale of 2-3. The note included that the physician was notified and that it was requested that the physician change the pain scale for [MEDICATION NAME] from 7-10 to 4-10. During an interview conducted on (MONTH) 7, (YEAR) at 10:36 AM with the Director of Nursing (DON/staff #61), the DON stated that the protocol for administering as-needed pain medication includes asking the resident to rate their pain, administering the resident the appropriate medication, and following up with the resident to see if the pain was relieved. She stated that the expectation is that staff will administer medications according to the physician's orders [REDACTED]. The facility's policy titled Medication Management Guidelines revealed a policy statement that the policy provides guidelines for the administration of medications to residents per physician orders [REDACTED].",2020-09-01
379,HAVEN OF FLAGSTAFF,35091,800 WEST UNIVERSITY AVENUE,FLAGSTAFF,AZ,86001,2019-01-24,600,D,1,1,IZUS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure one resident (#5) was free from abuse by another resident (#37). Findings include: -Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] included that the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive deficits. The MDS also included that the resident needed a two person assist for bed mobility and for transfers into her wheelchair. The MDS coded that the resident did not have any behaviors toward others at the time of the assessment. Review of the resident's fall care plan included that the resident had gait and balance difficulties and a goal that she be free from injuries. A review of the nurses notes dated 10/16/2018 included that resident #5 said, Yes, I hit (resident #37) with my brush after she hit me first. -Resident #37 was admitted on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] included that the resident had a BIMS score of 15 and was a one person assist with bed mobility and transfers. The MDS coded that the resident did not have any behaviors toward others at the time of the assessment. The nursing notes for 10/16/2018 noted that resident #37 reported to the nurse that resident #5 hit her with a brush for no reason. Resident #5 was asked if she hit resident #37 and she admitted she did hit resident #37 but only after she was hit by resident #37 first. Resident #37 then admitted she hit resident #5 first. A review of the facility's investigation dated 10/19/2018 revealed that on 10/15/18 at 8:37 PM, resident #37 reported that resident #5 hit her on the arm with her hair brush. A Licensed Practical Nurse (LPN/Staff #100) assessed the resident's arm and found no signs of injury. The LPN then spoke to resident #5 and she admitted she did hit resident #37 after resident #37 hit her first. The investigation also included that resident #37 admitted to hitting resident #5 first. No specific reason for the altercation was revealed by either resident. An interview was conducted on 1/23/19 at 10:55 AM with resident #5. She stated that she does not remember the incident but does remember (resident #37) used to be her roommate. She added that she has no bad feelings towards resident #5. In an interview with resident #37 on 1/23/19 at 12:20 PM, the resident stated that she does not remember the incident or having hit anyone. An interview was conducted on 01/24/19 at 1:45 PM with the Director of Nursing (DON/staff #13). The DON stated that she did investigate the incident and both residents admitted to the altercation. She also said that resident #37 did admit she hit resident #5 first, but could not explain why. She added that the residents were separated and stayed in separate rooms that evening and were monitored by staff as per protocol. She included that there were no previous incidents between the residents prior to the alleged incident. During an interview conducted on 01/24/19 at 02:01 PM with an LPN (staff #100), she stated that resident #37 approached her while she was in the hallway and stated that resident #5 hit her with a brush. She said she then went into the room and spoke with resident #5 who stated that she did, after resident #37 hit her first. Resident #37 admitted that she did hit resident #5 first because she was not being nice. Staff #100 stated that she separated the residents and assessed each one for injuries and none were present. She then added that she called the DON and reported the incident. Staff #100 concluded that the resident #37 stayed the night in another room in another hall, both residents were monitored all night, and that neither resident appeared upset or traumatized after the incident. Staff #100 also stated that while the two residents did occasionally speak loudly to each other, they appeared happy with each other and there were no physical contact between the residents prior to the incident. A review of the abuse policy noted that the facility strives to prevent abuse of residents and that abuse in any form will not be condoned. It also stated that the goal is to provide a safe haven for the residents and that the resident's right to freedom of abuse will be upheld by preventative measures.",2020-09-01
380,HAVEN OF FLAGSTAFF,35091,800 WEST UNIVERSITY AVENUE,FLAGSTAFF,AZ,86001,2019-01-24,604,D,1,1,IZUS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, review of facility documentation, staff interviews, and facility policy review, the facility failed to ensure one resident (#324) was free from a physical restraint. Findings include: Resident #324 was admitted to the facility on (MONTH) 21, (YEAR) with [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment dated (MONTH) 28, (YEAR) revealed the resident was severely cognitively impaired, required extensive assistance by one or more staff for Activities of Daily Living (ADLs), and had a history of [REDACTED]. Review of the resident's care plan included no evidence that a restraint was to be in use for the resident. An interdisciplinary team fall review dated (MONTH) 29, (YEAR) revealed the resident had a fall on (MONTH) 28, (YEAR) at 7:26 p.m. and experienced a minor injury, a skin tear to the left arm. Review of facility investigation documentation dated (MONTH) 2, (YEAR) included that on (MONTH) 29, (YEAR), the Director of Nursing (DON/staff #13) was alerted that a gait belt may have been used inappropriately on the resident's wheelchair which initiated an investigation. The report indicated that the resident had a history of [REDACTED]. The resident was also noted to have a history of dementia and cognitive impairments. During the investigation it was determined that on (MONTH) 28, (YEAR), the gait belt was observed around the waist of the resident and the wheelchair. All staff on that shift were interviewed and it was determined that a night nurse had placed the gait belt around the resident's waist in an attempt to assist with positioning. All staff who were identified as observing the gait belt being utilized as a restraint were given a final written warning for failure to report a potential violation of policy and resident's rights. The night nurse (staff #141) admitted to utilizing the gait belt as a positioning device in an attempt to keep the resident safe. Further review of the facility investigation revealed witness statements from the following staff: -A Registered Nurse (RN/staff #94) who included that the resident had sustained a fall earlier in the shift and was subsequently observed to keep trying to stand up out of his wheelchair. The RN stated, I am unsure of the time, but at one point in the night a gait belt was put on the resident in a restraining fashion for his safety. The gait belt was put on by the other nurse that was working that night, which was (staff #141). -The DON who questioned staff #141 regarding the gait belt and he admitted that he had used a gait belt to secure the resident in a wheelchair because he was concerned the resident would slide out of the wheelchair and potentially hurt himself. Further, she noted she requested him to sign a written warning and complete a witness statement, which he did not do and was informed that he failed to comply with the investigation. -A Certified Nursing Assistant (CNA/staff #140) noted that she arrived to work on (MONTH) 28, (YEAR) around 10:00 p.m. when she noticed resident #324 was in a wheelchair with a gait belt around him and the wheelchair. -A CNA (staff #142) included that she was rounding on (MONTH) 28, (YEAR) and witnessed the resident fixed to his wheelchair with a gait belt. Review of the clinical record revealed no evidence the resident had an order from a physician to be restrained in any way. Attempts to contact staff #141 via telephone were unsuccessful. In an interview with the DON (staff #13) on (MONTH) 23, 2019 at 10:59 a.m., she stated the morning this was discovered, she became aware because a staff member reported to her that resident #324 was observed to have a gait belt around the back of his wheelchair. At that time the resident was not observed to have the gait belt around him, however she began an investigation to find out why the gait belt was around the resident's chair in the first place. She stated, through interviews, she was able to determine there were witnesses who observed the gait belt around the resident in a restraining manner. She stated the night nurse (staff #141) was determined to be the one who put the gait belt on the resident and he admitted to doing it to keep the resident from falling. Further, she stated staff #141 refused to come in and give a written statement or sign his disciplinary action. She stated, ultimately, staff #141 was terminated. She stated a lot of education was done after this incident regarding restraints and reporting. In a phone interview with an RN (staff #94) on (MONTH) 23, 2019 at 12:04 p.m., he stated he remembers this resident and the incident. He stated the resident had been attempting to get out of is wheelchair a lot and it was not safe. He stated the other nurse working, staff #141, put the gait belt around the resident for safety reasons and not in a malicious manner. Further, he stated he took the gait belt off when he helped put the resident to bed later in the shift. In a phone interview with a CNA (staff #140 and a previous employee) on (MONTH) 23, 2019 at 12:09 p.m., she stated that she remembers this incident as she came into work around 10:00 p.m. and she saw resident #324 seated in front of the nurses station with a gait belt around his waist and the back of the wheelchair he was sitting in. She stated she asked the nurse (whose name she did not remember) about it and the nurse suggested they get him into bed. She stated they then unbuckled the gait belt and took the resident to his room and lay him down in his bed. Further, she stated she got him up and ready in the morning and did not reapply the gait belt to the resident. She stated she had thought the gait belt was being used inappropriately. In an interview with the DON (staff #13) on (MONTH) 23, 2019 at 2:35 p.m., she stated her expectation of staff is not to use any device to secure a resident. She stated if staff witness a resident being restrained, they are to report it immediately. Review of a facility policy titled, Restraint Use Policy included that the facility, strives to be a restraint free environment .Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls.",2020-09-01
381,HAVEN OF FLAGSTAFF,35091,800 WEST UNIVERSITY AVENUE,FLAGSTAFF,AZ,86001,2019-01-24,607,D,1,1,IZUS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to follow their abuse policy for two residents (#5) and (#37). Findings include: -Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] included that the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive deficits. The MDS also included that the resident needed a two person assist for bed mobility and for transfers into her wheelchair. The MDS coded that the resident did not have any behaviors toward others at the time of the assessment. -Resident #37 was admitted on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] revealed that the resident had a BIMS score of 15 and that the resident was a one person assist with bed mobility and transfers. The MDS coded that the resident did not have any behaviors toward others at the time of the assessment. A review of the facility's investigation dated 10/19/18 revealed that on 10/15/2018 at 8:37 PM resident #37 reported that resident #5 hit her on the arm with her hair brush. The Licensed Practical Nurse (LPN/Staff #100) assessed the resident's arm and found no signs of injury. The nurse then spoke to resident #5 and she admitted she did hit resident #37 after resident #37 hit her first. The investigation also included that resident #37 admitted to hitting resident #5 first. No specific reason for the altercation was revealed by either resident. Further review of the investigation revealed no evidence that Adult Protective Services (APS) was notified of the allegation. An interview was conducted on 01/24/19 at 1:45 PM with the Director of Nursing (DON/staff #13). The DON stated that she did investigate the incident and both residents admitted to the altercation. The DON admitted that she knows the facility's policy is to report the allegation, however after speaking with the resident's families, she felt it was not necessary to notify APS because neither the families nor the residents wanted the incident reported. An interview was conducted on 01/24/19 at 02:01 PM with an LPN (staff #100). The nurse stated that she was unaware if APS had been notified but she believes that the facility policy states that they should be and she left this up to the DON. Review of the facility's abuse policy revealed that if abuse is witnessed or suspected, reporting and investigation will take place and the incident will be reported by the Executive Director or the DON to APS. The policy did not indicate that APS would be notified within 2 hours as requied.",2020-09-01
382,HAVEN OF FLAGSTAFF,35091,800 WEST UNIVERSITY AVENUE,FLAGSTAFF,AZ,86001,2019-01-24,609,D,1,1,IZUS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to report an allegation of abuse to Adult Protective Services (APS) for two residents (#5) and (#37). Findings include: -Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] included that the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive deficits. The MDS also included that the resident needed a two person assist for bed mobility and for transfers into her wheelchair. The MDS coded that the resident did not have any behaviors toward others at the time of the assessment. -Resident #37 was admitted on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] included that the resident had a BIMS score of 15 and was a one person assist with bed mobility and transfers. The MDS coded that the resident did not have any behaviors toward others at the time of the assessment. A review of the facility's investigation dated 10/19/18 revealed that on 10/15/2018 at 8:37 PM resident #37 reported that resident #5 hit her on the arm with her hair brush. The Licensed Practical Nurse (LPN/Staff #100) assessed the residents and found no signs of injury. The nurse then spoke to resident #5 and she admitted she did hit resident #37 after resident #37 hit her first. The investigation also included that resident #37 admitted to hitting resident #5 first. No specific reason for the altercation was revealed by either resident. Further review of the investigation revealed no evidence that APS was notified of the allegation. An interview was conducted on 01/24/19 at 1:45 PM with the Director of Nursing (DON/staff #13). The DON stated that she did investigate the incident and both residents admitted to the altercation. She also said after speaking with the resident's families, she felt it was not necessary to notify APS because neither the families nor the residents wanted the incident reported. An interview was conducted on 01/24/19 at 02:01 PM with an LPN (staff #100). The nurse stated that she was unaware if APS had been notified and she left this up to the DON. Review of the facility's abuse policy revealed that if abuse is witnessed or suspected, reporting and investigation will take place and the incident will be reported by the Executive Director or the DON to APS. The policy did not indicate that APS would be notified within 2 hours as requied.",2020-09-01
383,HAVEN OF FLAGSTAFF,35091,800 WEST UNIVERSITY AVENUE,FLAGSTAFF,AZ,86001,2016-10-20,160,E,0,1,BR6Q11,"Based on record review, staff interviews, and facility policy, the facility failed to ensure personal funds were conveyed, with a final accounting of those funds, to the individual or probate jurisdiction administering the resident's estate within 30 days of the resident's death for one resident (#200). Findings include: Resident #200 was admitted to the facility on (MONTH) 27, (YEAR) and expired in the facility on (MONTH) 3, (YEAR). On (MONTH) 19, (YEAR), a review of the Trust and Transaction History of the resident's personal funds account revealed the resident's account balance had not been conveyed to the individual or probate jurisdiction administering the resident's estate. In an interview conducted with the Business Office Manager (staff #12) on (MONTH) 19, (YEAR) at 2:15 p.m., staff # 12 stated the resident had no family in this country. Staff #12 stated she has made multiple calls (at least 25) to the County Fiduciary Office to obtain information as to where the money should be sent. She also stated she does not have a record of the calls and that she did not seek assistance or direction from the administrator or corporate office. In a follow-up interview with staff #12 on (MONTH) 20, (YEAR) at 9:00 a.m., staff #12 stated resident #200 does have a sister that does not live in this country however she does not have her name or home telephone number. In an interview with the Administrator (staff #25) on (MONTH) 20, (YEAR) at 9:30 a.m., the Administrator stated she was just informed that this account had not been closed. She further stated staff #12 never informed her about the issue and that there is a corporate liaison that could have assisted staff #12. Review of the facility policy titled Refunds included any funds on deposit with the facility shall be refunded upon request or the death of the resident. The policy further included, 2. Within thirty (30) days of a resident's death, the facility will provide the resident's personal funds and a final accounting of those funds to the resident's representative or to the probate administering the resident's estate.",2020-09-01
384,BELLA VITA HEALTH AND REHABILITATION CENTER,35092,5125 NORTH 58TH AVENUE,GLENDALE,AZ,85301,2017-06-15,225,D,0,1,SD6H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, staff interviews, and policy and procedures, the facility failed to ensure a resident to resident altercation involving two residents (#191 and #189) was reported to the State agency. Findings include: -Resident #191 was admitted to the facility on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. Review of the annual MDS (Minimum Data Set) assessment dated (MONTH) 8, (YEAR) revealed the resident had a BIMS (Brief Interview for Mental Status) score of 12, which indicated the resident had moderate cognitive impairment. -Resident #189 was readmitted to the facility on (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated (MONTH) 12, (YEAR) revealed the resident BIMS was unable to be conducted because the resident was rarely/never understood. However, review of the nurses progress notes revealed the resident was oriented times two but had [MEDICAL CONDITION]. Review of a facility's investigative report revealed that resident #191 and resident #189 (who was oriented to person and situation) were involved in a resident to resident altercation on (MONTH) 2, (YEAR). Resident #191 reported to nursing staff that she tried to move around resident #189, but he struck her in the arm with a closed hand, while waiting in line for a smoke break. Per the report, staff separated the residents and no injuries were noted. The report included that all responsible parties were notified, however, there was no documentation that the State Agency was notified of the allegation of abuse. During an interview conducted with resident #191 conducted (MONTH) 13, (YEAR) at 9:22 a.m., she stated she had been struck by resident #189 while waiting to smoke. A telephone interview was conducted with a licensed practical nurse (LPN/staff #134) on (MONTH) 14, (YEAR) at 1:54 p.m. She stated that she did not witness the incident first hand, but she heard yelling and went to investigate. She stated that she interviewed the residents involved and documented the incident in the progress notes. Staff #134 stated that she notified additional staff, the DON (Director of Nursing/staff #214), and the physician. An interview was conducted on (MONTH) 13, (YEAR) at 10:28 a.m., with the Director of Nurses (DON/staff #214), a corporate nurse (staff #216), and the Executive Director (staff #215). The DON stated that the incident was unwitnessed and was a he said/she said situation. She stated that since no injury or psychosocial effects were noted, the incident was not called into the State Agency. A facility policy regarding Abuse Prevention included that the facility will notify the state survey agency and other authorities as required by the Abuse Prohibition Policy and as required by law. It also included that all alleged violations will be reported via phone or in writing within 24 hours to the State Licensing Agency. The facility shall follow-up to the State Licensing Agency in writing the findings and results of the completion of the investigation within allowed timeframe per State/Federal rules or whichever is more stringent.",2020-09-01
385,BELLA VITA HEALTH AND REHABILITATION CENTER,35092,5125 NORTH 58TH AVENUE,GLENDALE,AZ,85301,2017-06-15,226,D,0,1,SD6H11,"Based on facility documentation, staff interviews, and review of policy and procedures, the facility failed to implement their policy regarding an allegation of resident to resident abuse involving two residents (#191 and #189). Findings include: Review of a facility's investigative report revealed that resident #191 and resident #189 were involved in a resident to resident altercation on (MONTH) 2, (YEAR). Resident #191 reported to nursing staff that she tried to move around resident #189, but he struck her in the arm with a closed hand, while waiting in line for a smoke break. Per the report, staff separated the residents and no injuries were noted. The report included that all responsible parties were notified, however, there was no documentation that the State Agency was notified of the allegation of abuse. An interview was conducted on (MONTH) 13, (YEAR) at 10:28 a.m., with the Director of Nurses (DON/staff #214), a corporate nurse (staff #216), and the Executive Director (staff #215). The DON stated that the incident was unwitnessed and was a he said/she said situation. She stated that since no injury or psychosocial effects were noted, the incident was not called into the State Agency. A facility policy regarding Abuse Prevention included that the facility will notify the state survey agency and other authorities as required by the Abuse Prohibition Policy and as required by law. It also included that all alleged violations will be reported via phone or in writing within 24 hours to the State Licensing Agency. The facility shall follow-up to the State Licensing Agency in writing the findings and results of the completion of the investigation within allowed timeframe per State/Federal rules or whichever is more stringent.",2020-09-01
386,BELLA VITA HEALTH AND REHABILITATION CENTER,35092,5125 NORTH 58TH AVENUE,GLENDALE,AZ,85301,2017-06-15,441,D,0,1,SD6H11,"Based on observation, staff interview, Center for Disease Control (CDC) guidelines and policy review, the facility failed to ensure that one staff member followed proper hand washing procedures. Findings include: During a medication pass observation on (MONTH) 13, (YEAR) at 8:10 a.m., a licensed nurse (staff #92) was observed to provide medications to a resident. The nurse then touched the resident's clothing and bedding and then went into the resident's bathroom to wash her hands. The nurse was observed to wash her hands with soap and water, and then turned off the faucet with her clean hand, without using a barrier, and then obtained a paper towel to dry her hands. The nurse then proceeded to provide medications to additional residents. During an interview conducted on (MONTH) 13, (YEAR) at 8:45 a.m., staff #92 stated that proper handwashing procedure required the use of a paper towel to turn off the faucet, after washing with soap and water. Staff #92 stated that she had not followed proper handwashing procedure, by turning off the faucet with her bare wet hand after washing her hands. According to a facility handwashing policy, it is their policy to cleanse hands to prevent the transmission of possible infectious material and to provide a clean healthy environment for residents and staff. The policy also stated that hand washing/hand hygiene is generally considered the most important single procedure for preventing the transmission of infection. The policy included to refer to the CDC most current guidelines for handwashing procedures. Review of the CDC guidelines titled, Techniques for Washing Hands with Soap and Water dated (MONTH) 24, (YEAR), contained the following: Rinse your hands with water and use disposable towels to dry. Use towel to turn off the faucet.",2020-09-01
387,BELLA VITA HEALTH AND REHABILITATION CENTER,35092,5125 NORTH 58TH AVENUE,GLENDALE,AZ,85301,2018-08-02,602,D,1,1,X06U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident and staff interviews, review of facility investigation, documents, and policy, the facility failed to ensure one resident (#10) was free from misappropriation of property. Findings include: Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of quarterly MDS assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15, that indicated the resident was cognitively intact. During an initial interview with resident #10 conducted on 07/31/18 at 09:29 AM, resident #10 stated that his I-pad had been missing since Friday, (MONTH) 27, (YEAR). He stated the I-pad had a purple cover on it. He further stated that he had been out to an appointment and did not return to the facility until approximately 4:30 PM, but was told a former resident was here and she came into his room. He stated the former resident comes here 1-2 times each week and doesn't sign in, but goes around to residents and asks for money and some residents give money to her. Resident #10 stated she left the facility in (MONTH) or June. Resident #10 stated he asked the facility to call the police. The former resident identified was admitted to the facility on [DATE] and discharged from the facility on 05/27/18. The facility Administrator (staff #225) was advised of the allegation on 07/31/18 at approximately 1:30 PM and relayed he was aware of the incident and that it was being handled as a grievance by the Social Worker. Review of the facility Grievance Resolution form dated 07/29/18 documented the resident reported his I-pad missing. The police were called, witnesses were talked to, the Find my I-phone application was installed and activated, and staff were interviewed. The I-pad charging cord was found outside and returned to the resident. Included with the grievance form were summaries of interviews with resident #10, 3 Certified Nursing Assistant (CNA) staff members, one of which stated the I-pad was seen charging in the resident's room at approximately 4:00 PM on 07/27/18. There were also summaries of interviews with three witnesses, one of which stated she saw the former resident in the facility on the day in question and another that stated she saw the former resident going out with something in a towel. The grievance report included the Ombudsman and Adult protective Services were notified. Review of the facility visitor sign-in logs for 07/27/18 revealed the former resident did not sign in as a visitor to the facility. In an interview conducted with the Social Worker (staff #75) on 08/01/18 at 10:29 AM, staff #75 stated she had a staff member add an application to the I-pad to trigger a message to return the I-pad to the facility when and if it is turned on. In a follow-up interview with resident #10 on 08/02/18 at 10:15 AM, he stated the former resident is not his friend. Resident #10 stated the former resident would come to visit resident #121 and would then walk around and ask for money. Resident #10 stated he never invited her into his room. He also stated that a couple on the Assisted Living side of the building saw her leaving with his I-pad on 07/27/18 before he returned from his appointment, but did not tell him until 07/29/18 what had happened. In an interview conducted with resident #121 on 08/02/18 at 10:30 AM Resident #121 stated on 07/27/18, the former resident had come in his room and hit me up for money. Resident #121 stated he was with resident #10 when a couple from the assisted living side told him they saw her going out of the facility with his i-pad. In an interview conducted with the receptionist (staff #134) on 08/02/18 at 10:50 AM, the receptionist stated she tries to get everyone who comes to visit to sign in, but some do just walk right in without stopping. In an interview conducted with a man and woman from the assisted living side of the facility on 08/02/18 at 12:55 PM, the couple stated on Friday, (MONTH) 27, (YEAR) at about 4:30 PM, they were in the front lobby and saw the former resident leaving with a white satchel with a lot of things stuffed in the satchel and we could see the purple I-pad sticking out of the satchel. They further stated she comes around the facility asking us on the assisted living side and others in the nursing home for $10 or $20 for different things and some of the people are so nice they fall for what she is saying and they give it to her. She comes here 1-2 times each week and walks right up the ramp and never signs in. They stated she has asked resident #10 and several others for money. The couple stated at the time she was here and walked out of the facility with the I-pad, resident #10 wasn't here because he was at an appointment and didn't return until after she was gone from here. In an interview conducted with a Licensed Practical Nurse (LPN/staff #6) on 08/02/18 at 01:41 PM, the LPN stated if a resident told me someone stole an I-pad, she would report it to Social Services, the Director of Nursing, and the Administration because that is potential misappropriation of property. The police should also be notified. In a follow up interview with staff #75 on 08/02/18 at 01:59 PM, staff #75 stated the weekend manager reported the theft to her. Police were called because of the resident's missing I-pad. In an interview conducted with the Administrator (staff #225) on 08/02/18 at 02:09 PM with the Director of Nursing and Staff #75 present, the Administrator stated that if there is a suspicion of abuse or misappropriation, myself or a delegate will interview the resident immediately, other staff working at the time, as well as other residents that are in the area. If the abuse is suspicious of a crime the police are called and the State Agency and Ombudsman are also notified. We make sure the resident feels safe and that we have addressed their needs. If a staff member is involved, they are removed from the schedule and sent home pending the investigation. If the abuse is suspicious of a crime, the police are called and the State Agency and Ombudsman are also notified. A facility investigation report for Allegation of Abuse (Misappropriation) dated (MONTH) 2, (YEAR) was provided by the facility and documented that on Sunday, (MONTH) 29, (YEAR) resident #10 was alert and oriented to person, place and time, with a BIMS score of 15. The report included that the Social Services Director interviewed resident #10 on 07/29/18 and reported to management that his I-pad was missing from his room when he returned from spending the day at an appointment. He said he talked with a CNA who saw it charging not long before he returned. The resident talked with police. The resident reported he talked to a few friends who reported that they saw a lady leave the facility with what appeared to be something wrapped in a white towel. The resident reported he made friends with a man from church at the facility, who then discovered was a woman. Review of the facility policy titled Resident Rights: Visitation, the policy documented visitors are not allowed to stand in a hallway and are not permitted to enter another resident's room. The policy also documented that prior residents and/or staff need to get written approval from the Administrator or designee for visits. Review of the facility policy titled Resident Rights: Grievances, the policy documented the facility has a grievance process to address resident concerns and make prompt efforts to resolve grievances the resident may have. The policy also included the Grievance Official (Social Services Director), will immediately report all alleged violations involving neglect, abuse, injuries of unknown origin, and/or misappropriation of resident property to the Administrator; as required by law. Review of the facility policy titled Resident Rights: Abuse: Prevention of and Prohibition Against, the policy statement included that each resident has a right to be free from misappropriation of resident property. The policy included that all identified events are reported to the administrator immediately and that after receiving the allegation, the administrator will ensure all residents are protected from harm during and after the investigation. The policy documented that all allegations of misappropriation will be promptly and thoroughly investigated by the Administrator and will include interview with the person making the report, interview with residents, witnesses, the alleged perpetrator, staff, review of the resident clinical record, and review of all circumstances surrounding the incident. The policy included that all allegations of misappropriation of resident property will be reported to outside the Facility and to appropriate State or Federal agencies in the applicable timeframe.",2020-09-01
388,BELLA VITA HEALTH AND REHABILITATION CENTER,35092,5125 NORTH 58TH AVENUE,GLENDALE,AZ,85301,2018-08-02,607,D,1,1,X06U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident and staff interviews, review of facility investigation, documents, and policy, the facility failed to implement their policy on abuse/misappropriation of resident property for one resident (#10). Findings include: Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an initial interview with resident #10 conducted on 07/31/18 at 09:29 AM, resident #10 stated that his I-pad had been missing since Friday, (MONTH) 27, (YEAR). He stated the I-pad had a purple cover on it. He further stated that he had been out to an appointment and did not return to the facility until approximately 4:30 PM, but was told a former resident was here and she came into his room. He stated the former resident comes here 1-2 times each week and doesn't sign in, but goes around to residents and asks for money. Resident #10 stated she left the facility in (MONTH) or June. Resident #10 stated he asked the facility to call the police. The former resident identified was admitted to the facility on [DATE] and discharged from the facility on 05/27/18. The facility Administrator (staff #225) was advised of the allegation on 07/31/18 at approximately 1:30 PM and relayed he was aware of the incident and that it was being handled as a grievance by the Social Worker. Review of the facility Grievance Resolution form dated 07/29/18 documented the resident reported his I-pad missing. The police were called, witnesses were talked to, the Find my I-phone application was installed and activated, and staff were interviewed. The I-pad charging cord was found outside and returned to the resident. Included with the grievance form were summaries of interviews with resident #10, 3 Certified Nursing Assistant (CNA) staff members, and three witnesses. The grievance report included the Ombudsman and Adult protective Services were notified. Review of the facility visitor sign-in logs for 07/27/18 revealed the former resident did not sign in as a visitor to the facility. In a follow-up interview with resident #10 on 08/02/18 at 10:15 AM, he stated a couple on the Assisted Living side of the building saw her leaving with his I-pad on 07/27/18 before he returned from his appointment, but did not tell him until 07/29/18 what had happened. In an interview conducted with the Administrator (staff #225) on 08/02/18 at 02:09 PM with the Director of Nursing and Staff #75 present, the Administrator stated that if there is a suspicion of abuse or misappropriation, myself or a delegate will interview the resident immediately, other staff working at the time, as well as other residents that are in the area. If the abuse is suspicious of a crime the police are called and the State Agency and Ombudsman are also notified. A facility investigation report for Allegation of Abuse (Misappropriation) dated (MONTH) 2, (YEAR) was provided by the facility and documented that on Sunday, (MONTH) 29, (YEAR) resident #10 was alert and oriented to person, place and time, with a BIMS score of 15. The report included that the Social Services Director interviewed resident #10 on 07/29/18 and reported to management that his I-pad was missing from his room when he returned from spending the day at an appointment. He said he talked with a CNA who saw it charging not long before he returned. The resident talked with police. The resident reported he talked to a few friends who reported that they saw a lady leave the facility with what appeared to be something wrapped in a white towel. Review of the facility policy titled Resident Rights: Visitation, the policy documented visitors are not allowed to stand in a hallway and are not permitted to enter another resident's room. The policy also documented that prior residents and/or staff need to get written approval from the Administrator or designee for visits. Review of the facility policy titled Resident Rights: Grievances, the policy documented the facility has a grievance process to address resident concerns and make prompt efforts to resolve grievances the resident may have. The policy also included the Grievance Official (Social Services Director), will immediately report all alleged violations involving neglect, abuse, injuries of unknown origin, and/or misappropriation of resident property to the Administrator; as required by law. Review of the facility policy titled Resident Rights: Abuse: Prevention of and Prohibition Against, the policy statement included that each resident has a right to be free from misappropriation of resident property. The policy included that all identified events are reported to the administrator immediately and that after receiving the allegation, the administrator will ensure all residents are protected from harm during and after the investigation. The policy included that all allegations of misappropriation of resident property will be reported to outside the Facility and to appropriate State or Federal agencies in the applicable timeframe. There was no indication or documentation that the resident had received written permission from the Administrator to visit after being a resident at the facility, that her visits were stopped or checked after the allegation of misappropriation, or that the former resident was kept from entering resident rooms when a resident is not given permission for them to do so. The suspicion of theft of the resident's property was then treated as a grievance, instead of as possible abuse/misappropriation of property until advised by surveyor of misappropriation investigation.",2020-09-01
389,BELLA VITA HEALTH AND REHABILITATION CENTER,35092,5125 NORTH 58TH AVENUE,GLENDALE,AZ,85301,2018-08-02,609,D,1,1,X06U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident and staff interviews, review of facility investigation, documents, and policy, the facility failed to ensure a allegation of misappropriation of property was reported within the required time frames for one resident (#10). Findings include: Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an initial interview with resident #10 conducted on 07/31/18 at 09:29 AM, resident #10 stated that his I-pad had been missing since Friday, (MONTH) 27, (YEAR). He further stated that he had been out to an appointment and did not return to the facility until approximately 4:30 PM, but was told a former resident was here and she came into his room. He stated the former resident comes here 1-2 times each week and doesn't sign in, but goes around to residents and asks for money. Resident #10 stated she left the facility in (MONTH) or June. Resident #10 stated he asked the facility to call the police. The former resident identified was admitted to the facility on [DATE] and discharged from the facility on 05/27/18. The facility Administrator (staff #225) was advised of the allegation on 07/31/18 at approximately 1:30 PM and relayed he was aware of the incident and that it was being handled as a grievance by the Social Worker. Review of the facility Grievance Resolution form dated 07/29/18 documented the resident reported his I-pad missing. The police were called, witnesses were talked to, the Find my I-phone application was installed and activated, and staff were interviewed. The I-pad charging cord was found outside and returned to the resident. Included with the grievance form were summaries of interviews with resident #10, 3 Certified Nursing Assistant (CNA) staff members, and three witnesses. The grievance report included the Ombudsman and Adult protective Services were notified. In an interview conducted with the Administrator (staff #225) on 08/02/18 at 02:09 PM with the Director of Nursing and Staff #75 present, the Administrator stated that if there is a suspicion of abuse or misappropriation, the police are called and the State Agency and Ombudsman are also notified within the required time frames. A facility self report was received by the State Agency on 07/31/18 at 12:40 PM and the resident made the suspicious theft know on 07/29/18, unknown time. Review of the facility policy titled Resident Rights: Grievances, the policy documented the facility has a grievance process to address resident concerns and make prompt efforts to resolve grievances the resident may have. The policy also included the Grievance Official (Social Services Director), will immediately report all alleged violations involving neglect, abuse, injuries of unknown origin, and/or misappropriation of resident property to the Administrator; as required by law. Review of the facility policy titled Resident Rights: Abuse: Prevention of and Prohibition Against, the policy statement included that each resident has a right to be free from misappropriation of resident property. The policy included that all identified events are reported to the administrator immediately and that after receiving the allegation, the administrator will ensure all residents are protected from harm during and after the investigation. The policy included that all allegations of misappropriation of resident property will be reported to outside the Facility and to appropriate State or Federal agencies in the applicable timeframe.",2020-09-01
390,BELLA VITA HEALTH AND REHABILITATION CENTER,35092,5125 NORTH 58TH AVENUE,GLENDALE,AZ,85301,2018-08-02,623,B,0,1,X06U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record reviews, staff interviews, and policy review, the facility failed to notify the State Long Term Care Ombudsman of the transfer and/or discharge of two residents (#121 and #122). Findings include: -Resident #121 was admitted to the facility on (MONTH) 2, (YEAR), with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of a nursing note dated (MONTH) 14, (YEAR), revealed the resident was discharged /transferred to the hospital on (MONTH) 14, (YEAR) at 10:30 p.m., due to the resident's multiple refusals to leave the facility upon discharge earlier that day. The note stated that medical transport took the resident to the hospital. -Resident #122 was admitted to the facility on (MONTH) 28, (YEAR), with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of the discharge nursing note dated (MONTH) 12, (YEAR) revealed that the resident was discharged to home on (MONTH) 12, (YEAR) at 2:30 p.m. Review of the facility's (MONTH) (YEAR) and (MONTH) (YEAR) monthly fax notifications to the Ombudsman revealed there was no evidence that the Ombudsman was notified of the discharge of resident #121 or #122. The facility was unable to provide any documentation that the Ombudsman was sent a copy of the transfer/discharge notices for resident #121 and #122. During an interview conducted on (MONTH) 31, (YEAR) at 3:16 p.m. with the Director of Medical Records (staff #155), she stated that the medical records department is responsible for notifying the Ombudsman of discharges. She stated that the facility only notifies the Ombudsman of facility initiated discharges and does not notify the Ombudsman of resident initiated discharges. She stated that facility-initiated discharges include transfers to the hospital and planned discharges with 30 day notice. She stated that resident initiated discharges include discharges to home. During a follow-up interview on (MONTH) 1, (YEAR) at 1:12 pm with staff #155, she stated that the medical records department notifies the Ombudsman for any resident who is sent to the hospital, whether they are admitted , not admitted , returning to the facility, or not returning to the facility. An interview was conducted on (MONTH) 1, (YEAR) at 1:50 p.m. with the Director of Nursing (staff # 221). She stated that the medical records department is responsible for notifying the Ombudsman of discharges. She stated that the facility's policy is to notify the Ombudsman of facility initiated discharges only. She stated that a facility initiated discharge occurs when a resident is transferred to the hospital, and that a resident initiated discharge occurs when the resident is discharged to home or discharged at the resident's request. During an interview on (MONTH) 2, (YEAR) at 1:08 p.m. with a Clinical Resource staff member (staff #216), he stated the facility does not have a specific policy for notifying the Ombudsman of discharges. He stated the facility follows the CMS regulations for notification of the Ombudsman. Review of the facility's policy regarding Discharge or Transfer revealed it did not address the notification of the Ombudsman for discharges/transfers.",2020-09-01
391,HAVEN OF COTTONWOOD,35093,197 SOUTH WILLARD STREET,COTTONWOOD,AZ,86326,2018-02-15,552,D,0,1,9KJ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and the facility's policy, the facility failed to ensure one resident (#53) was informed of the risks and benefits of a [MEDICAL CONDITION] medication prior to the administration of the medication. Findings include: Resident #53 was admitted to the facility on (MONTH) 25, (YEAR), with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of the MAR (Medication Administration Record) for (MONTH) and (MONTH) (YEAR), revealed the resident was administered [MEDICATION NAME] per the physician's orders [REDACTED]. An admission Minimum Data Set assessment dated (MONTH) 1, (YEAR), revealed the resident was administered an antipsychotic medication all 7 days of the look back period. The assessment also included the resident had a Brief Interview for Mental Status score of 13, which indicated the resident was cognitively intact. However, continued review of the clinical record revealed no evidence the resident had been informed of the risks and benefits of [MEDICATION NAME]. An interview was conducted on (MONTH) 15, (YEAR), at 1:22 p.m. with a Registered Nurse (staff #6). She stated staff will inform the resident or the resident's representative the reason for the medication and the possible side effects. Staff #6 also stated the resident's permission is required to administer a [MEDICAL CONDITION] medication. During an interview conducted on (MONTH) 15, (YEAR) at 2:08 p.m. with the Director of Nursing (staff #48), he stated a consent form for the [MEDICATION NAME] informing the resident of the risks and benefits was unable to be located for this resident. Staff #48 further stated the expectation is that a consent form explaining the risks and benefits would be obtained prior to administering [MEDICATION NAME] to a resident. The facility's policy Behavioral Assessment, Intervention and Monitoring included, The resident and family/representatives will be informed of the resident's condition as well as the potential risks and benefits.",2020-09-01
392,HAVEN OF COTTONWOOD,35093,197 SOUTH WILLARD STREET,COTTONWOOD,AZ,86326,2018-02-15,578,D,0,1,9KJ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and the facility's policy, the facility failed to ensure one resident's (#43) advance directives were completed upon admission. Findings include: Resident #43 was admitted on (MONTH) 11, (YEAR), with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. However, review of the advance directive paperwork revealed that it had not been completed upon admission. Further review of the form revealed the advance directive was optional and that the form was not going to be completed. Additional review of the clinical record revealed the advance directive was not completed until (MONTH) 12, (YEAR). During an interview conducted with the health information specialist (staff #91) on (MONTH) 14, (YEAR) at 11:05 a.m., she stated she was unable to find any advance directive paperwork prior to the form completed on (MONTH) 12, (YEAR). She said that normally, the staff would complete the paperwork upon admission. Staff #91 stated that it is important that the advance directive paperwork be completed and accurate upon admission. She also stated an audit of the advance directives was conducted, but that this one was missed. An interview was conducted on (MONTH) 14, (YEAR) at 1:30 p.m. with a Registered Nurse (RN/staff #64). He stated the unit coordinator is normally responsible for completing new admission paperwork which includes the advance directives. Staff #64 stated if the unit coordinator was unavailable, he would discuss and complete the advance directive paperwork with the resident or the resident's representative within the first few hours of admission. He further stated the advance directives should not be completed several days after the resident is admitted . During an interview conducted on (MONTH) 15, (YEAR) at 1:40 p.m. with the Director of Nursing (staff #48), he stated the advance directive form is to be completed upon admission, not days after the admission. Staff #48 stated that if the resident or the resident's representative refuses to do the paperwork, the resident would be considered a full code until the paperwork is completed. An interview was conducted with an RN unit coordinator (staff #69) on (MONTH) 15, (YEAR) at 3:30 p.m. She stated she usually completes the admission paperwork including the advance directives. Staff #69 stated the advance directive paperwork should be completed within 24 hours but that it is usually completed sooner. She stated she did not know why this resident's advance directive was completed days after admission. Staff #69 further stated a resident would be a full code until the advance directive paperwork is completed. The facility's policy Advance Directives included revealed that prior to or upon admission to the facility, the social service director or designee will provide written information to the resident concerning his/her right to formulate advance directives. The policy further included that prior to or upon admission; the social service director or designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directives. The policy also included information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. The policy included that if the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives and that the resident will be given the option to accept or decline the assistance. The policy also included that nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline.",2020-09-01
393,HAVEN OF COTTONWOOD,35093,197 SOUTH WILLARD STREET,COTTONWOOD,AZ,86326,2018-02-15,641,D,0,1,9KJ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, the facility's policy, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure one resident's (#61) Minimum Data Set (MDS) assessment was accurate. Findings include: Resident #61 was admitted on (MONTH) 1, (YEAR) with [DIAGNOSES REDACTED]. Review of the discharge assessment dated (MONTH) 3, (YEAR), revealed the resident left the facility Against Medical Advice (AMA). However, review of the discharge MDS assessment dated (MONTH) 3, (YEAR), revealed the resident was discharged to an acute hospital. An interview was conducted on (MONTH) 14, (YEAR) at 11:00 a.m. with the MDS coordinator (staff #8). After reviewing the discharge MDS assessment, he stated that the resident left the facility AMA and was not discharged to the hospital and that this was an error. During an interview conducted on (MONTH) 15, (YEAR) at 1:40 p.m. with the Director of Nursing (staff #48), he stated that the MDS assessment was coded incorrectly. The facility's policy Accuracy of Assessment (MDS 3.0) included that the purpose is to ensure each resident receives an accurate assessment by staff that are qualified to assess relevant care areas and are knowledgeable about the resident's status. The policy also included that each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment. The RAI manual instructs to review the resident's clinical record for documentation of the discharge location. The RAI manual also included that it is required that the assessment accurately reflects the resident's status and that the importance of accurately completing and submitting the MDS assessments cannot be over-emphasized.",2020-09-01
394,HAVEN OF COTTONWOOD,35093,197 SOUTH WILLARD STREET,COTTONWOOD,AZ,86326,2018-02-15,655,E,0,1,9KJ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to ensure four residents (#'s 27, 28, 43, and 56) and/or their representatives were provided a written summary of their baseline care plan. Findings include: -Resident #28 was admitted on (MONTH) 12, (YEAR), with [DIAGNOSES REDACTED]. Review of the Admission Nursing Evaluation dated (MONTH) 12, (YEAR), revealed the resident required one person extensive physical assistance for bed positioning, toileting, and personal hygiene, consistent assessing and monitoring for pain, and visual impairment. In addition, the resident had a [NAME]-Pratt drain with care needs that included the assessment of the site and actual drainage contents. The admission Minimum Data Set assessment dated (MONTH) 19, (YEAR), revealed a Brief Interview for Mental Status score of 13 which indicated the resident was cognitively intact. Further review of the clinical record revealed no evidence the resident was provided a written summary of the baseline care plan. An interview was conducted with an Registered Nurse consultant (staff #97) on (MONTH) 15, (YEAR) at 2:35 p.m. Staff #97 stated that when a resident is admitted , the licensed nurse who admits the resident completes the baseline care plan, prints it, review the baseline care plan with the resident, and have the resident sign that the baseline care plan was reviewed with them. Staff #97 also stated that she was unable to find evidence that the baseline care plan was provided to the resident. During an interview conducted on (MONTH) 15, (YEAR) at 1:40 p.m. with the Director of Nursing (staff #48), he stated that he was aware the staff were not always providing a written summary of the baseline care plan to the residents. When requested staff #48 stated the facility did not have a written policy regarding baseline care plans. -Resident #27 was admitted on (MONTH) 20, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed an Admission Nursing Evaluation/Baseline Care plan dated (MONTH) 20, (YEAR), that the resident required the assistance of one person for transfers and was incontinent of bladder. The admission Minimum Data Set assessment dated (MONTH) 27, (YEAR), revealed a Brief Interview for Mental Status score of 15 which indicated the resident was cognitively intact. Continued review of the clinical record revealed no evidence the resident was provided a summary of his baseline care plan. An interview was conducted with an Registered Nurse consultant (staff #97) on (MONTH) 15, (YEAR) at 2:35 p.m. Staff #97 stated that when a resident is admitted , the licensed nurse who admits the resident completes the baseline care plan, prints it, review the baseline care plan with the resident, and have the resident sign that the baseline care plan was reviewed with them. Staff #97 also stated that she was unable to find evidence that the baseline care plan was provided to the resident. -Resident #43 was admitted on (MONTH) 11, (YEAR) with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. -Physical Therapy (PT) and Occupational Therapy (OT) evaluation and treat -Pain medication orders -As needed bowel care -Oxygen orders Review of the admission nursing assessment dated (MONTH) 11, (YEAR), revealed the resident was admitted with multiple care needs. These included: -Activities of Daily Living (ADL) assistance -Skin impairment -Cognitive impairment -Respiratory impairment -Bowel and bladder incontinence -Pain A physician's orders [REDACTED]. Review of the baseline care plan revealed multiple areas including: -Altered respiratory status related to his [DIAGNOSES REDACTED]. -Risk for falls -Oxygen therapy -Impaired cognitive function -Potential for skin impairment -Actual skin impairment: Stage 1 pressure ulcer on admit and boggy heels -ADL self-care performance deficit related to activity intolerance, fatigue, and weakness -Heart failure including medication therapy -Acute/chronic pain and pain medication use Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 18, (YEAR), revealed the resident scored a 3 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. Further review of the clinical record revealed no evidence that the resident or his representative was provided a written summary of the baseline care plan. -Resident #56 was admitted on (MONTH) 3, (YEAR) with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. -Bowel care -PT/OT evaluation and treat -Tube feeding orders -Pain medication orders Review of the admission nursing assessment dated (MONTH) 3, (YEAR), revealed the resident was admitted with multiple care needs that included: -ADL assistance -Skin impairment -Cognitive impairment -Cardiovascular impairment -Tube feeding -Bladder and bowel incontinence -Pain -Impaired range of motion Review of the baseline care plan revealed multiple areas including: -Bladder incontinence -Acute pain -Tube feeding Review of the admission MDS assessment dated (MONTH) 10, (YEAR), revealed the resident scored a 9 on the BIMS indicating moderate cognitive impairment. Further review of the clinical record revealed no evidence the resident or his representative was provided a written summary of the baseline care plan. An interview was conducted with a nurse consultant (staff #93) on (MONTH) 15, (YEAR) at 12:20 p.m. Staff #93 stated that she was unable to locate evidence that the written summary of the baseline care plans for resident #43 and #56 had been provided to the residents and their representatives. She further stated that some residents have not been provided a written summary of their baseline care plan as required. Staff #93 stated the current process is that as the admission nursing assessment is completed, the answers from the assessment generate the baseline care plan. She stated once the assessment is completed, the baseline care plan is printed, provided to the resident and the resident's representative, and signed by the resident or the resident's representative. Staff #93 also stated a copy is provided to the resident and the resident's representative and a copy is retained in the clinical record. She further stated the facility does not have a policy regarding the baseline care plan. During an interview conducted on (MONTH) 15, (YEAR) at 1:40 p.m. with the Director of Nursing (staff #48), he stated that he was aware the staff were not always providing a written summary of the baseline care plan to the residents.",2020-09-01
395,HAVEN OF COTTONWOOD,35093,197 SOUTH WILLARD STREET,COTTONWOOD,AZ,86326,2018-02-15,656,E,0,1,9KJ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, facility documentation, and the facility's policies, the facility failed to develop care plans for two residents (#43 and #13) regarding their health and safety needs. Findings include: -Resident #43 was admitted on (MONTH) 11, (YEAR) with [DIAGNOSES REDACTED]. Review of the progress notes dated (MONTH) 16, (YEAR) revealed the following: -Nursing note: When going over paperwork with the wife, the wife repeatedly expressed that she was not entirely sure if she wanted the facility to provide treatment to the resident and stated that she wished she could just euthanize him. She was informed that this was illegal and social service was informed of the incident. -Nursing note: A sign was placed on the resident's door informing all visitors to check in at the nurses' station. Staff were informed that the resident and his wife were not to be alone together or be in private areas and that the resident cannot leave with the wife on a day pass. -Social service note: Social service was notified by the hospital that they would be contacting APS regarding the resident's wife. The wife had been to the hospital that day and told them that her husband and her had a pact that if either of them were ever to be in the state that the resident was currently in, they would help euthanize each other and that she thought it was his time to go and did not see why the facility would continue to care for him. The note also included the facility will continue to monitor the resident and his wife when they are together and that staff interventions have been set up to ensure the resident's safety. Review of the physician's orders [REDACTED]. The psychology consult dated (MONTH) 16, (YEAR), revealed the nurse reported that the resident and his wife had a suicide pact from years ago. The consult also included that the resident will not be able to return home. The recommendation was to keep the resident focused on daily positive concrete outcomes. Review of the admission Minimum Data Set (MDS) dated (MONTH) 18, (YEAR), revealed the resident scored a 3 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The assessment included that the resident had exhibited 7 to 11 days (out of 14) thoughts that he would be better off dead or hurting himself in some way and that responsible staff or the provider was informed that there was a potential for resident self-harm. The resident was also coded as exhibiting 7 to 11 days (out of 14) where he felt bad about himself. Review of the care plan revealed no evidence that the resident's mood or the concern with the wife were addressed. An interview was conducted with the social service manager (staff #78) on (MONTH) 14, (YEAR) at 12:35 p.m. She stated that she was informed about this resident's wife and the euthanasia threat by the hospital. Staff #78 also stated that when the wife was filling out paperwork, she stated that did not want the resident to receive care because of the suicide pact. Staff #78 further stated that this concern was not covered in the care plan. During an interview conducted on (MONTH) 15, (YEAR) at 1:40 p.m. with the Director of Nursing (staff #48), he stated that this concern was not on the comprehensive care plan, but that it likely should have been because of the seriousness of the issue. -Resident #13 was admitted on (MONTH) 18, (YEAR), with [DIAGNOSES REDACTED]. A review of the facility's safe smoker program documentation revealed resident #13 is an independent smoker. Review of the resident's independent safe smoker contract dated (MONTH) 30, (YEAR), revealed the resident is required to retain smoking materials at the nurses station and all efforts will be made to ensure that all smoking policy and contact rules will be enforced for the health and safety of all residents, staff, and visitors. A review of a social services progress note dated (MONTH) 30, (YEAR), revealed the resident requested to go out and smoke for the first time since admission. Further review of the note revealed the resident was assessed as a safe independent smoker and was educated on the smoking policies, procedures, and contract. Review of the quarterly Minimum Data Set assessment (MDS) dated (MONTH) 14, (YEAR), revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was cognitively intact. The resident was coded as having no functional impairment to the upper or lower extremities and required supervision with one person physical assistance with bed mobility and transfers. The resident was also coded to need extensive assistance with one person physical assistance for locomotion on and off the unit. A review of the current care plan revealed there was no evidence of a smoking care plan in place. An interview was conducted on (MONTH) 12, (YEAR) at 11:34 a.m. with the resident. He stated he sometimes smokes and that he keeps his cigarettes in his room. During the interview an orange pack of cigarettes was observed on the resident's bedside table. During a follow up interview with the resident at 12:42 p.m. on the same day, he stated that he keeps his lighter with him as well. At this time, the resident was observed pulling a red lighter from the front pocket of his gray shirt. An interview was conducted on (MONTH) 13, (YEAR) at 1:51 p.m. with a registered nurse (staff #70). She stated that the resident sometimes smokes and needs assistance to transfer to his wheelchair but that he can wheel himself outside to the designated smoking area. Staff #70 stated the resident has a smoking evaluation and should be care planned for smoking. An interview was conducted on (MONTH) 13, (YEAR) at 1:58 p.m. with a care coordinator (staff #7). She stated smoking is care planned and updated based on a resident's smoking status. Staff #7 stated there is not a smoking care plan for this resident and that whoever completed his smoking evaluation did not care plan smoking. A follow up interview was conducted on (MONTH) 14, (YEAR) at 9:00 a.m. with resident #13. He stated he is unaware of the smoking instructions provided by staff and that he smokes outside in the designated smoking area. At this time, a pack of cigarettes was observed on the bedside table. An interview was conducted on (MONTH) 14, (YEAR) at 11:01 a.m. with the Director of Nursing (staff #48). He stated that once a resident is identified as a smoker; social services, the Assistant Director of Nursing, the Director of Nursing, or the MDS coordinator are to develop a smoking care plan. The facility's policy Care Planning - Interdisciplinary Team included the facility's care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident and that the comprehensive care plan is based on the resident's comprehensive assessment. A facility's policy Goals and Objectives of the Care Plan included that the care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. The policy also included care plan goals and objectives are derived from information contained in the resident's comprehensive assessment and are resident oriented, are behaviorally stated, are measurable, and contain timetables to meet the resident's needs. The policy further included goals and objectives are reviewed and/or revised when there has been a significant change in the resident's condition.",2020-09-01
396,HAVEN OF COTTONWOOD,35093,197 SOUTH WILLARD STREET,COTTONWOOD,AZ,86326,2018-02-15,684,D,0,1,9KJ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and resident and staff interviews, the facility failed to ensure the bowel movement protocol was implemented for one resident (#28). Findings include: Resident #28 was admitted on (MONTH) 12, (YEAR) with [DIAGNOSES REDACTED]. Review of the clinical record revealed a physician's orders [REDACTED]. A review of the standing medical orders revealed the bowel care program which included the following orders: If no bowel movement (BM) in 3 days: 1) administer one dose of Milk of Magnesia (MOM) 30 milliliters, 2) if no result the following morning from the MOM administer a [MEDICATION NAME] suppository, and 3) if no result from the suppository in 2 hours administer a Fleet's enema. Review of the admission Minimum Data Set assessment dated (MONTH) 19, (YEAR), revealed a Brief Interview for Mental Status score of 13 which indicated the resident was cognitively intact. A review of the Certified Nursing Assistant (CNA) bowel monitoring flowsheet revealed from (MONTH) 3 - 8, (YEAR), the resident did not have a BM. Review of the nursing progress notes and Medication Administration Records revealed no evidence the resident was administered the MOM, [MEDICATION NAME] suppository, or the Fleets enema despite not having a BM for 6 days in (MONTH) (YEAR). During an interview conducted with the resident on (MONTH) 12, (YEAR) at 1: 43 p.m., she stated she has had previous problems with constipation. An interview was conducted with a Registered Nurse (staff #69) on (MONTH) 15, (YEAR) at 1:15 p.m. She stated that the protocol is for the CNAs to ask the resident if he/she have had a BM and if the resident has had a BM, document the BM on the bowel monitoring flowsheet. Staff #69 stated the designated nursing staff then reviews the flowsheet and will add the resident's name to a list if the resident did not have a BM in three days and will initiate the BM protocol. She stated after the administration of the medications it is documented on the Medication Administration Record or progress notes. After reviewing the clinical record, staff #69 stated this resident was missed and should have had the prescribed medications on the third day. During an interview conducted with the Director of Nursing (staff #48) on (MONTH) 15, (YEAR) at 3:47 p.m., he stated that the expectation is for nurses to implement the BM protocol and document as appropriate.",2020-09-01
397,HAVEN OF COTTONWOOD,35093,197 SOUTH WILLARD STREET,COTTONWOOD,AZ,86326,2018-02-15,686,G,0,1,9KJ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, staff interviews, and the policies and procedures, the facility failed to ensure one resident's (#8) pain was managed during a pressure ulcer wound treatment. Findings include: Resident #8 was admitted on (MONTH) 6, (YEAR), with [DIAGNOSES REDACTED]. Review of the quarterly MDS (Minimum Data Set) assessment dated (MONTH) 7, (YEAR), revealed the resident had a BIMS (Brief Interview for Mental Status) score of 5, which indicated the resident was severely cognitively impaired. A significant change MDS assessment dated (MONTH) 4, (YEAR), revealed the resident was receiving Hospice services and had almost constantly experienced pain or was hurting over the last 5 days. The assessment did not include an assessment of the resident's cognitive patterns. Review of the current care plan revealed the resident had chronic pain and was being administered opioid [MEDICATION NAME] medications related to arthritis. The care plan interventions revealed the resident was to be administered [MEDICATION NAME] medication a half hour before treatments or care, that medications and treatments were to be provided as ordered to ensure comfort, and that the resident was able to express how much pain is being experienced as well as what increases or alleviates the pain. The interventions also included the physician should be notified if the interventions are unsuccessful or if the current complaint is a significant change from the resident's past pain experiences. A review of the resident's current physician's orders [REDACTED]. Additional review of the current physician's orders [REDACTED]. An unstageable pressure ulcer treatment observation was conducted on (MONTH) 13, (YEAR) at 1:45 p.m. with a Registered Nurse (RN/staff #5/Assistant Director of Nursing), a Certified Nursing Assistant (staff #25), and a RN consultant (staff# 94). Staff #5 stated the resident had been pre-medicated with [MEDICATION NAME] and [MEDICATION NAME]. The resident appeared comfortable and was sleeping. When staff #5 removed the resident's dressing from the left thigh, the pressure ulcer was observed to be beefy red in the center and surrounded by yellow slough. While staff #5 was cleaning the pressure ulcer with normal saline, the resident grimaced and groaned. Staff #5 and staff #25 reassured the resident that the treatment would be over soon. When staff #5 placed the long sterile cotton swab in the pressure ulcer to measure the depth, the resident screamed out in pain and had a grimace on her face. The pressure ulcer measured 1.4 centimeters (cm) x 4.5 cm x 0.5 cm. As the [MEDICATION NAME] was applied to the wound, the resident continued to grimace and groan. A dressing was placed over the wound. Resident #8 then stated, It hurts so bad. What can I do to make it stop? The resident was observed to have a grimace on her face throughout the treatment. At this time, while staff #5 was washing her hands and preparing to provide the next dressing change to the resident's right thigh, staff #94 questioned whether there were any more pain medications available for the resident. Staff #5 stated she thought the resident had [MEDICATION NAME] available and would check with the floor nurse after the treatment. Staff #5 then proceeded to administer the treatment to the resident's right thigh. Staff #5 stated she was going to classify the wound as healed. She cleaned the wound and placed a dressing on the area for preventative measures. The resident was then repositioned and covered. Review of the Medication Administration (MAR) Record dated (MONTH) (YEAR), revealed the resident was administered [MEDICATION NAME] 10-325 mg for a pain level of 7 and [MEDICATION NAME] 0.5 mg on (MONTH) 13, (YEAR) at 12:56 p.m., prior to the wound treatment. However, further review of the MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. An interview was conducted on (MONTH) 15, (YEAR) at 11:05 a.m. with Staff #5. She stated the pain the resident exhibited during the wound treatment on (MONTH) 13, (YEAR) was not normal for her. Staff #5 stated the resident had been pre-medicated prior to the treatment and that there was not much more they could do for her pain. She stated they tried to provide the treatment as quickly as possible and that the resident was medicated with [MEDICATION NAME] after the treatment. Staff #5 further stated that there was no reason for the resident to be in that much pain. During an interview conducted on (MONTH) 15, (YEAR) at 1:42 p.m. with the Director of Nursing (staff #48), he stated that if a resident is experiencing pain during a treatment, the expectation is that the resident would be made comfortable. Staff #48 stated a possibility would be to stop the treatment for [REDACTED]. He also stated that non-pharmacological interventions should be offered as well to relieve the pain. Staff #48 further stated the provider should be notified that the resident is experiencing more pain than usual. He stated that they want the resident to be as comfortable as possible. An interview was conducted on (MONTH) 15, (YEAR) at 1:11 p.m. with the Nurse Practitioner (staff #95). He stated that the resident's pain is being managed appropriately and that some pain would be expected with a wound like the resident has. The facility's policy Administering Pain Medication included that the pain management program is based on a facility-wide commitment to resident comfort. The policy also included Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. The policy further included to be familiar with verbal expressions such as groaning, crying, screaming and facial expressions such as grimacing, frowning, clenching of the jaw, etc. The facility's policy titled Wound Management Program included, All Residents with wounds receive treatment and services consistent with the resident's goals of treatment. These goals may be primarily to promote healing or in some cases they may be centered on palliative care .The Wound Management Program is structured and implemented using processes founded on accepted standards of practice, research driven clinical guidelines and interdisciplinary involvement.",2020-09-01
398,HAVEN OF COTTONWOOD,35093,197 SOUTH WILLARD STREET,COTTONWOOD,AZ,86326,2018-02-15,689,D,0,1,9KJ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, resident and staff interviews, facility documentation, and the facility's policy, the facility failed to ensure the smoking protocol was implemented for one resident (#13). Findings include: Resident #13 was admitted on (MONTH) 18, (YEAR), with [DIAGNOSES REDACTED]. A review of the facility's safe smoker program documentation revealed resident #13 is an independent smoker. Review of the resident's independent safe smoker contract dated (MONTH) 30, (YEAR), revealed the resident is required to retain smoking materials at the nurses' station and all efforts will be made to ensure that all smoking policy and contact rules will be enforced for the health and safety of all residents, staff, and visitors. A review of a social services progress note dated (MONTH) 30, (YEAR), revealed the resident requested to go out and smoke for the first time since admission. Further review of the note revealed the resident was assessed as a safe independent smoker and was educated on the smoking policies, procedures, and contract. Review of the quarterly Minimum Data Set assessment (MDS) dated (MONTH) 14, (YEAR), revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. The resident was coded as having no functional impairment to the upper or lower extremities and required supervision with one person physical assistance with bed mobility and transfers. The resident was also coded to need extensive assistance with one person physical assistance for locomotion on and off the unit. An interview was conducted on (MONTH) 12, (YEAR) at 11:34 a.m. with the resident. He stated he sometimes smokes and that keeps his cigarettes in his room. During the interview, an orange pack of cigarettes was observed on the resident's bedside table. During a follow up interview with the resident at 12:42 p.m. the same day, he stated that he keeps his lighter with him as well. At this time, the resident was observed pulling a red lighter from the front pocket of his gray shirt. An interview was conducted on (MONTH) 12, (YEAR) at 12:47 p.m. with a registered nurse (staff #70). She stated resident #13 is an independent smoker and that he has his lighter and cigarettes with him. An interview was conducted on (MONTH) 12, (YEAR) at 12:48 p.m. with the care coordinator (staff #7). She stated resident #13 is an independent smoker and that independent smokers are allowed to keep cigarettes and lighters with them. A follow up interview was conducted on (MONTH) 13, (YEAR) at 1:51 p.m. with staff #70. She stated that the resident sometimes smokes and needs assistance to transfer to his wheelchair but that he can wheel himself outside to the designated smoking area. A follow up interview was conducted on (MONTH) 13, (YEAR) at 1:58 p.m. with staff #7. She stated that if a resident is considered a safe smoker, the resident is allowed to store their cigarettes and lighter. Staff #7 stated that if a resident is unsafe and needs supervision, the facility keeps the cigarettes and lighters locked at the nurses' station. A follow up interview was conducted on (MONTH) 14, (YEAR) at 9:00 a.m. with resident #13. He stated he is unaware of the smoking instructions provided by staff and that he smokes outside in the designated smoking area. At this time, a pack of cigarettes was observed on the bedside table. An interview was conducted on (MONTH) 14, (YEAR) at 9:45 a.m. with a certified nursing assistant (staff #24). She stated that the resident smokes occasionally and is an independent smoker. Staff #24 also stated that independent smokers are allowed to keep their cigarettes, but that the staff will keep the lighters at the nurses station. An interview was conducted on (MONTH) 14, (YEAR) at 11:01 a.m. with the Director of Nursing (DON/staff #48). He stated upon admission while the nursing assessment is being completed, residents are asked if they smoke or have a history of smoking. Staff #48 stated social services or the DON will complete a smoking assessment and a smoking contact for the resident that smokes. He stated smoking materials (lighters and cigarettes) are kept locked at the nurses' station for residents that are independent with smoking and for residents that need assistance with smoking and that this information is also in the smoking contact. Staff #48 further stated the expectation is that resident #13 is not keep his lighter or cigarettes and that it was explained to the resident that he cannot keep his lighter or cigarettes with him. The facility's policy Smoking included that assisted smokers will have cigarettes and lighters kept at the nurses' station with no exceptions. However, the policy did not specifically address where the cigarettes and lighters will be kept for residents that are independent with smoking. Review of the Safe Smoker Contract for the Independent Safe Smoking Program revealed the resident is required to retain smoking materials at the nurses' station and all efforts will be made to ensure that all smoking policy and contract rules will be enforced for the health and safety of all residents, staff, and visitors.",2020-09-01
399,HAVEN OF COTTONWOOD,35093,197 SOUTH WILLARD STREET,COTTONWOOD,AZ,86326,2019-05-02,640,E,0,1,71MW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure discharge Minimum Data Set (MDS) assessments were completed and submitted to the Centers for Medicare and Medicaid Services (CMS) System within the required timeframe for 2 of 21 sampled residents (#2 and #3). The deficient practice could result in lack of resident specific information for quality measure purposes. Findings include: -Resident #2 was admitted on (MONTH) 22, (YEAR) with [DIAGNOSES REDACTED]. Review of the discharge assessment revealed the resident was discharged home on (MONTH) 13, (YEAR). However, review of the clinical record and the CMS System did not reveal a discharge MDS assessment had been completed and submitted to the CMS System. -Resident #3 was admitted on (MONTH) 29, (YEAR) with [DIAGNOSES REDACTED]. Review of the discharge assessment revealed the resident was discharged home on (MONTH) 11, (YEAR). However, review of the clinical record and the CMS System did not reveal a discharge MDS assessment had been completed and submitted to the CMS System. An interview was conducted the MDS Coordinator (staff #47) on (MONTH) 1, 2019 at 11:18 a.m. Staff #47 stated that discharge MDS assessments have to completed and submitted to the CMS System within 14 days. Staff #47 stated that a discharge MDS assessment was completed for resident #2 but not submitted to the CMS System. Staff #47 stated that a discharge MDS assessment for resident #3 was initiated (MONTH) 7, (YEAR) but was not completed and submitted to the CMS System. He also stated that he did not know why the assessments had not been submitted to the CMS System. During an interview conducted with another MDS Coordinator (staff #12) on (MONTH) 1, 2019 at 12:20 p.m., staff #12 stated that the discharge assessments for resident #2 and resident #3 were not completed. An interview was conducted with Director of Nursing (DON/staff #65) on (MONTH) 2, 2019 at 11:03 a.m. The DON stated that there was no system in place to ensure MDS assessments were submitted. The DON also stated the expectation is that the MDS Coordinators review the assessments to ensure the assessments are complete and submitted to the CMS System. The RAI manual revealed a discharge MDS assessment must be completed when a resident is discharged from the facility to a private residence. The RAI manual also included the discharge MDS assessment must be completed within 14 days after the discharge date . The RAI manual instructs discharge MDS assessments must be transmitted (submitted and accepted into the MDS database) electronically no later than 14 calendar days after the MDS assessment completion date.",2020-09-01
400,HAVEN OF COTTONWOOD,35093,197 SOUTH WILLARD STREET,COTTONWOOD,AZ,86326,2019-05-02,641,D,0,1,71MW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure Minimum Data Set (MDS) assessments for 2 of 21 sampled residents (#119 and #69) were accurate. This deficient practice could affect continuity of care. Findings include: -Resident #119 was readmitted to the facility on (MONTH) 13, (YEAR), with [DIAGNOSES REDACTED]. A health status note dated (MONTH) 18, (YEAR) at 11:08 a.m., revealed the resident had a fall at approximately 10:50 a.m. The note included the resident sustained [REDACTED]. It also included the resident was sent to the ER (emergency room ) at approximately 11:05 a.m. A health status note dated (MONTH) 18, (YEAR) at 1:05 p.m., revealed the resident returned to the facility. The Interdisciplinary Team Fall Review note dated (MONTH) 19, (YEAR), revealed the resident had a fall on (MONTH) 18, (YEAR) at 6:40 p.m. The resident stated that he was in his wheelchair and reached for something on the floor, and slid out of the wheelchair scraping his back on the edge of the bed. The note included the skin tear to the back was 5 cm (centimeter) x 3 cm. However, review of the admission/5 day MDS assessment dated (MONTH) 20, (YEAR) revealed the resident had only one fall with injury (not major) since admission or the prior assessment. During an interview conducted with the MDS Coordinator (staff #12) on (MONTH) 2, 2019 at 10:53 a.m., he stated that he uses the RAI manual to code falls. Staff #12 stated that he obtains the fall report that that contains the number of falls a resident has had. He further stated that when a resident has two falls on the same day, there should be a report for each fall. Staff #12 stated that the fall report only reflected one fall on (MONTH) 18, (YEAR). In an interview with the Director of Nursing (DON/staff #65) conducted on (MONTH) 2, 2019 at 1:18 p.m., she stated that the IDT review note dated (MONTH) 19, (YEAR) was for the fall documented in the health status note dated (MONTH) 18, (YEAR). She stated the different time in the two notes was a typographical error. She said that the different locations of skin tears in the two notes was because the staff completing the fall incident report can only enter one wound site. An interview was conducted with another MDS Coordinator (staff #47) on (MONTH) 2, 2019 at 1:42 p.m. Staff #47 stated that she was the one who documented the health status note regarding the fall the resident was sent to the ER for. The MDS Coordinator stated that based on the IDT note, there were two falls on (MONTH) 18, (YEAR) and that only one of the falls was coded on the MDS assessment. An interview was conducted with the Assistant DON (ADON/staff #11) on (MONTH) 2, 2019 at 1:59 p.m. She stated that she wrote the IDT note dated (MONTH) 19, (YEAR) and that the resident fell on ce on (MONTH) 18, (YEAR). Staff #11 stated that she could have easily screwed up the time of the fall and that the resident had left arm skin tears that she did not include. During another interview conducted with the DON (staff # 65) on (MONTH) 2, 2019 at 2:26 p.m., she stated that when a resident falls, the nurse documents the fall in the progress note and the IDT meet to discuss the fall. The DON stated that she understood why the inconsistencies in the documentation could be confusing. The RAI manual instructs to review incident reports, fall logs, and the medical record (physician, nursing, therapy, and nursing assistant note) to determine the number of falls that occurred from admission to the Assessment Reference Date. The manual includes if the resident had a fall code yes and code the level of fall-related injury for each fall. -Resident #69 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review if the clinical record revealed a physician order [REDACTED]. Review of the Medication Administration Record [REDACTED]. However, review of the admission MDS assessment dated (MONTH) 10, 2019, revealed the resident was not administered any IV medications during the 14 day look-back period. During an interview conducted with the ADON (staff #11) on 05/02/19 at 11:52 AM., the ADON stated that the expectation is that the MDS assessments are accurate. An interview was conducted with the MDS coordinator (staff #12) on 05/02/19 at 11:59 AM. Staff # 12 stated that he gathers data for the MDS assessments through interviews with the residents and staff. Staff #12 stated that the MDS assessment was coded incorrectly for the resident receiving IV medications because documentation confirms the resident was administered IV medications. The RAI manual instructs to review the resident's medical record to determine whether or not the resident received any IV medications within the last 14 days. The RAI manual also included .the importance of accurately completing and submitting the MDS cannot be over-emphasized. The MDS is the basis for the development of an individualized care plan . Federal regulations require that the assessment accurately reflects the resident's status.",2020-09-01
401,HAVEN OF COTTONWOOD,35093,197 SOUTH WILLARD STREET,COTTONWOOD,AZ,86326,2019-05-02,677,E,0,1,71MW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, interviews, and policy review, the facility failed to ensure one of two sampled residents (#16) received the necessary services to maintain good grooming and oral hygiene. This deficient practice could result in grooming and oral hygiene needs not being met. Findings include: Resident (#16) was admitted to the facility on (MONTH) 8, 2019 and readmitted on (MONTH) 8, 2019 with [DIAGNOSES REDACTED]. Review of the care plan initiated (MONTH) 8, 2019 revealed the resident had activities of daily living self-care performance deficit related to activity intolerance, fatigue, and impaired mobility. The goal was that the resident would improve the current level of function in personal hygiene and dressing. Interventions included the resident required staff participation with personal hygiene, oral care, and dressing. The admission Minimum Data Set assessment dated (MONTH) 15, 2019, revealed a score of 14 on the Brief Interview Mental Status which indicated the resident was cognitively intact. The MDS assessment included the resident required total assistance with dressing and extensive assistance with personal hygiene which included brushing teeth. Review of the oral care on the CNA Activities of Daily Living Task Sheet for (MONTH) 2019 revealed the resident received assistance with oral care or was provided set up only. The documentation also revealed the resident did not refuse oral care. During an initial interview conducted with the resident's family member on (MONTH) 29, 2019 at 10:24 a.m., the family member stated that the resident's pajama top is not being changed daily by staff. The family member stated that for the past week, the resident had worn the same purple pajama top that buttons down the front for about 5 days. The family member also stated that the resident stated the staff are not brushing the resident's dentures. The family member stated that they have been requesting the staff clean the resident's dentures for the last 2 to 3 months. The family member also stated that the resident is able to put the dentures in water, but that it does not always happen because the resident forgets and when the family member arrive in the morning, the resident is still wearing the dentures. On (MONTH) 1, 2019 at 12:55 p.m., an interview was conducted with resident #16 and the resident's family member. The resident was observed to be wearing a cream colored pajama top with long sleeves that buttoned up the front. The pajama top was wrinkled and had a brown stain running along the front of the pajama top by the buttons and another brown stain on the top right of the pajama top just below the collar. The resident's family member stated that the resident was wearing the cream colored pajama top yesterday. The resident stated that she asked the staff for a clean top and that staff replied they will help her change the top when they are not so busy. The resident stated that the staff do not come back. The resident also stated that the Certified Nursing Assistants (CNA) are not cleaning her dentures. The resident stated that she told staff that her gums are sore. The resident also stated that there is a denture cup available for her to put the dentures in at night, but that she does not always do it. During an observation conducted of the resident on (MONTH) 2, 2019 at 10:15 a.m., the resident was observed to be awake and wearing the same cream colored pajama top with brown stains. On (MONTH) 1, 2019 at 1:27 p.m., an interview was conducted with a CNA (staff #50) who said that the resident spills food and drinks when she is eating her meals. The CNA stated that she changes the resident clothes as needed which includes changing soiled clothing. The CNA also stated that the resident needs assistance with setup for oral hygiene. She stated that sometimes the resident is not able to complete her oral care because of pain. She stated that the resident is able to put the tablet for cleaning her dentures in the cup of water, but the cleaning of the dentures and the glue has to be done by a CN[NAME] During an interview conducted on (MONTH) 2, 2019 at 8:07 a.m. with another CNA (staff #56), staff #56 stated that the resident's clothing is changed every day, when the clothing is dirty, and when the resident wants to change clothes. An interview was conducted with a Registered Nurse, (RN/staff #34) on (MONTH) 2, 2019 at 8:12 a.m. The RN stated that staff assist with residents with dressing in clean clothes every morning. The RN also stated staff will change soiled clothing if the resident allows. Staff #34 stated that the dental task is to be done by a CNA every shift. She further stated that it would not be appropriate to provide setup assistance for a resident who needed extensive assistance. An interview was conducted with the Central Supply Manager (staff #13) on (MONTH) 2, 2019 at 8:35 a.m. Staff #13 stated that she and the Director of Nursing are responsible for checking that the activities of daily living documentation is completed by the CNAs, but that they do not check each entry. She stated that the resident is able to clean her dentures, which means the CNA only sets up the supplies needed for the resident to clean the dentures. She also said the resident may require additional assistance if she is having a bad day. Staff #13 stated a CNA may or may not be present to watch the resident clean her dentures and may come back later to put supplies away. The facility's policy titled Quality of Life - Accommodation of Needs revealed staff attitudes and behaviors must be directed towards assisting the residents in maintaining and/or achieving independent functioning, dignity and well-being. The policy included the resident's individual needs and preferences shall be acommodated to the extent possible.",2020-09-01
402,HAVEN OF COTTONWOOD,35093,197 SOUTH WILLARD STREET,COTTONWOOD,AZ,86326,2019-05-02,686,E,0,1,71MW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure 1 of 2 sampled residents (#38) with pressure ulcers received the necessary treatment and services consistent with professional standards of practice. The deficient practice could result in delayed healing and/or worsening of pressure ulcers. Findings include: Resident #38 was readmitted on (MONTH) 26, 2019 with [DIAGNOSES REDACTED]. Review of the Pressure Ulcer Documentation and assessment dated (MONTH) 26, 2019 revealed the resident was admitted with an unstageable pressure ulcer to the right hip and a stage 3 pressure ulcer to the left heel. The assessment included the resident had a pressure reduction device to the wheelchair and had heel protectors. The Braden scale dated (MONTH) 26, 2019 revealed a score of 14 which indicated the resident was a moderate risk for pressure ulcers. A Nurse Practitioner (NP) progress note dated (MONTH) 29, 2019 revealed the resident was a severely medically complex resident with multiple advanced comorbidities and that ongoing decline and complications are unfortunately reasonably expected. The progress noted included a low air loss mattress was ordered for the resident. A nurse progress note dated (MONTH) 29, 2019 revealed the resident was declining and refusing care. Review of the Significant Change in Status Minimum Data Set assessment dated (MONTH) 2, 2019 revealed a score of 6 on the Brief Interview for Mental Status which indicated the resident had severe cognition impairment. The assessment also included the resident had one stage 3 pressure ulcer and one unstageable pressure ulcer that were present on admission. Review of the current care plan revealed the resident had one unstageable pressure ulcer to the right hip and one stage 3 pressure ulcer to the left heel. Interventions included following the facility policies/protocols for the prevention/treatment of [REDACTED]. A Braden scale dated (MONTH) 2, 2019 revealed a score of 12 indicating the resident was a high risk for pressure ulcers. Review of the clinical record revealed weekly skin checks were conducted and the pressure ulcers were assessed weekly. Regarding the right hip pressure ulcer: The Pressure Ulcer Documentation and assessment dated (MONTH) 26, 2019 revealed the right hip pressure ulcer measured 1 centimeter (cm) x 1 cm x UTD (depth unable to be determined). The assessment included there was necrotic tissue, no drainage, and no odor. Review of the clinical record revealed a physician order [REDACTED]. However, review of the Treatment Administration Record (TAR) for (MONTH) 2019 and (MONTH) 2019 revealed the order had not been transcribed onto the MAR for (MONTH) 26-31 and (MONTH) 1-7. Review of the progress notes for this time frame revealed no documentation the treatments were provided to the right hip. A physician order [REDACTED]. Review of the TAR for (MONTH) 2019 revealed no evidence the treatment was provided to the right hip on (MONTH) 11, 14, and 18. A wound observation was conducted on (MONTH) 1, 2019 at 10:01 a.m. with a Registered Nurse (RN/staff #34), RN (staff #83), and the Corporate nurse (staff #95). Staff #34 removed the dressing from the right hip and cleansed the area with normal saline. Staff #34 then measured the wound. The wound was 1.5 cm x 1.5 cm x UTD, had 70% slough, and was irregular shape with dark colored edges. Staff #34 then applied the ordered treatment. Regarding the left heel pressure ulcer: The Pressure Ulcer Documentation and assessment dated (MONTH) 26, 2019 revealed the pressure ulcer to the left heel measured 2 cm x 3 cm x 0.8 cm. The assessment included the wound bed was dull pink and that there was no odor or drainage. Review of the clinical record revealed a physician order [REDACTED]. Review of the TAR for (MONTH) 2019 revealed the treatment was transcribed onto the MAR and administered as ordered. A physician's orders [REDACTED]. Review of the TAR for (MONTH) 2019 revealed no evidence the treatment was provided to the left heel on (MONTH) 18, 2019. A wound observation was conducted on (MONTH) 1, 2019 at 10:01 a.m. with a RN (staff #34), RN (staff #83), and the Corporate nurse (staff #95). Staff #34 removed the dressing from the left heel and stated that the wound was healed. She then cleansed the heel with normal saline, and then put on a sock and the heel protector. An interview was conducted with a RN (staff #89) on (MONTH) 1, 2019 at 11:00 a.m. The RN stated that if a new wound is identified, the wound nurse and the physician are notified. She stated that treatment orders are obtained from the physician and transcribed onto the TAR. The RN stated that once the treatment has been administered, it is documented on the TAR. She stated the wound nurse does the weekly skin checks and weekly wound measurements and the floor nurses provide the treatments. The RN also stated that the resident has not refused any care from her. An interview was conducted with the wound RN (staff #34) on (MONTH) 1, 2019 at 12:39 p.m. The wound nurse stated that upon admission, the admission nurse documents any skin issues and that she conducts a skin assessment after admission. She stated that she obtains treatment orders from the physician for any wound identified. The RN stated that she does weekly measurements and assessments of the wound. She stated that the treatments are documented on the TAR. She stated that resident #38 bed was moved so he could lie on his left side and that the right hip wound is showing improvement. The wound nurse stated that the resident has a low loss air mattress, heel protector, and is turned every 2 hours. She also stated that the resident refusal of treatment varies. After reviewing the clinical record, she stated that the treatment for [REDACTED]. The RN stated that documentation that the right hip treatment was provided would be on the TAR unless the nurse wrote a progress note. An interview was conducted with the Director of Nursing (DON/staff #65) on (MONTH) 2, 2019 at 11:03 a.m. The DON stated that when a resident is admitted with a pressure ulcer, the wound nurse is notified and ensure the appropriate interventions are implemented and treatment is obtained. She stated a Braden scale is done and that if the resident is determined to be a high risk for pressure ulcer development, preventative interventions are implemented such as turning and repositioning, floating heels, etc. The DON stated that the nurses document the treatment was done on the TAR. She stated that the right hip order dated (MONTH) 26, 2019 was selected as a standard/FYI order and did not transmit to the TAR. She further stated that the right hip pressure ulcer went from unstageable to a stage 2 and did not worsen. The facility's policy titled Acute Condition Changes-Clinical Protocol revealed the physician will help identify and authorize appropriate treatments and the nurse will repeat any verbal orders to the physician to ensure accurate transcription. The policy also included the staff will monitor and document the resident's progress and responses to treatment. The facility's policy regarding Refusal of Treatment revealed that if a resident refuses treatment, the Unit Manager, Charge Nurse, or Director of Nursing will interview the resident to determine what and why the resident is refusing in order to try to address the resident's concerns and explain the consequences.",2020-09-01
403,HAVEN OF COTTONWOOD,35093,197 SOUTH WILLARD STREET,COTTONWOOD,AZ,86326,2019-05-02,688,E,0,1,71MW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one of one sampled resident (#17) with limited range of motion consistently received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. This deficient practice could result in reduction in range of motion. Findings include: Resident #17 was readmitted to the facility on (MONTH) 26, (YEAR), with [DIAGNOSES REDACTED]. Review of the care plan initiated (MONTH) 7, (YEAR), revealed the resident had activities of daily living self-care deficits related to [MEDICAL CONDITION], fatigue, and activity intolerance. The goal was that the resident would improve current level of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene. Interventions included the resident required extensive assistance for toilet use, bed mobility, bathing, personal hygiene, and dressing, limited assistance for transfer, and set up assistance for eating. Review of the clinical record revealed a physician order [REDACTED]. The OT evaluation & plan of treatment with a (MONTH) 13, (YEAR) start of care date revealed the resting hand splint and shoulder orthosis had arrived that was ordered for the resident during her last OT therapy sessions. The short term goal was that the resident would tolerate the use of the resting hand splint for the RUE and the right shoulder orthosis to reduce sublux of right shoulder to promote comfort and increase functional use of the extremity. The long-term goal was educating the staff to the wearing schedule, proper donning/doffing, and the purpose of the splint and orthosis to assist the resident with wearing compliance. A quarterly Minimum Data Set assessment dated (MONTH) 15, (YEAR), revealed a score of 7 on the Brief Interview for Mental Status, which indicated the resident was severely impaired. The MDS assessment included the resident did not reject care. Review of the OT progress note dated (MONTH) 26, (YEAR), revealed the resident was observed not wearing the right shoulder orthosis. The note included the Certified Nursing Assistants (CNAs) were given instructions to don the shoulder orthosis in the AM and have the resident wear it until bedtime. The note also included the therapist spent time locating the shoulder orthosis, which was found in the dirty laundry. The orthosis was wiped off and placed on the resident. The resting hand splint was found in the top drawer. The note included the resident was a poor historian but reported the resting hand splint had not been donned at bedtime on her right hand. The note also included the therapist reviewed the purpose of the hand splint and shoulder orthosis. The OT progress note dated (MONTH) 28, (YEAR) revealed the resident was not wearing the shoulder orthosis or the hand splint and that the therapist assisted the resident with donning the shoulder orthosis and hand splint. The note also included the therapist remade the visuals for applying the shoulder orthosis and the hand splint for the caregivers. Review of the OT progress note dated (MONTH) 10, (YEAR), revealed the resident was not wearing the shoulder orthosis or the hand splint. The brace was found in the side dresser and the splint was bent and needed to be straightened. The visual posters with the instructions on how to apply the equipment had been removed. The note included the therapist applied the shoulder orthosis and the hand splint and made new visual aids. The note also included the resident tolerated the orthosis and the splint throughout the therapy session. Review of the OT Discharge Summary dated (MONTH) 19, (YEAR), revealed the staff had been inconsistent with applying the hand splint and the shoulder orthosis. The note included the resident was generally found without the shoulder orthosis in place. The note also included visual posters for correct donning/doffing of the hand splint and the shoulder orthosis were placed at the nursing station for the entire staff. Review of the nursing progress notes for (MONTH) and (MONTH) (YEAR), revealed no documentation that the resident had refused the shoulder orthosis and hand splint or that the physician was notified of any refusals. On (MONTH) 2, 2019 at 1:47 p.m., an interview was conducted with an OT (staff #40). The OT stated the resident was supposed to wear a shoulder orthosis on the right arm and that the resident tolerated wearing the shoulder orthosis when she was receiving therapy. An interview was conducted on (MONTH) 2, 2019 at 2:08 p.m. with a Licensed Practical Nurse (LPN/staff #22). The LPN stated that if the resident was supposed to wear a shoulder orthosis and a hand splint, he would be the person responsible for ensuring they were applied. The LPN also stated that he had never seen the resident wearing the shoulder orthosis and the hand splint since he started working in (MONTH) (YEAR). During an interview conducted with the Director of Nursing (DON/staff #65) on (MONTH) 2, 2019 at 2:10 p.m., the DON stated that the resident refused to wear the shoulder orthosis and hand splint. The DON also stated that she would look for documentation that the resident refused to wear the shoulder orthosis and the hand splint. Another interview was conducted with OT (staff #40) on (MONTH) 2, 2019 at 3:00 p.m. The OT stated that the shoulder orthosis is to keep the right arm in the correct position and the hand splint was to keep the fingers from curling up. On (MONTH) 2, 2019 at 3:53 p.m., an interview was conducted with two Registered Nurses (RN/staff #34 and staff #83). Staff #34 stated that once therapy finishes their evaluation, they instruct nursing how to apply the equipment and the therapy schedule. Staff #34 stated the nurses observe and document the equipment was applied correctly by the CNAs. Staff #83 stated that the CNAs should document if the resident refuses to have the equipment applied and notify the nurse. Staff #83 also stated the nurse should document the refusal in the progress notes and notify the physician. Review of the facility's policy titled Resident Mobility and Range of Motion revised (MONTH) (YEAR), revealed residents with limited range of motion (ROM) will receive treatment and services to increase and/or prevent a further decrease in ROM. The policy included that residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. The policy also included interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts.",2020-09-01
404,HAVEN OF COTTONWOOD,35093,197 SOUTH WILLARD STREET,COTTONWOOD,AZ,86326,2019-05-02,689,D,0,1,71MW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, and policy review, the facility failed to ensure a fall safety measure was implemented for one of five sampled residents (#120). This deficient practice could result in further falls with injury. Findings include: Resident #120 was admitted on (MONTH) 26, 2019 with [DIAGNOSES REDACTED]. Review of the fall risk evaluation dated (MONTH) 26, 2019, revealed the resident had no history of falls within the last 6 month. It also included a fall risk score of 10 which indicated the resident was a moderate risk for falls. A health status note dated (MONTH) 28, 2019 revealed the resident was found lying on the floor with his pillow under his head. The resident stated he just rolled out of bed. The note also included interventions to place the bed against the wall and put a fall mat on the floor. The IDT (interdisciplinary) Fall Review note dated (MONTH) 28, 2019 revealed the resident had a fall on (MONTH) 28, 2019 at 6:30 a.m. with no injury. The note included the resident's family reported the resident frequently rolls out of bed. The note also included a fall mat would be placed by the right side of the bed. Review of the fall care plan dated (MONTH) 28, 2019 revealed the resident was at risk for falls related to confusion and deconditioning. Interventions included wearing appropriate footwear, keeping the call light within reach, and placing a fall mat next to the right side of the bed. Further review of the clinical record revealed no documentation that the fall mat was implemented. During observations conducted on (MONTH) 29, 2019 at 10:00 a.m., 10:52 a.m. and at 12:00 p.m., the resident was observed sleeping in the bed which was against the wall. No fall mat was observed on the floor. An interview was conducted with two Registered Nurse (RN/staff #34 and staff #33) on (MONTH) 1, 2019 at 10:04 a.m. Staff #34 stated that a fall mat is an intervention implemented for a resident who is at risk for a fall. Staff #34 stated that resident #120 has a fall mat on the floor when he is in bed. Staff #33 stated that resident #120 does not have a fall mat in the room. Staff #34 then stated that there should be a fall mat in the resident's room. During an interview conducted with a Certified Nursing Assistant (CNA/staff #13) on (MONTH) 2, 2019 at 11:43 a.m., the CNA stated that they are informed of new fall interventions for a resident during report at the beginning of the shift and that the interventions are included in the resident's care plan. The CNA stated that the CNAs check the fall mats and document it under the CNA tasks. An interview was conducted with another CNA (staff #17) on (MONTH) 2, 2019 at 12:16 p.m. She stated the resident tends to roll over on his side and is at risk for falls. The CNA stated that is the reason the bed is against the wall. She further stated the night shift staff told her there was supposed to be a fall mat on the floor and that she does not know why the mat is not on the floor. Later that day at 2:07 p.m., staff #17 retracted her statement and stated that the resident does have a folded gray mat that is placed on the floor when the resident is in bed. At this time, the CNA pointed out the folded gray mat against the wall by the sink in the resident's room. She was unable to say where the fall mat was prior to this day. An interview was conducted with the Director of Nursing (DON/staff #65) on (MONTH) 2, 2019 at 2:26 p.m. The DON stated that after a resident has a fall, the IDT (interdisciplinary team) meet to discuss the events that led to the fall and develop fall interventions as appropriate. The DON stated that the expectation is that the staff implement the fall interventions. She stated the fall interventions are added to the care plan and the CNAs Kardex. She stated that the CNA tasks can include checking for mats on the floor and that the electronic record system will alert the CNA if the task is not complete. Regarding the fall mat is not being on the CNA tasks for resident #120, the DON stated that not all interventions are put in the CNAs tasks. Regarding the mat not being in place before (MONTH) 2, the DON had no comment. The facility's policy titled Fall Prevention Program revealed the DON coordinates implementation of the individualized care plans. The policy also revealed the Restorative Nursing Aide (RNA) acts as a leader among the frontline staff ensuring interventions are being properly followed.",2020-09-01
405,HAVEN OF COTTONWOOD,35093,197 SOUTH WILLARD STREET,COTTONWOOD,AZ,86326,2019-05-02,697,E,0,1,71MW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#119) was administered pain medications consistent with professional standards of practice. The deficient practice could result in unrelieved pain. Findings include: Resident #119 was readmitted to the facility on (MONTH) 13, (YEAR) with [DIAGNOSES REDACTED]. The resident was discharged (MONTH) 3, (YEAR). The admission Minimum Data Set assessment dated (MONTH) 20, (YEAR) revealed a score of 11 on the Brief Interview for Mental Status which indicated the resident had moderately impaired cognition. The assessment included the resident almost constantly had pain and rated the pain intensity at a 6 on a scale of 0-10. Review of the clinical record revealed the following physician orders: -Tylenol 325 milligrams (mg) 2 tablets by mouth every 6 hours as needed for a mild pain level of 1-3 dated (MONTH) 13, (YEAR). -[MEDICATION NAME] 5-325 mg 1 tablet by mouth every 6 hours as needed for a moderate pain level 3-6 and 2 tablets by mouth every 6 hours as needed for a severe pain level of 7-10 dated (MONTH) 13, (YEAR) and discontinued (MONTH) 17, (YEAR). -[MEDICATION NAME]-[MEDICATION NAME] 5-325 mg 1 tablet by mouth for a pain level 3-6 and 2 tablets by mouth for a pain level 7-10 every 4 hours as needed dated (MONTH) 17, (YEAR) and discontinued on (MONTH) 28, (YEAR). -[MEDICATION NAME] 10 mg 1 tablet by mouth every 4 hours as needed for a pain level of 1-5 dated (MONTH) 26, (YEAR). -[MEDICATION NAME] 15 mg 1 tablet by mouth every 4 hours as needed for a pain level of 6-10 dated (MONTH) 26, (YEAR). Review of the Medication Administration Record [REDACTED]. Continued review of the MAR indicated [REDACTED]. Additional review of the MAR for (MONTH) (YEAR) revealed [MEDICATION NAME] 5 mg was administered on (MONTH) 17 for a pain level of 8 and on (MONTH) 20, 21, 24, and 28 for a pain level of 7. The MAR indicated [REDACTED]. Review of the MAR for (MONTH) (YEAR) revealed Tylenol was administered on (MONTH) 2 for a pain level of 8. Additional review of the MAR indicated [REDACTED]. Review of the clinical record revealed no documentation why the resident was administered pain medications outside of the ordered parameters and no documentation that the physician was notified. An interview was conducted with a Registered Nurse (RN/staff #33) on (MONTH) 1, 2019 at 10:04 a.m. The RN stated that pain medications are to be administered as ordered. She stated that if a resident's pain is outside of the ordered parameters for the pain medication, she would contact the physician for orders. The RN stated that if the resident requests a specific pain medication for a pain level that is not within the ordered parameters, she would administer the medication and notify the physician. During an interview conducted with the Director of Nursing (DON/staff #65) on (MONTH) 2, 2019 at 2:26 p.m., the DON stated the expectation is that the nurses assess a resident's complaint of pain, provide NPI (Non Pharmacological Intervention), and administer pain medications according to the ordered parameters. The DON stated that if a resident request a pain medication for a pain level outside of the ordered parameters, she would expect the nurse to administer the medication, notify the physician, and document it in the progress notes and/or eMAR administration notes. The facility's policy on Administering Medications revealed Medications shall be administered in a safe and timely manner and as prescribed. The policy also revealed medications must be administered in accordance with the orders, including any required time frame.",2020-09-01
406,HAVEN OF SEDONA,35094,505 JACKS CANYON ROAD,SEDONA,AZ,86351,2017-04-14,156,D,0,1,MZPX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure that notification regarding the end of Medicare covered services was issued to one resident (#214). Findings included: Resident #214 was admitted (MONTH) 20, (YEAR), with [DIAGNOSES REDACTED]. The resident was discharged (MONTH) 2, (YEAR). Review of the clinical record revealed there was no evidence the resident had been issued the Notice of Medicare Non-Coverage (NOMNC) letter which included the date that Medicare coverage of services would end. An interview was conducted on (MONTH) 12, (YEAR) at 10:21 a.m. with the Business Office Manager (staff #94), she stated there was a mistake and the resident did not receive a NOMNC letter. She stated the resident was on Medicare billing until (MONTH) 2, (YEAR) and then became private pay. She stated the Social Services Director (staff #105) is the one responsible for NOMNC letter notifications. An interview was conducted on (MONTH) 12, (YEAR) at 10:40 a.m. with the Social Services Director (staff #105). She stated she did not issue a NOMNC letter to the resident. She stated the resident was discharged on (MONTH) 2, (YEAR) and should have had the NOMNC letter 3 days prior to his last Medicare covered day. A review of the facility policy included the NOMNC letter must be delivered to the beneficiary at least two calendar days before Medicare covered services end.",2020-09-01
407,HAVEN OF SEDONA,35094,505 JACKS CANYON ROAD,SEDONA,AZ,86351,2017-04-14,241,D,0,1,MZPX11,"Based on observations, staff interviews, and review of facility policy and procedure, the facility failed to ensure that several residents were treated with dignity and respect while being fed. Findings include: An observation was conducted on the secured unit at 12:20 p.m. on (MONTH) 10, (YEAR). A Certified Nursing Assistant (CNA/staff #21) was standing and feeding four residents at a table. After a few minutes had passed, a second CNA (staff #28) came over to assist and started to feed two of the residents. She stood while feeding the residents. The first CNA stood for a few minutes continuing to feed two of the residents and then pulled a chair over to sit down while feeding. The second CNA did not sit down and continued to feed two residents while standing. There were no stools observed in the dining room and there were only a few chairs available on the other side of the dining room. During the observation, a nurse was in the room and she assisted a few residents with eating as well. She kneeled down most of the time, but did feed residents while standing a few times. In an interview with a CNA (staff #28) at 1:25 p.m. on (MONTH) 10, (YEAR), she stated she does not normally stand while feeding residents, but that she was very busy and had a lot to do including feeding residents, getting beverages for residents, and other tasks. She stated she should have been sitting as she has been instructed not to stand and feed residents. A second observation of dining on the secured unit was conducted at 8:20 a.m. on (MONTH) 12, (YEAR). During this meal service, stools were observed in the dining room for staff to sit on and the staff were sitting while feeding the residents. An interview was conducted with a Licensed Practical Nurse (LPN/staff #18) at 9:50 a.m. on (MONTH) 12, (YEAR). She stated she had seen CNAs standing while feeding residents in the dining room from time to time. She stated they are supposed to be seated when they are feeding residents as they should be personable with the residents. She stated she did not work on (MONTH) 10, (YEAR) so she did not observe the CNAs feeding residents while standing, but if she had, she would have instructed them to sit down while feeding the residents. She stated the facility has stools for the CNAs to use while feeding residents, but that they are stored in the shower room to prevent the residents from sitting on unsteady stools. She stated the residents may or may not know the difference between a staff who is feeding them while standing versus a staff that is sitting while feeding them, but the staff are aware of the difference and the families may know the difference. She stated all staff are educated to sit while feeding residents. During an interview with a CNA (staff #21) at 8:50 a.m. on (MONTH) 13, (YEAR), he stated he realized he was standing while feeding residents on (MONTH) 10, (YEAR) and that he knows he should have been seated. He stated mealtime is very busy, in addition to feeding four residents, he is trying to accomplish other tasks which can be difficult to accomplish. He stated the CNAs are pulled in a lot of different directions and his focus was on ensuring the residents were fed. He stated the stools are kept in the shower room and that staff are to bring them out of the shower room at meal times, but sometimes it is so busy that they may forget to retrieve them. He stated one of the nurses spoke to him regarding (MONTH) 10, (YEAR) and instructed him to sit when feeding residents. In an interview with the Director of Nursing (DON/staff #64) and the Assistant Director of Nursing (ADON/staff #100) at 10:15 a.m. on (MONTH) 13, (YEAR), they stated the expectation is that CNAs feed residents while sitting as they should be eye level with the resident. They stated this has not been an issue that they had noticed before. Review of the facility's policy and procedure for feeding residents included residents that are unable to feed themselves are assisted in a manner that provides dignity and social interactions and in a way that reduces the risk of aspiration. The procedure included to sit down next to the resident. This included not feeding a resident while standing as the resident should be able to see the staff member during the meal. The policy further included when sitting eye-level with the resident, the resident avoids hyperextension of their neck which could lead to choking.",2020-09-01
408,HAVEN OF SEDONA,35094,505 JACKS CANYON ROAD,SEDONA,AZ,86351,2017-04-14,281,D,0,1,MZPX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure nutrition interventions were ordered and implemented for one resident (#110). Findings include: Resident #110 was admitted to the facility on (MONTH) 2, (YEAR) with [DIAGNOSES REDACTED]. The resident's nutrition care plan was reviewed and revealed the resident was at nutritional risk in relation to his medical [DIAGNOSES REDACTED]. Review of a dietary note dated (MONTH) 20, (YEAR) revealed the dietary manager documented he would recommend a dietary supplement or the Special Nutrition Program (SNP) as dietary interventions. A second dietary note dated (MONTH) 4, (YEAR) was reviewed. In this note the Diet Technician Registered (DTR) recommended the same interventions, specifically super cereal at breakfast (part of the SNP) and no sugar added health shake once per day. Further review of a third dietary note dated (MONTH) 16, (YEAR) revealed the resident had lost weight and that interventions were already in place per the DTR. Review of the orders revealed no evidence that SNP or a dietary supplement was ordered for the (MONTH) (YEAR) or (MONTH) (YEAR) recommendations. Review of the Medication Administration Order (MAR) for (MONTH) and (MONTH) (YEAR) revealed no evidence that a supplement or SNP had been administered. A review of the diet slips revealed no evidence the SNP or the health shake had been included on the slips. An interview was conducted with the dietary manager (staff #67) at 11:00 a.m. on (MONTH) 12, (YEAR). He stated he wrote the note on (MONTH) 20, (YEAR), but did not know what had happened to the recommendation for the SNP or the health shake. He stated there should be an order for [REDACTED]. He stated it is possible that the recommendation did not become an order. He stated this could have happened because there was a time when the process was more difficult: he would have to write a recommendation to nursing who would then write the order and contact the physician to implement it. He stated this is no longer an issue now because he is able to write the order himself. He stated he could not find any of the paperwork from these recommendations and did not know for sure what happened to them. He stated review of the computer tray slip system revealed the SNP was included, so the resident was administered the SNP, it just was not ordered. He stated the health shake was documented on the tray card, but that this was just a place to note it, the nurses would be the ones documenting that the resident was administered the health shake. In an interview with the corporate dietitian (staff #103) at 11:10 a.m. on (MONTH) 12, (YEAR), she stated both interventions, SNP and the health shake, should have been ordered and documented on the MAR to be included as part of the dietitian's calculations. She stated a new dietary slip would show the interventions after they had been ordered. She stated the DTR usually checks to see that dietary interventions are in place, and as such, this should have been noted when the tech documented on (MONTH) 4, (YEAR). An interview was conducted with the Director of Nursing (DON/staff #64) at 10:15 a.m. on (MONTH) 13, (YEAR). She stated the dietary staff either recommends or writes an order for [REDACTED]. She stated she was not aware that there had been an issue and that now the dietary manager writes his own orders. After reviewing this resident's medical record, she stated it does not appear as though the dietary recommendations were ordered when they should have been. She stated she did not know why this occurred, but wondered if the nurses were ever aware of the interventions that were recommended. A policy regarding house supplements included when an order for [REDACTED]. The procedure included that a physician's orders [REDACTED]. The policy also included frequency and amounts must be specified in the physician's orders [REDACTED]. Review of the special nutrition program policy and procedure included the SNP is a fortified food program that should provide for the increased nutritional requirements of residents who are underweight, are experiencing significant weight loss, or have poor intake. The procedure included the supplement orders should read SNP or SNP with 2 calorie per milliliter (ml) med pass (a high calorie, high protein supplement).",2020-09-01
409,HAVEN OF SEDONA,35094,505 JACKS CANYON ROAD,SEDONA,AZ,86351,2018-06-21,578,D,0,1,COCL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and review of policy and procedure, the facility failed to ensure that a Do Not Resuscitate (DNR) form for one resident (#39) was explained and witnessed by a licensed healthcare provider. Findings include: Resident #39 was admitted on (MONTH) 30, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed a form titled Code Status and Preferred Intensity of Care dated (MONTH) 31, (YEAR). The form contained multiple options regarding the resident's advanced directives, including an option for cardiopulmonary resuscitation (CPR). The option for CPR contained a check in the space that read I do not want cardiopulmonary resuscitation measures to be undertaken on my behalf. The code status form was signed by the resident's wife and witnessed by a social worker. A State form located in the clinical record titled Prehospital Medical Care Directive (Do Not Resuscitate) dated (MONTH) 31, (YEAR), contained a section labeled General Information and Instructions and included A Prehospital Medical Care Directive document signed by you and your doctor that informs emergency medical technicians (EMTs) or hospital emergency personnel not to resuscitate you. The DNR form contained instructions that the form must be completed and signed in front of a witness and included Your healthcare provider and your witness must sign this form. The DNR form was signed by the resident and his wife. However, the section of the DNR form labeled Signature of Doctor or Other Healthcare Provider that contained the statement I have explained this form and its consequences to the signer and obtained assurance that the signer understands death may result from any refused care listed above did not reveal a doctor or any other healthcare provider signature. An interview was conducted on (MONTH) 20, (YEAR) at 2:34 p.m. with a Licensed Practical Nurse (LPN/staff #90). The nurse stated that a social worker completes the DNR form by obtaining the necessary signatures. The nurse also stated that there should have been a signature from a licensed healthcare provider on the DNR form for resident #39. An interview was conducted on (MONTH) 20, (YEAR) at 3:21 p.m. with the social service director (staff #85). Staff #85 stated that advanced directives including DNR status (if requested) are addressed with the resident and/or the resident's legal representative and explained by the social worker during the admission process. If a resident or their legal representative direction is that the resident is to be DNR, the resident or their legal representative signs the DNR form. The form is then placed in the front of the resident's clinical record to be signed by the physician or licensed healthcare provider. The staff stated that there should have been a signature on the DNR form for resident #39 by the physician or a licensed healthcare provider. During an interview conducted on (MONTH) 20, (YEAR) with the Director of Nursing (DON/staff #88), the DON stated that the social worker is responsible for the completion of DNR forms. The DON also conceded that there was no documented evidence that the risks and benefits of the DNR status had been explained to resident #39 or his wife by a physician or licensed healthcare provider. A facility's policy titled Do Not Resuscitate Order included A Do Not Resuscitate Order (DNRO) form must be completed and signed by the attending physician and resident or the resident's legal surrogate as permitted by state law.",2020-09-01
410,HAVEN OF SEDONA,35094,505 JACKS CANYON ROAD,SEDONA,AZ,86351,2018-06-21,641,D,0,1,COCL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interview, and policy, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurate for one resident (#39). Findings include: Resident #39 was admitted on (MONTH) 30, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed a physician's orders [REDACTED].#39 to wear a wander guard at all times, to test the wander guard transmitter every Thursday on the night shift, and to replace the wander guard as needed. A care plan dated (MONTH) 20, (YEAR), included a problem that the resident was at risk elopement, and the goal was to keep the resident secure on a locked unit. One of the approaches included a wander guard. Review of a quarterly MDS assessment dated (MONTH) 9, (YEAR), revealed the assessment did include the resident utilized a wander/elopement alarm. During an observation conducted on (MONTH) 18, (YEAR) at 12:00 p.m., resident #39 was observed to have a wander guard attached to his right ankle. An interview was conducted on (MONTH) 20, (YEAR) with the MDS Coordinator (staff #54). The MDS Coordinator stated that she talks with the resident, reviews the physician's orders [REDACTED]. The MDS Coordinator stated that she did not know why the MDS assessment had been coded incorrectly for the use of a wander guard for resident #39. The facility's policy titled MDS Completion and Submission Timeframe included a statement that The assessment must accurately reflect the resident's status.",2020-09-01
411,HAVEN OF SEDONA,35094,505 JACKS CANYON ROAD,SEDONA,AZ,86351,2018-06-21,658,D,0,1,COCL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, and review of policy, the facility failed to ensure medications were not left in the room of one resident (#268). Findings include: During a medication administration observation conducted on (MONTH) 20, (YEAR) at 8:09 a.m., a Registered Nurse (RN/staff #83) prepared an intravenous (IV) solution of 100 milliliters of Normal Saline and a vial of [MEDICATION NAME] 2 Grams (antibiotic) powder, added an IV tubing and flushed the tubing, then proceeded to the room of resident #268. En route to the room, staff #83 stated, I probably can't start this now because the [MEDICATION NAME] is probably still running. Upon entering the resident's room, staff #83 observed the [MEDICATION NAME] would not be completed until approximately 9:15 a.m. The nurse hung the [MEDICATION NAME]/Normal saline solution on the IV pole and left the room. An interview was conducted on (MONTH) 20, (YEAR) at 08:09 a.m. with staff #83. She stated that a medication can be left with a resident un-administered if the resident has been assessed to be safe to administer his/her own medications and there is an order for [REDACTED]. During an interview conducted on (MONTH) 20, (YEAR) at 11:22 a.m. with the RN/Assistant Director of Nursing (staff #75), staff #75 stated all medications are to be secured. Staff # 75 stated IV solutions and antibiotics are medications and should be secured and not left in the resident's room not administered. The facility's Medication Storage policy revealed medications are stored safely and securely and accessible only to licensed nursing personnel authorized to administer medications.",2020-09-01
412,HAVEN OF SEDONA,35094,505 JACKS CANYON ROAD,SEDONA,AZ,86351,2018-06-21,689,D,0,1,COCL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, and staff interviews, the facility failed to ensure that scheduled maintenance and testing was provided for a wander guard alarm for one resident (#39). Findings include: Resident #39 was admitted on (MONTH) 30, (YEAR), with [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment dated (MONTH) 9, (YEAR), included that resident #39 was rarely understood, had short and long term memory problems, and had severely impaired cognition. A physician's progress note dated (MONTH) 1, (YEAR), revealed the resident was alert and oriented to name, calm and confused, and that he wandered. A Nurse practitioner note dated (MONTH) 8, (YEAR), revealed the resident was up ambulating on the unit and had episodes of being difficult to redirect. The note also included that the resident had exit seeking behaviors and will attempt to open doors and find ways off the unit. A physician's orders [REDACTED]. The order also included that staff were to test the wander guard transmitter every Thursday on the night shift, to replace it as needed, and to check for an expiration dated in a book on the unit. A care plan dated (MONTH) 20, (YEAR), included a problem that the resident was at risk elopement, and the goal was to keep the resident secure on a locked unit. One of the approaches included a wander guard. A nurse practitioner note dated (MONTH) 1, (YEAR), revealed the resident was having increasing agitation in the evenings, was exit seeking, and that he was difficult to redirect. A nurse practitioner note dated (MONTH) 8, (YEAR), revealed the resident was very active, attempts elopement, frequently exit seeks, and that he could be redirected but was difficult at times. A Nurse practitioner's note dated (MONTH) 29, (YEAR), revealed the resident had pacing and exit seeking behaviors that he was up ambulating in the hallway and was trying to open doors. Review of the Treatment Administration Record (TAR) for (MONTH) (YEAR), did not reveal documentation that the nurse checked the transmitter on the resident's wander guard each Thursday on the night shift for (MONTH) 8, 15, 21, and 29. A Physician's progress note dated (MONTH) 19, (YEAR), revealed the resident was alert and oriented to name, calm and confused, and that the resident had exit seeking behaviors that continue to be an ongoing issue. Continued review of the TAR for April, May, and (MONTH) (YEAR), did not reveal documentation that the wander guard transmitter had been checked on Thursdays on the night shift for (MONTH) 5, 12, 19, and 26, (MONTH) 16, 24, and 31, and (MONTH) 7 and 14, (YEAR). An observation of the resident was conducted on (MONTH) 21, (YEAR) at 11:00 a.m. The resident was observed to have a wander guard device attached to his right ankle. During an interview conducted on (MONTH) 19, (YEAR) at 2:35 p.m. with a Licensed Practical Nurse (LPN/staff #32), the nurse stated that the resident spends time near the exit doors to the unit and tries to leave when staff go in and out of the door. She stated that is the reason that the resident requires a wander guard. The nurse also stated that the night shift nurse is responsible for checking the transmitter on the wander guard and documenting it on the TAR. She also stated that she was unable to locate a log book for the expiration date of the transmitter. Interviews were conducted on (MONTH) 20, (YEAR) at 3:54 p.m. and (MONTH) 21, (YEAR) at 1:08 p.m. with the Director of Nursing (DON/staff #90). During the interviews, the DON conceded that there was missing documentation on the TARs for March, April, May, and (MONTH) (YEAR) regarding checking the wander guard transmitter and that the wander guard transmitter had not been checked on those dates. The DON stated that a supply staff was responsible for checking the wander guard transmitter, not the nurse, and that because the supply staff no longer works at the facility, the wander guard transmitter had not been checked. The facility did not have a policy for the maintenance of the wander guard.",2020-09-01
413,HAVEN OF SEDONA,35094,505 JACKS CANYON ROAD,SEDONA,AZ,86351,2018-06-21,761,D,0,1,COCL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and policy, the facility failed to ensure medications were securely stored. Findings include: During a medication administration observation conducted on (MONTH) 20, (YEAR) at 7:50 a.m., a Registered Nurse (RN/staff #83) was observed to leave the medication cart with an intravenous (IV) solution of 100 milliliters of Normal Saline and a vial of [MEDICATION NAME] 2 Grams (antibiotic) powder on the top of the medication cart unattended while she went to administer medications to a resident. Staff #83 returned to the medication cart, prepared additional medications for another resident and left the cart unattended at 8:00 a.m. with the IV solution and antibiotic on top of the cart while she went to administer the medications. Multiple residents and staff members were observed to walk by the cart. Staff #83 left the medication cart at 8:04 a.m. to wash her hands and access the medication room, again leaving the cart unattended with the IV solution and antibiotic on top of the cart. During this time, multiple residents and staff walked by the cart. Staff #83 returned to the cart at 8:06 a.m. and prepared the IV solution and antibiotic for administration. An interview was conducted on (MONTH) 20, (YEAR) at 8:09 a.m. with staff #83, who stated all medications should always be locked and secured, including IV solutions and antibiotics. An interviewed was conducted on (MONTH) 20, (YEAR) at 11:22 a.m. with the RN/Assistant Director of Nursing (staff #75). Staff #75 stated all medications are to be secured and that IV solutions and antibiotics are medications that should be secured. The facility's policy titled Medication Storage included, Medications and biologicals are stored safely, securely, and properly . The medication supply is only accessible to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.",2020-09-01
414,HAVEN OF SEDONA,35094,505 JACKS CANYON ROAD,SEDONA,AZ,86351,2018-06-21,880,D,0,1,COCL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, policy, and manufacturer's guidelines, the facility failed to ensure a glucose meter was properly cleaned after resident use. Findings include: During a medication administration observation conducted on (MONTH) 20, (YEAR) at 11:36 a.m., a Registered Nurse (RN/staff #15) was not observed to clean the glucose meter after completing a glucose check on a resident. At 11:43 a.m., staff #15 then prepared glucose testing supplies and administered a finger-stick glucose test to another resident. The nurse was observed to use an alcohol pad to moisten the glucose meter following this use. The meter sat on top of the medication cart for approximately 5 minutes until the nurse returned the meter to the drawer of the medication cart. An interview was conducted on (MONTH) 20, (YEAR) at 11:52 a.m. with staff #15. She stated that she has always cleaned the glucose meters with the alcohol wipes. Staff #15 stated that she does have bleach wipes on her cart that she uses to clean the top of the cart. She stated that the bleach wipes could be used for the glucose meter as well. During an interview conducted on (MONTH) 21, (YEAR) at 8:10 a.m. with the RN/Director of Nursing (DON/staff #88), the DON stated the glucose meters, per their skills checklist are to be disinfected with bleach wipes before and after each use and that the meter should have 3 minutes of wet contact time with the bleach for disinfection. The facility's policy titled Infection Prevention and Control Program included the facility .maintains an organized, effective facility-wide program designed to systematically identify and reduce the risk of acquiring, transmitting infections among residents, visitors, and healthcare workers. The policy included that low-level disinfection is used for non-critical equipment. Review of the manufacturer's Cleaning and Disinfection Guidelines revealed, We suggest cleaning and disinfecting the meter between patient use. The guidelines offered two options to perform the cleaning and disinfection process. Option 1: -Cleaning and disinfecting can be completed by using a commercially available EPA (Environmental Protection Agency) registered disinfectant detergent or germicide wipe. -To use a wipe, remove from container and follow product label instructions to disinfect the meter. Take extreme care not to get liquid in the test strip and key code ports of the meter. -Many wipes act as both a cleaner and disinfectant, though if blood is visibly present on the meter, two wipes must be used; use one to clean and a second wipe to disinfect. Option 2: -To clean the outside of the blood glucose meter, use a lint-free cloth dampened with soapy water or [MEDICATION NAME] alcohol (70%-80%) -To disinfect the meter, dilute 1 ml (milliliter) of household bleach (5% - 6% sodium Hypochlorite solution) in 9 ml of water to achieve a 1:10 dilution (final concentration of 0.5%-0.6% sodium Hypochlorite). The solution can then be used to dampen a paper towel. Then use the dampened paper towel to thoroughly wipe down the meter. Please note that there are commercially available 1:10 bleach wipes from a variety of manufacturers. Take extreme care not to get the liquid in the test strip and key code ports of the meter.",2020-09-01
415,HAVEN OF SEDONA,35094,505 JACKS CANYON ROAD,SEDONA,AZ,86351,2019-08-28,600,D,1,1,Y0DU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, resident and staff interviews, facility documentation and policy review, the facility failed to ensure 3 residents (#2, #53 and #9) were free from physical abuse. The deficient practice could result in further incidents of resident to resident abuse. Findings include: -Resident #2 was admitted on (MONTH) 15, 2013, with [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment dated (MONTH) 7, 2019, revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderate impaired cognition. The assessment included the resident did not exhibit physical or verbal behavioral symptoms directed towards others. A care plan with a review date of (MONTH) 2019 revealed the resident has episodes of inappropriate behaviors as evidenced by dementia with behavioral disturbance, anxiety, [MEDICAL CONDITION], anger, combative and agitation. The goal was that the behavioral episodes would be reduced to less than daily. Interventions included monitoring for early warning signs of behavior, removing the resident from unwanted stimuli, and monitoring and charting behaviors every shift and reporting to the provider. Review of a psychiatric consultation/follow up note dated (MONTH) 26, 2019 revealed staff reported an increase in aggressive behaviors. The note included the resident had been striking out at staff, putting her feet on the table at lunch, and was difficult to redirect. A nursing progress note dated (MONTH) 17, 2019 revealed resident #2 was in her wheelchair in the hallway near the dining room when she started kicking another resident (#53) in the right lower leg. The other resident (#53) slapped resident #2 on the left arm. The note included resident #2 was removed from the area by the nurse and kept away from the other resident (#53). A nursing progress note dated (MONTH) 21, 2019 revealed the resident was pushing residents out of her way on the evening shift. Review of the behavioral monitoring flow sheet for (MONTH) 2019 revealed no combative, agitation, and/or crying behaviors were present. Regarding resident #53 -Resident #53 was admitted on (MONTH) 31, (YEAR) with [DIAGNOSES REDACTED]. The quarterly MDS assessment dated (MONTH) 16, 2019 revealed a BIMS score of 9 which indicated the resident had moderate impaired cognition. A nursing progress note dated (MONTH) 17, 2019 at 6:45 p.m. revealed resident #53 was talking with a nurse in the hallway when another resident (#2), who was sitting in the hallway in her wheelchair, started kicking resident #53 on the right lower leg. The note also revealed resident #53 started slapping the other resident (#2) on the left arm. The note included the nurse stepped between the two residents and that the other resident (#2) was removed from the area and kept away from resident #53. The note also included there were no injuries. Review of the facility investigative report dated (MONTH) 19, 2019 revealed that on (MONTH) 17, 2019 at 6:45 p.m. resident #53 was in the hallway by the main dining room speaking with the nurse (staff #6) when resident #2, who was also in the hallway in her wheelchair, kicked resident #53 on the right leg. Resident #53 then slapped resident #2 on the left arm. The note revealed staff #6 intervened after resident #2 landed a second kick to resident #53's right leg, and that resident #2 was removed from the area. There was no injury to either resident. Both residents were interviewed by the Director of Nursing (DON/staff #70) on (MONTH) 19, 2019. The report included resident #2 denied the incident ever took place. An interview was conducted on (MONTH) 25, 2019 at 1:39 p.m. with resident #53. She stated that resident #2 kicked her on her knee. Resident #53 stated that resident #2 should not be around the other residents because she is not safe. She said that her right knee still hurts where resident #2 kicked her. On (MONTH) 25, 2019 at 2:07 p.m., an interview was conducted with resident #2. Resident #2 stated, I didn't do anything. She said that I kicked her, but I didn't. I don't know what the problem is. People keep saying that I do these things, but I don't. An interview was conducted on (MONTH) 25, 2019 at 2:27 p.m. with the Registered Nurse (RN/staff #6). She confirmed that on (MONTH) 17, 2019 she had parked her medication cart outside of the dining room in the hallway. The RN said that as residents were exiting the dining room, resident #2 stopped her wheelchair in the hallway, against the wall opposite to the medication cart. Staff #6 said as resident #53 was leaving the dining room, resident #53 stopped at the medication cart to speak with her. She said at that point, resident #53 was standing in front of resident #2. The RN stated that it was at that time resident #2 kicked resident #53 in the right lower leg, around the knee area. She stated that resident #53 then slapped resident #2 on the left arm. The RN stated resident #2 then kicked resident #53 in the right lower leg a second time as she stepped between them. She stated that resident #2 was quickly removed from the situation, and that the two residents were kept apart for the rest of the evening. During an interview conducted on (MONTH) 27, 2019 at 9:23 a.m. with a Certified Nursing Assistant (CNA/staff #2), the CNA stated that resident #2 does not exhibit any warning signs that she may become combative. She said the resident usually acts out in the dining room. The CNA stated that recently, within the past few weeks, the resident had attempted to stab a CNA with her fork. She also stated that the resident hits others for no reason. On (MONTH) 27, 2019 at 1:33 p.m., an interview was conducted with the DON (staff #70). She stated that her expectation is that staff first intervene to keep the residents safe when there is a resident to resident altercation and then report the incident immediately to her or the administrator. She said she expects the nursing staff to immediately assess the residents, to notify the physician/obtain any new orders, and to notify the residents' families. The DON stated that if the residents are not able to be redirected, her expectation is for staff to call 911. She said that once residents are separated, there are no given timeframes to recheck the residents, but the expectation is to keep an eye on both residents. Regarding resident #9 -Resident #9 was admitted on (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. A quarterly MDS assessment dated (MONTH) 18, 2019, included a BIMS score of 4 indicating the resident had severely impaired cognition. A nursing progress note dated (MONTH) 21, 2019 revealed resident #9 was hit by another resident (#2) on the arm while sitting in her chair. The note included a CNA intervened immediately. Review of the facility reportable event record revealed that a resident to resident incident occurred on (MONTH) 21, 2019 at approximately 7:30 p.m. in the hallway. Resident #9 was in the hallway in the wheelchair as resident #2 was wheeling towards the dining room. Resident #2 attempted to push resident #9 out of her way. Staff intervened and moved resident #9 out of resident #2 path allowing resident #2 to proceed towards dining room area. Resident #2 was up near the dining room for a few minutes and came back down the hallway. As resident #2 got close to resident #9, resident #2 reached out and slapped resident #9 on the right arm. Staff intervened immediately and separated the residents. The report included resident #9 was assessed to have no injuries. During an interview conducted on at (MONTH) 26, 2019 at 1:21 p.m. with the RN (staff #6), the RN stated that if resident #2 gets too close to someone, she might kick them. She stated that resident #2 gets into an altercation every now and then. An interview was conducted on (MONTH) 26, 2019 at 1:56 p.m. with a CNA (staff #64). Staff #64 stated that on (MONTH) 21, 2019 at about 7:30 p.m., she was sitting at the nurses' station charting when she heard resident #2 shouting at resident #9 using inappropriate language. The CNA stated that she came out of the nurses' station and saw resident #2 slapping resident #9 on her right arm. The CNA stated that she immediately separated the residents and took resident #2 to her room and resident #9 to her room. She stated the nurse who was also at the nurses' station was notified immediately of the incident. The CNA stated that these types of incidents involving resident #2 happens often, 2 - 3 times a week, and that it is usually in the evening. She stated that she does not know what triggers the incidents. The CNA also stated that if she observes that resident #2 is agitated, she will remove resident #2 from the situation. In an interview conducted on (MONTH) 26, 2019 at 2:16 p.m. with a CNA (staff #61), the CNA stated that on (MONTH) 21, 2019 at about 7:30 p.m. she was in the kitchenette in the nurses' station when she heard yelling. She stated that she came out of the kitchenette and observed resident #9 laughing and heard resident #2 tell resident #9 to get out of the way. The CNA stated resident #9 was in the way, but that resident #2 could have gone around resident #9. She stated that she saw resident #2 slap resident #9 a couple of times on her right arm. She stated staff #64 separated the residents. The CNA stated that when she checked on resident #9, resident #9 stated that her arm hurts and that she told resident #9 that she would let the nurse know. She said that resident #2 is usually kind and nice but that night resident #2 was complaining about dinner and had stated that she wouldn't give it to her dog and it was disgusting. An interview was conducted on at (MONTH) 27, 2019 at 2:15 p.m. with a RN (staff #21). Staff #21 stated that she was the nurse taking care of resident #9 and resident #2 when the altercation happened on (MONTH) 21, 2019 at about 7:30 p.m. The RN stated that she did not observe the incident but that a CNA reported the incident to her. She stated that she conducted a skin check and did not observe any bruising or redness. The RN also stated resident #2 was angry that night when she was in the dining room and did not want to eat but that a CNA calmed her down. She further stated that resident #2 is aggressive towards staff and other residents. The RN stated that once they document behavior monitoring at the beginning of their shift, they do not document behavior monitoring again even if there are incidents or behaviors that occur afterwards. Review of the facility's Abuse policy revealed the facility strives to prevent the abuse of all their residents but that due to the proximity of their residents one to another, situations may arise where they are not able to prevent all incidents of abuse. The policy included their objective is to provide a safe haven for their residents through preventative measures that protect every resident's right to be free from abuse. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. The policy also revealed abuse includes verbal abuse, sexual abuse, mental abuse, and physical abuse and potential abusers can be residents.",2020-09-01
416,HAVEN OF SEDONA,35094,505 JACKS CANYON ROAD,SEDONA,AZ,86351,2019-08-28,607,D,0,1,Y0DU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility documentation, clinical record review, staff interviews, and policy review, the facility failed to implement their policy regarding reporting and investigating allegations of abuse for three residents (#2, #53 and #9). The deficient practice could result in further abuse investigations not being thoroughly completed and delays in notifying the State Survey Agency regarding allegations of abuse. Findings include: -Resident #2 was admitted on (MONTH) 15, 2013, with [DIAGNOSES REDACTED]. -Resident #53 was admitted on (MONTH) 31, (YEAR) with [DIAGNOSES REDACTED]. Review of the facility investigative report dated (MONTH) 19, 2019 revealed that on (MONTH) 17, 2019 at 6:45 p.m. resident #53 was in the hallway by the main dining room speaking with the nurse (staff #6) when resident #2, who was also in the hallway in her wheelchair, kicked resident #53 on the right leg. Resident #53 then slapped resident #2 on the left arm. The note revealed staff #6 intervened after resident #2 landed a second kick to resident #53's right leg, and that resident #2 was removed from the area. There was no injury to either resident. Both residents were interviewed by the Director of Nursing (DON/staff #70) on (MONTH) 19, 2019. The report also included a written statement from staff #6. However, review of the State data system revealed the incident was not reported to the State Survey Agency until (MONTH) 19, 2019 at 11:27 a.m. and there was no evidence other residents or staff members were interviewed during the investigation. An interview was conducted on (MONTH) 26, 2019 at 1:21 p.m. with the Registered Nurse (RN/staff #6). The RN stated that she did not view the incident between resident #2 and #53 as dangerous or intentional, so she did not report the incident to administration. During an interview conducted with the DON (staff #70) on (MONTH) 26, 2019 at 2:04 p.m., the DON stated that she interviewed resident #2, resident #53, and staff #6. She stated other residents were not interviewed. The DON said the social worker should have interviewed other individuals, but she did not. The DON also stated that she spoke to staff #6 regarding her failure to report the incident. -Resident #9 was admitted on (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. Review of the facility reportable event record revealed that a resident to resident incident occurred on (MONTH) 21, 2019 at approximately 7:30 p.m. in the hallway. Resident #9 was in the hallway in the wheelchair as resident #2 was wheeling towards the dining room. Resident #2 attempted to push resident #9 out of her way. Staff intervened and moved resident #9 out of resident #2 path allowing resident #2 to proceed towards dining room area. Resident #2 was up near the dining room for a few minutes and came back down the hallway. As resident #2 got close to resident #9, resident #2 reached out and slapped resident #9 on the right arm. Staff intervened immediately and separated the residents. Resident #9 was assessed to have no injuries. The report included a statement from two Certified Nursing Assistants (staff #61 and staff #64). However, there was no documented evidence that interviews were conducted with resident #2, resident #9, or other residents. In an interview conducted on (MONTH) 26, 2019 at 11:05 a.m. with the DON (staff #70), the DON stated she did not interview resident #9 because she is cognitively impaired. She stated that since resident #2 refused to admit she hit a resident in an incident that happened on (MONTH) 17, 2019, she did not interview her. She stated that she did not interview any other residents to determine if resident #2 was aggressive towards other residents. The DON also stated that she had not heard about resident #2 being aggressive or mean to other residents so she did not feel it was necessary to interview other residents. Another interview was conducted on (MONTH) 27, 2019 at 1:33 p.m. with the DON (staff #70). The DON stated that they have 2 hours to report an allegation of abuse to the State Agency. She stated the Administrator, DON, or Assistant DON will direct the investigation. The DON stated that during a resident to resident altercation investigation, the residents involved are interviewed as well as other residents to rule out a trend of potential abuse from the aggressor. She stated that any staff that witnessed the incident would be interviewed. She stated she should have interviewed other residents but that she did not. The facility's policy regarding Abuse revealed if abuse is witnessed or suspected, reporting and investigation will take place. The Administrator will be notified and the Administrator and the witness reporting the incident will notify the State Agency. Suspected abuse will be reported in accordance with timeframes and standards required by CMS (Center for Medicare and Medicaid Services). The Administrator will begin investigation immediately. A minimum of three residents will be interviewed in order to determine if there is a trend. The policy included staff members will document their own statements and sign and date the bottom of the statement.",2020-09-01
417,HAVEN OF SEDONA,35094,505 JACKS CANYON ROAD,SEDONA,AZ,86351,2019-08-28,609,D,1,1,Y0DU11,"> Based on facility documentation, staff interviews, and policy review, the facility failed to ensure an allegation of abuse was reported within the required timeframe for two residents (#2 and #53). The deficient practice could result in additional allegations of abuse not being reported timely to the State Survey Agency. Findings include: Review of the facility investigative report dated (MONTH) 19, 2019 revealed that on (MONTH) 17, 2019 at 6:45 p.m. resident #53 was in the hallway by the main dining room speaking with the nurse (staff #6) when resident #2, who was also in the hallway in her wheelchair, kicked resident #53 on the right leg. Resident #53 then slapped resident #2 on the left arm. The note revealed staff #6 intervened after resident #2 landed a second kick to resident #53's right leg, and that resident #2 was removed from the area. There was no injury to either resident. However, review of the State data system revealed the incident was not reported to the State Survey Agency until (MONTH) 19, 2019 at 11:27 a.m. An interview was conducted on (MONTH) 26, 2019 at 1:21 p.m. with the Registered Nurse (RN/staff #6). The RN stated that she did not view the incident between resident #2 and #53 as dangerous or intentional, so she did not report the incident to administration. During an interview conducted with the DON (staff #70) on (MONTH) 26, 2019 at 2:04 p.m., the DON stated that she spoke to staff #6 regarding her failure to report the incident. Another interview was conducted on (MONTH) 27, 2019 at 1:33 p.m. with the DON (staff #70). The DON stated that they have 2 hours to report an allegation of abuse to the State Agency. The facility's policy regarding Abuse revealed if abuse is witnessed or suspected, reporting will take place. The Administrator will be notified and the Administrator and the witness reporting the incident will notify the State Agency. The policy also revealed suspected abuse will be reported in accordance with timeframes and standards required by CMS (Centers for Medicare and Medicaid Services).",2020-09-01
418,HAVEN OF SEDONA,35094,505 JACKS CANYON ROAD,SEDONA,AZ,86351,2019-08-28,610,D,0,1,Y0DU11,"Based on facility documentation, staff interviews, and facility policy, the facility failed to ensure allegations of abuse were thoroughly investigated for 3 residents (#2, #53, and #9). The deficient practice could result in additional allegations of abuse not being thoroughly completed. Findings include: -Review of the facility investigative report dated (MONTH) 19, 2019 revealed that on (MONTH) 17, 2019 at 6:45 p.m. resident #53 was in the hallway by the main dining room speaking with the nurse (staff #6) when resident #2, who was also in the hallway in her wheelchair, kicked resident #53 on the right leg. Resident #53 then slapped resident #2 on the left arm. The note revealed staff #6 intervened after resident #2 landed a second kick to resident #53's right leg, and that resident #2 was removed from the area. There was no injury to either resident. Both residents were interviewed by the Director of Nursing (DON/staff #70) on (MONTH) 19, 2019. The report also included a written statement from staff #6. However, there was no evidence other residents or staff members were interviewed during the investigation. During an interview conducted with the DON (staff #70) on (MONTH) 26, 2019 at 2:04 p.m., the DON stated that she interviewed resident #2, resident #53, and staff #6. She stated other residents were not interviewed. The DON said the social worker should have interviewed other individuals, but she did not. -Review of the facility reportable event record revealed that a resident to resident incident occurred on (MONTH) 21, 2019 at approximately 7:30 p.m. in the hallway. Resident #9 was in the hallway in the wheelchair as resident #2 was wheeling towards the dining room. Resident #2 attempted to push resident #9 out of her way. Staff intervened and moved resident #9 out of resident #2 path allowing resident #2 to proceed towards dining room area. Resident #2 was up near the dining room for a few minutes and came back down the hallway. As resident #2 got close to resident #9, resident #2 reached out and slapped resident #9 on the right arm. Staff intervened immediately and separated the residents. Resident #9 was assessed to have no injuries. The report included a statement from two Certified Nursing Assistants (staff #61 and staff #64). However, there was no documented evidence that interviews were conducted with resident #2, resident #9, or other residents. In an interview conducted on (MONTH) 26, 2019 at 11:05 a.m. with the DON (staff #70), the DON stated she did not interview resident #9 because she is cognitively impaired. She stated that since resident #2 refused to admit she hit a resident in an incident that happened on (MONTH) 17, 2019, she did not interview her. She stated that she did not interview any other residents to determine if resident #2 was aggressive towards other residents. The DON also stated that she had not heard about resident #2 being aggressive or mean to other residents so she did not feel it was necessary to interview other residents. Another interview was conducted on (MONTH) 27, 2019 at 1:33 p.m. with the DON (staff #70). The DON stated the Administrator, DON, or Assistant DON will direct the investigation. The DON stated that during a resident to resident altercation investigation, the residents involved are interviewed as well as other residents to rule out a trend of potential abuse from the aggressor. She stated that any staff that witnessed the incident would be interviewed. She stated she should have interviewed other residents but that she did not. The facility's policy regarding Abuse revealed if abuse is witnessed or suspected, investigation will take place. The Administrator will begin investigation immediately. A minimum of three residents will be interviewed in order to determine if there is a trend. The policy included staff members will document their own statements and sign and date the bottom of the statement.",2020-09-01
419,HAVEN OF SEDONA,35094,505 JACKS CANYON ROAD,SEDONA,AZ,86351,2019-08-28,640,E,0,1,Y0DU11,"Based on clinical record review, facility documentation, staff interviews, policy review and the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure Minimum Data Set (MDS) assessments were transmitted to the Centers for Medicare and Medicaid Services (CMS) within 14 days of completion for 6 residents (#1, #2, #3, #4, #5, and #25). The deficient practice could result in delays in receiving resident specific information related to quality measure purposes. Findings include: -Resident #1 was admitted to the facility on (MONTH) 26, (YEAR). Review of the clinical record revealed a quarterly MDS assessment dated (MONTH) 6, 2019 with a completion date of (MONTH) 13, 2019. However, review the facility's CMS Submission Report revealed the assessment was not transmitted to CMS until (MONTH) 27, 2019 and included it was submitted late. -Resident #2 was admitted to the facility on (MONTH) 15, 2013. Review of the quarterly MDS assessment dated (MONTH) 7, 2019 revealed a completion date of (MONTH) 11, 2019. However, review of the facility's CMS Submission Report revealed the assessment was not transmitted to CMS until (MONTH) 27, 2019 and included it was submitted late. -Resident #3 was admitted to the facility on (MONTH) 15, (YEAR). Review of the clinical record revealed a quarterly MDS assessment dated (MONTH) 24, 2019 with a completion date of (MONTH) 1, 2019. Review of the facility's CMS Submission Report revealed the assessment was not transmitted to CMS until (MONTH) 27, 2019 and included it was submitted late. -Resident #4 was admitted to the facility on (MONTH) 12, 2013. Review of the quarterly MDS assessment dated (MONTH) 23, 2019 revealed a completion date of (MONTH) 1, 2019. Review of the facility's CMS Submission Report revealed the assessment was not transmitted to CMS until (MONTH) 27, 2019 and included it was submitted late. -Resident #5 was admitted to the facility on (MONTH) 14, (YEAR). Review of a quarterly MDS assessment dated (MONTH) 22, 2019 revealed a completion date of (MONTH) 28, 2019. Review of the facility's CMS Submission Report revealed the assessment was not transmitted to CMS until (MONTH) 27, 2019 and included the assessment was submitted late. -Resident #25 was admitted to the facility on (MONTH) 26, (YEAR). Review of the clinical record revealed a significant change in status MDS assessment dated (MONTH) 3, 2019. The care plan completion date was (MONTH) 17, 2019. Review of the facility's CMS Submission Report revealed the assessment was not transmitted to CMS until (MONTH) 28, 2019 and included it was submitted late. During an interview conducted with the MDS coordinator on (MONTH) 27, 2019 at 1:00 p.m., she stated that she was unable to find the MDS assessment validation reports for residents #1, #2, #3, #4, #5, and #25. During an interview conducted with the Administrator (staff #86) on (MONTH) 27, 2019 at 1:22 p.m., he provided the facility's submission reports for residents #1, #2, #3, #4, #5, and #25. However, the report did not reveal whether the MDS assessments were transmitted, accepted or rejected by the CMS system. An interview was conducted with the Assistant Director of Nursing (ADON/staff #53) on (MONTH) 28, 2019 at 8:18 a.m. She stated that batches/assessments had been created in the system on (MONTH) 14, 2019 and (MONTH) 1, 2019 for the MDS assessments for residents #1, #2, #3, #4, and #5, but that the batches/assessments had not been transmitted to the CMS system as required. The ADON stated that the assessment for resident #25 was transmitted but had been rejected with a fatal error. She stated that they did not notice the rejection and did not resubmit the assessment. The ADON stated that they did not transmit the assessments with the required time frame. She stated that they follow the RAI manual for direction and clarification when completing the MDS assessments. The facility's policy regarding MDS completion and submission timeframes revealed that the facility will conduct and submit resident assessments in accordance with current Federal and State submission timeframes. The policy included that the assessment coordinator or designee is responsible for ensuring resident assessments are submitted to the CMS system in accordance with current Federal and State guidelines. The policy stated that timeframes for completion and submission of assessments is based on the current requirements published in the RAI Manual. The RAI manual dated (MONTH) (YEAR) revealed a quarterly MDS assessment transmission date is to be no later than the MDS completion date (Z0500B) plus 14 calendar days. The manual also revealed a significant change in status MDS assessment transmission date is to be no later than the care plan completion date (V0200C2) plus 14 calendar days.",2020-09-01
420,HAVEN OF SEDONA,35094,505 JACKS CANYON ROAD,SEDONA,AZ,86351,2019-08-28,658,D,0,1,Y0DU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, facility documentation, staff interviews, and policy and procedures, the facility failed to ensure that care and services were provided according to accepted standards of practices for one resident (#26) who sustained a burn. The deficient practice could result in delayed assessment and treatment of [REDACTED]. Findings include: Resident #26 was admitted to the facility on (MONTH) 20, (YEAR), with [DIAGNOSES REDACTED]. A provider's progress note dated (MONTH) 4, (YEAR) revealed the resident was very debilitated from progressive [MEDICAL CONDITION] to the point where he is wheelchair bound and dependent on others for the majority of Activities of Daily Living (ADL), due to severe joint deformities, contractures, weakness, and muscle wasting. The note included the resident had joint pain to bilateral shoulders, elbows, wrists and fingers, had major motor weakness and generalized intermittent muscle spasms. The note also included the resident had decreased ROM to bilateral shoulders, elbows and wrists, and had bilateral upper extremity weakness. A provider's progress note dated (MONTH) 11, 2019 revealed the resident had significant, longstanding [MEDICAL CONDITION] arthritis (RA) and had joint pain to bilateral shoulders, elbows, wrists and fingers, and chronic RA changes about the hands with swan neck deformity of the fingers, and z deformity of the left thumb, wrists, elbows and shoulders. The note further included the resident had swelling of bilateral wrists and had bilateral upper extremity weakness. Review of an Interdisciplinary Team (IDT) note dated (MONTH) 20, 2019 revealed the resident had jerking movements to the upper body at times and had bilateral hand deformities from arthritis. Review of a quarterly Minimum Data Set (MDS) assessment dated (MONTH) 30, 2019, revealed a Brief Interview for Mental Status score of 13, which indicated the resident had intact cognition. The MDS included the resident required extensive assist with eating and drinking, and had functional limitation in ROM to bilateral upper and lower extremities. An observation was conducted on (MONTH) 25, 2019 at 11:58 a.m. of the resident sitting in his wheelchair in the hall near the nurses' station. The resident was observed to have spastic movements bilaterally to the upper and lower extremities and the residents hands were contracted. At this time, a Certified Nursing Assistant (CNA) approached the resident with a cup of coffee (which was in a plastic coffee cup with a single handle and no lid) and placed the cup of coffee on the bedside table next to the resident and stated, Be careful, it's hot. The resident then picked up the cup of coffee and as he brought the cup to his lips, he quickly jerked it away and some of the coffee spilled on the front of his torso/lap area. The resident's hands jerked again and the majority of the coffee spilled on his lap. The resident then made a moaning noise and exhibited uncontrollable, spastic movements of all extremities. The CNA told the resident that she would help him change out of his wet clothes and took him to his room immediately. A nursing progress note dated (MONTH) 25, 2019 a.m. was marked as a late entry, however, the actual date and time that this note was written was not documented. The note included that after lunch, the resident was in the wheelchair near the nurses station begging for coffee, and the CNA gave him coffee with supervision. The CNA placed the coffee on the table beside the resident and he knocked the coffee off the table and onto his leg, making a red mark on his leg. The resident denied pain, but ice was applied to the area immediately. Another nursing progress note dated (MONTH) 25, 2019 eve included the CNA discovered the resident had a blister and assumed that someone had given him hot coffee and had burned himself. Per the note, the resident had a blister which was about 4 centimeters (cm) long and 2 cm wide. The note included that the night nurse cleaned and applied a dressing to ensure the wound stayed clear from contamination and from sudden movements from the resident. Review of the clinical record including the nurses notes for (MONTH) 25, 2019, revealed there was no documentation that the provider was notified regarding the red area on the resident's leg from the hot coffee. A nursing progress note dated (MONTH) 26, 2019 at 1:00 a.m. revealed the resident had a blister, which measured 8 cm by 11 cm, and the area was covered with a 4 x 4 dressing for protection. A nursing progress note dated (MONTH) 26, 2019 at 5:00 a.m. revealed the resident stated that he spilled coffee yesterday morning and had no complaints of pain. A nursing progress note dated (MONTH) 26, 2019 at 7:20 a.m. revealed the Nurse Practitioner (NP) was notified at 7:20 a.m. This was the first documentation that the physician/NP had been notified since the burn occurred on (MONTH) 25 at 11:58 a.m. A nursing progress note dated (MONTH) 26, 2019 at 7:30 a.m. revealed that a call was placed to the hospice provider. A wound observation was conducted on (MONTH) 26, 2019 at 9:22 a.m. with a Registered Nurse (RN/staff #8) and a CNA (staff #51). A dressing was observed to be in place on the resident's left thigh. Staff #51 stated that the dressing was where the resident dropped coffee on himself on (MONTH) 25. Staff #8 removed the dressing and there was a reddened area of irregular shape which measured 10 cm by 9 cm, with two raised fluid filled blisters. The larger blister was draining clear fluid. Staff #8 said the wound was from a burn and that the provider would be coming in pretty soon to assess the burn for treatment. A nursing progress note dated (MONTH) 26, 2019 at 10:20 a.m. revealed the left upper thigh has a pink/red large area with two blisters. The documentation included the resident spilled hot coffee on his thigh yesterday p.m. and would talk to the provider to assess the wound and to write orders for treatment. According to the Weekly Wound Measurement/Condition Report dated (MONTH) 26, 2019, the resident had a left thigh burn that was 11 cm long by 8 cm wide, with a superficial depth. The documentation included there were two draining blisters and that the wound was new. A physician's orders [REDACTED]. The order included for [MEDICATION NAME] cream to the left thigh burn daily until resolved. Review of the incident report dated (MONTH) 26, 2019 revealed that on (MONTH) 25, 2019 at 12:30 p.m., the resident was at the nurses station in his wheelchair after lunch begging for coffee. The CNA gave the resident a cup of coffee and put it on the side table near him. When the resident went to get it, he spilled it on his left leg. The report included the resident had a light red area to the left anterior thigh, with no blistering or pain and that an ice pack was applied. The report also documented that the medical doctor was notified in the a.m. A care plan dated (MONTH) 26, 2019 identified the resident had a burn to the left thigh. The goal was for the injury to resolve within 28 days. The approaches included to notify the medical doctor and responsible party of skin injury and report any changes; wound evaluation by medical doctor or nurse practitioner; observe for signs and symptoms of infection or complications to injury area; treatment to area as ordered, monitor for effectiveness of treatment; pain assessment and management as needed; and to provide education to resident/family. A provider progress note dated (MONTH) 27, 2019 included the visit was to evaluate a skin change to the left lateral/upper thigh. The noted included there was no overt signs of infection and to refer to the nursing notes for full measurements. The documentation included the resident had a wound disruption and there was no severe harm. An interview was conducted with a CNA (staff #51) on (MONTH) 26, 2019 at 1:06 p.m. She stated that on (MONTH) 25, 2019 around 12:45 p.m., the resident asked for coffee which she provided. She stated the resident spilled the coffee on himself while she was with him. She stated that she and another CNA (staff #19) took him to his room and cleaned him up and there was no redness noted at that time. She said that staff #19 went in after and noted that the area was getting red, so they notified the nurse (RN/staff #6) and the nurse told staff #19 to put ice on the burn. An interview was conducted with a CNA (staff #19) who stated that on (MONTH) 25, 2019, the resident had called about 15 minutes after she and CNA (staff #51) cleaned him up from spilling the coffee, and asked for the nurse. She stated that she noticed a red area from the coffee spill and reported it to the nurse. She stated the nurse told her to put an ice pack on the area. She stated that around 6:00 p.m. on (MONTH) 25, she noticed that the area had a small blister, so she reported it to the nurse (RN/staff #21). An interview was conducted with a RN (staff #6) on (MONTH) 26, 2019 at 1:59 p.m. She stated that she believed the resident spilled the coffee on himself around 12:30 p.m. on (MONTH) 25, 2019. She stated the CNA's had notified her that the resident had a red area from the coffee spill. She said that she looked at it and it was light red and ice was put on it. She said the resident denied having pain. She stated that she did not think that she documented anything at that time and was going to follow up and see if the redness was still there. She stated that she had planned to start a change of condition form on her shift if the redness continued but she did not. She stated that she believed that she had reported to the oncoming nurse (RN/staff #21) that the resident had spilled coffee on himself and had some redness, but she was not sure if she told the oncoming nurse about the burn in report. She stated that she knew the CNA's were following up on the area and were going to let her know if there were any changes, as well as keep the ice pack on the area. She stated that she worked on the unit with resident #26 until 2:30 p.m. on (MONTH) 25, 2019 and did not notify the physician. An interview was conducted with a RN (staff #21) on (MONTH) 26, 2019 at 2:14 p.m. , who worked the 2pm-10pm shift on (MONTH) 25. She stated that she did not get the information in report on (MONTH) 25, by the previous nurse (staff #6) that the resident had spilled coffee on himself and had a burn. She stated that one of the CNA's told her that the resident had blisters on his skin around 8:30 to 9:00 p.m. on (MONTH) 25, 2019. She stated that she had 30 residents so she was unable to look at the area, until the next nurse came in for change of shift (on the night shift). She stated that she and the oncoming night nurse went together to assess the burn on resident #26. She stated the wound was blistered and she did not know that the burn was at that level until that time. She said it was worse than what she understood it to be. She said that she assumed the burn was caused by hot liquid, because he spills everything. She said the resident was sleepy and did not say what had caused the burn. She stated that she documented what happened but did not make any notifications to the physician/provider, because her shift was over and the oncoming night nurse was going to do the incident report. An interview was conducted with the Assistant Director of Nursing (ADON/staff #53) on (MONTH) 27, 2019 at 11:04 a.m. She stated that when an accident occurs with a resident, the CNA should notify the nurse, the nurse should assess the resident, put the resident on change of condition charting, fill out an incident report, and notify the provider and hospice on that shift, per their policy even if there were no signs or symptoms of an injury. She stated that once the incident report was done and change of condition charting was started, the resident should be assessed and charted on each shift and that the incident should be reported to the oncoming nurse at shift change. She said the aftercare following the incident did not meet her expectations, as the nurse working at the time of the incident did not put the resident on change of condition charting, did not report the incident to the oncoming nurse and did not call the practitioner. She said that when the CNA reported to the nurse that a blister had developed, that nurse should have called the practitioner and obtained orders. She said if the change of condition charting would have been initiated and a treatment put into place, the area may not have developed further injury/blistering. She stated that staff did not follow expectations or facility policy related to change of condition requirements following an accident. Review of the policy for a Change in a Resident's Condition of Status revealed the facility shall promptly notify the resident, his/her attending physician, and resident representative of changes in the resident's medical/mental conditions and/or status. The policy included that the nurse shall notify the resident's attending physician or physician on call, when there has been an accident involving the resident. The policy stated that prior to notifying the physician or health care provider; the nurse will make detailed observations and gather relevant and pertinent information for the provider. Review of the policy for Investigating Injuries revealed the Director of Nursing services or designee will assess all injuries and document clinical findings in the clinical record. The policy included the nursing staff shall discuss the situation with the attending physician or medical director.",2020-09-01
421,HAVEN OF SEDONA,35094,505 JACKS CANYON ROAD,SEDONA,AZ,86351,2019-08-28,689,G,1,1,Y0DU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, clinical record review, facility documentation, staff and resident interviews and policy and procedures, the facility failed to identify individual risks factors and implement interventions and provide assistive devices and adequate staff assistance to prevent an accident for one resident (#26). The deficient practice could result in further accidents and injuries to residents. Findings include: Resident #26 was admitted to the facility on (MONTH) 20, (YEAR), with [DIAGNOSES REDACTED]. A provider's progress note dated (MONTH) 4, (YEAR) revealed the resident was very debilitated from progressive [MEDICAL CONDITION] to the point where he is wheelchair bound and dependent on others for the majority of Activities of Daily Living (ADL), due to severe joint deformities, contractures, weakness, and muscle wasting. The note included the resident had joint pain to bilateral shoulders, elbows, wrists and fingers, had major motor weakness and generalized intermittent muscle spasms. The note also included the resident had decreased ROM to bilateral shoulders, elbows and wrists, and had bilateral upper extremity weakness. Review of an Activities of Daily Living (ADL) care plan revealed the resident required assistance with ADL's related to the following: [MEDICAL CONDITIONS], anxiety, [MEDICAL CONDITION], contractures of extremities, palsy, extensive sarcopenia, chronic contractures, pseudo [MEDICAL CONDITION], spastic and history of encephalitis. An intervention was to assist with ADL's as needed. A provider's progress note dated (MONTH) 11, 2019 revealed the resident had significant, longstanding [MEDICAL CONDITION] arthritis (RA) and had joint pain to bilateral shoulders, elbows, wrists and fingers, and chronic RA changes about the hands with swan neck deformity of the fingers, and z deformity of the left thumb, wrists, elbows and shoulders. The note further included the resident had swelling of bilateral wrists and had bilateral upper extremity weakness. Review of an Interdisciplinary Team (IDT) note dated (MONTH) 20, 2019 revealed the resident had jerking movements to the upper body at times and had bilateral hand deformities from arthritis. A provider's progress note dated (MONTH) 17, 2019 revealed the resident had joint pain, stiffness to fingers bilaterally and had tremors. A provider's progress note dated (MONTH) 25, 2019 revealed the resident had [MEDICAL CONDITION] joint contractures, had [MEDICAL CONDITION] joint changes and was pseudo-quadriplegic and spastic. Review of a quarterly Minimum Data Set (MDS) assessment dated (MONTH) 30, 2019, revealed a Brief Interview for Mental Status score of 13, which indicated the resident had intact cognition. The MDS included the resident required extensive assist with eating and drinking, and had functional limitation in ROM to bilateral upper and lower extremities. A care plan dated (MONTH) 2019 included the resident was on a therapeutic or altered consistency diet. The care plan also included the resident had motor agitation/restlessness with a goal that the resident would be free of injury. The care plan further included to utilize double handled cups for increased ADL independence. A provider's progress note dated (MONTH) 19, 2019 revealed the resident had severe global muscle wasting/atrophy, as well as abnormal ROM with contractures present to the bilateral shoulders, elbows and wrists. Despite clinical record documentation that the resident had [MEDICAL CONDITION] joint contractures to the hands, pseudo-quadriplegic and spastic movements, motor agitation/restlessness, major motor weakness, generalized intermittent muscle spasms, stiffness to fingers bilaterally and tremors and jerking movements to the upper body at times, there was no documentation that the resident had been assessed for safety risks related to drinking hot liquids. Review of the physician's orders [REDACTED]. Further review of the clinical record revealed no documentation of the resident using a covered sippy cup, nor any documentation that the resident had refused to use a covered sippy cup. An observation was conducted on (MONTH) 25, 2019 at 11:58 a.m. of the resident sitting in his wheelchair in the hall near the nurses' station. The resident was observed to have spastic movements bilaterally to the upper and lower extremities and the residents hands were contracted. At this time, a Certified Nursing Assistant (CNA) approached the resident with a cup of coffee (which was in a plastic coffee cup with a single handle and no lid) and placed the cup of coffee on the bedside table next to the resident and stated, Be careful, it's hot. The CNA was not observed to assist the resident with the cup of coffee. The resident then picked up the cup of coffee and as he brought the cup to his lips, he quickly jerked it away and some of the coffee spilled on the front of his torso/lap area. The resident's hands jerked again and the majority of the coffee spilled on his lap. The resident then made a moaning noise and exhibited uncontrollable, spastic movements of all extremities. The CNA told the resident that she would help him change out of his wet clothes and took him to his room immediately. Review of the nursing progress notes revealed a note dated (MONTH) 25, 2019 a.m. which was marked as a late entry. However, the actual date and time that this progress note was written was not included. The note stated that after lunch the resident was in the wheelchair near the nurses station begging for coffee, and the CNA gave him coffee with supervision. The CNA placed the coffee on the table beside the resident and he knocked the coffee off the table and onto his leg, making a red mark on his leg. The note included the CNA placed the resident into bed and called the nurse to look at his leg and ice was applied to the area immediately. An interview with the resident was conducted on (MONTH) 25, 2019 at 1:08 p.m. Resident #26 stated stated that he spilled coffee on himself and was having some pain to the affected area. At this time, the resident was observed to have bilateral hand malformations/hyperextension especially of the fingers and wrists. The resident was observed to have uncontrolled spastic movements to the upper extremities when using a washcloth to wipe his face, however, there was no [DIAGNOSES REDACTED] at rest. An observation of the resident was conducted on (MONTH) 25, 2019 at 2:03 p.m. The resident was observed independently drinking ice water in the hallway, by holding a cup between his upper palms and maneuvering the cup to his lips. The resident was observed to have [DIAGNOSES REDACTED] movement to the upper extremities on purposeful movement, but not at rest. As the resident drank the water, his hands jerked in a spastic manner and a small amount of water spilled onto the front of his clothing. A nursing progress note dated (MONTH) 26, 2019 at 1:00 a.m. revealed the resident had a blister which measured 8 cm by 11 cm, and the area was covered with a 4 x 4 dressing for protection. A nursing progress note dated (MONTH) 26, 2019 at 5:00 a.m. revealed the resident stated that he spilled coffee yesterday morning and had no complaints of pain. A wound care observation was conducted on (MONTH) 26, 2019 at 9:22 a.m., with a Registered Nurse (wound nurse/staff #8) and a CNA (staff #51). The resident had a dressing in place to the left thigh, which was dated (MONTH) 25, 2019. The CNA (staff #51) stated the dressing was covering the area where the resident dropped coffee on himself. Staff #8 removed the dressing and there was a reddened area of irregular shape which measured 10 cm by 9 cm., with two raised blisters. The larger blister was draining clear fluid. Staff #8 said the wound was from a burn. An observation of the resident was conducted on (MONTH) 26, 2019 at 9:32 a.m. The resident continued to have spastic movements to the upper extremities with purposeful movement, but no [DIAGNOSES REDACTED] was noted at rest. A nursing progress note dated (MONTH) 26, 2019 at 10:20 a.m. revealed documentation that the left upper thigh has pink/red large area with two blisters, larger blister is draining clear water. Per the note, the resident spilled hot coffee on his thigh yesterday p.m., and would talk to the provider to assess the wound and write orders for treatment. Review of the Weekly Wound Measurement/Condition Report dated (MONTH) 26, 2019 revealed the left thigh burn was 11 cm long by 8 cm wide with superficial depth. The documentation included there were two draining blisters and the wound was new. A physician's orders [REDACTED]. The order also included for a sippy cup to be used with any warm beverages, with supervision. According to the incident report dated (MONTH) 26, 2019, the resident was at the nurses station begging for coffee after lunch on (MONTH) 25, 2019. The CNA gave the resident a cup of coffee and put it on the side table near him. When the resident went to get it, he spilled it on his left leg. The report included the resident had a light red area to the left anterior thigh, with no blistering on skin, no pain and an ice pack was applied. An interview was conducted with the wound care nurse (staff #8) on (MONTH) 26, 2019 at 9:55 a.m. She stated the area on the left thigh was a burn and the provider was coming in that day to assess the burn for treatment. She stated that she was not aware of any past burn injuries for this resident. On (MONTH) 26, 2019 at 10:07 a.m., this surveyor was informed by a CNA (staff #51) that the coffee that resulted in the resident's burn on (MONTH) 25, was obtained from the coffee machine on the kitchenette on the East unit nurses station. The surveyor then obtained hot water from this same coffee machine, as the coffee carafe was empty at this time. The temperature reading was 168 degrees Fahrenheit (F). An observation was conducted on (MONTH) 26, 2019 at 11:55 a.m. of staff #87 (clinical support staff)obtaining a temperature of the coffee which was poured from the coffee machine carafe in the East unit nursing station kitchenette. Staff #87 stated the coffee temperature was 174.5 degrees F. Shortly following the observation she was heard to say that the coffee from the East Unit kitchenette was too warm and a CNA was notified not to use the machine. An interview was conducted with a CNA (staff #19) on (MONTH) 26, 2019 at 1:01 p.m. She stated that she has newly been told to use a sippy cup with resident #26. She stated that he spills ice water on himself a lot of the time related to his uncontrollable movements. She stated they tried sippy cups in the past for him, but that he hates them. She said this was the first time that she heard of him spilling coffee. An interview was conducted with a CNA (staff #51) on (MONTH) 26, 2019 at 1:06 p.m. She stated that on (MONTH) 25, 2019, resident #26 asked her for some coffee. She stated that she gave him a cup, but he said it was too cold and wanted fresh coffee. She said that she brewed a fresh pot of coffee and brought it to him approximately 10-15 minutes after it was made. She said that she placed the coffee on the bed side table and knelt to eye level in front of him to tell him to be careful, because the coffee was very hot. She said that as she was standing back up, he spilled the coffee on himself. She stated they had tried sippy cups with lids, but he refused to use them and wanted his coffee in a regular coffee cup. She stated it is rare for him to spill fluids and that she has never known him to spill coffee on himself. She stated that he has altered movements in his hands and arms and would guess them to be uncontrollable movements. An interview was conducted with a registered nurse (staff #21) on (MONTH) 26, 2019 at 2:14 p.m. She stated the resident is always asking for water or coffee and that he spills everything. She stated that she has tried to give him straws, but he just throws them out. She said that he has only spilled cold water when she has cared for him and this is the first time he has gotten burned. She stated that once in a while he has spastic/uncontrolled movements, which improve with [MEDICATION NAME] use. When questioned regarding the resident spilling fluids on himself and the possibility of getting burned, she replied that she did not think about that because she only gives him cold fluids. An interview with the resident was conducted on (MONTH) 27, 2019 at 8:37 a.m. He stated that he had a big burn on his leg and that it was hurting worse today. During the interview, the resident was observed to have spastic movements to the upper extremities with purposeful movement, but no [DIAGNOSES REDACTED] at rest. Another interview was conducted with resident #26 on (MONTH) 27, 2019 at 10:25 a.m. He stated that sometimes he spills drinks, but has never spilled anything hot on himself before. He stated that staff has tried to serve coffee to him in a cup with a lid, but he did not like it and wanted it in a coffee cup. He stated that staff had not educated him on the risks of burning himself and did not think it would ever happen. He stated that if he were to drink coffee now, he would drink it in a cup with a lid. He said that he will not be drinking coffee anymore, because he is afraid that he will burn himself again. He stated that his leg was burning and that he had a pain level of 8 out of 10, but had not asked for more pain medication yet. An interview was conducted with a registered nurse (staff #6) on (MONTH) 27, 2019 at 10:34 p.m. She stated the resident has multiple contractures of the fingers and has had spastic movements of his arms for some time, and that it's worse when he is agitated. She said that he has spilled drinks, but he is careful with hot drinks and has never spilled them before. She stated that they do not give him anything without a CNA close by, and that a CNA was with the resident at the time of the spill. When questioned regarding the resident's burn risk, she said that she was sure that they had assessed his burn risk and that is probably why they were doing closer supervision. An interview was conducted with the Assistant Director of Nursing (ADON/staff #53) on (MONTH) 27, 2019 at 11:04 a.m. She stated the spastic movements and altered joint status for resident #26 was not new, and that he had a history of [REDACTED]. She said if the resident refused to use the sippy cups, there should be documentation of this and notification to the provider. She stated this resident would be at risk of spills [MEDICAL CONDITION] hot liquids and that they did not do what was needed to prevent the accident and resulting burn to the resident. She stated that as a result of the accident, the resident now has a burn with blisters and associated pain. She said that staff did not follow expectations or facility policy related to accident prevention. An observation of the resident was conducted on (MONTH) 28, 2019 at 9:15 a.m. The resident was supine in bed and was observed to have altered fine movements to the upper extremities. The resident was able to do larger movements (i.e. rub his ear, and wipe his face), however the movements were over exaggerated and were not fully controlled. The resident's head movements were also over exaggerated and his head bounced, when raised up and down from the pillow. An interview with the Executive Director was conducted on (MONTH) 28, 2019 at 1:29 p.m., who stated there was no policy specific for assessing resident's risk for burns. Review of the policy on [MEDICAL CONDITION] hot beverages revealed that hot food and beverages will be served at safe temperatures to prevents burns. The policy included that staff will monitor hot beverages on a regular basis at the point they are served. The policy stated that the optimum temperatures of hot beverages is 160 to 185 degrees Fahrenheit (F), however, to [MEDICAL CONDITION] beverages may be served at no more that 155 degrees F. The policy included that residents who are at risk [MEDICAL CONDITION] choose to drink beverages above 155 degrees F. will be educated on the risks and benefits of hot beverages. Appropriate supervision to obtain hot beverages will be provided to any individual demonstrating decreased safety awareness and/or anyone who is at risk [MEDICAL CONDITION] scalds, based on clinical assessment. The policy further included that lap trays, slip guards or cup holders on wheelchairs may be used to help hot liquids remain upright. A policy on Safety and Supervision of Residents revealed that resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The policy included that safety risks and environmental hazards are identified on an ongoing basis. Employees shall be trained and in-serviced on potential accident hazards, how to identify and report accident hazards, and preventing avoidable accidents. The policy identified resident-oriented approaches to safety which included the following: address the safety and accident hazards for individual residents; staff shall use various sources to identify risk factors for residents including the information obtained from the medical history, physical exam, observations of the resident and the MDS; the interdisciplinary team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for the resident and shall target interventions to reduce the potential for accidents; implement interventions to reduce accident risks and monitoring to ensure that interventions are implemented correctly and consistently.",2020-09-01
422,HAVEN OF SEDONA,35094,505 JACKS CANYON ROAD,SEDONA,AZ,86351,2019-08-28,732,B,0,1,Y0DU11,"Based on observations, facility documentation, staff interviews and policy review, the facility failed to ensure the daily posted nurse staffing information included the resident census. The deficient practice could result in residents and visitors not being made aware of the current staffing information. Findings include: Observations were conducted on (MONTH) 26 and 27, 2019 of the Posting of Licensed and Unlicensed Direct Care Staff information, which was located at the front desk. The form contained information regarding the daily number and hours worked for Licensed Nurses and Certified Nursing Assistants. However, the postings did not include the resident census. Review of the facility Posting of Licensed and Unlicensed Direct Care Staff forms from (MONTH) 26 to (MONTH) 25, 2019, revealed the resident census was not included on 13 out of 30 days. An interview was conducted with the Staffing Coordinator (staff #69) on (MONTH) 27, 2019 at 8:25 a.m. She stated the forms are prepared daily to make sure the facility has appropriate staffing for the resident census and resident care. She stated that the daily posting form needs to be filled out with the date and the starting resident census for the day. Staff #69 said the forms did not contain the resident census and therefore did not meet the requirements and expectations for completing the posted nurse staffing information. An interview was conducted with the Administrator (staff #86) on (MONTH) 27, 2019 at 8:39 a.m. He stated the staff posting form includes the projected resident census for the day and if the resident census was not on the form, it would not meet the expectations/requirements for completion of the posted nurse staffing information. Review of the facility's policy for Posting Direct Care Daily Staffing Numbers revealed the facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents and will include the resident census at the beginning of each shift.",2020-09-01
423,HAVEN OF SEDONA,35094,505 JACKS CANYON ROAD,SEDONA,AZ,86351,2019-08-28,812,D,0,1,Y0DU11,"Based on observations, staff interviews, and policy review, the facility failed to serve food in accordance with professional standards for food service safety. The deficient practice could place residents at risk for food borne illnesses. Findings include: During a dining observation conducted on (MONTH) 25, 2019 at 11:57 a.m., a staff member (#4) was observed assisting a resident by spreading butter on the resident's bread. The staff member was observed touching the bread with bare hands. A second dining observation was conducted the same day at 12:03 p.m. Staff #4 was observed assisting another resident by spreading butter on the resident's bread. The staff member was observed touching the bread with bare hands. An interview was conducted with a Certified Nursing Assistant (CNA/staff #55) on (MONTH) 26, 2019 at 10:40 a.m. He stated that when touching residents' food, staff members should wear gloves. He stated that staff did not need to wear gloves when passing out meal trays, only when touching or cutting up food. An interview was conducted with the CNA (staff #4) on (MONTH) 27, 2019 at 10:15 a.m. She stated that staff should wash their hands prior to serving food to residents. The CNA stated that sometimes she touch residents' bread when setting up meals, but that she always washes her hands prior to serving meals. Review of the facility's policy for General Food Preparation and Handling, revealed staff will handle utensils, cups, glasses and dishes in such a way as to avoid touching surfaces that food or drink would come in contact with. The policy included tongs or other serving utensils will be used to serve breads or other items to avoid bare hand contact with food.",2020-09-01
424,HAVEN OF SEDONA,35094,505 JACKS CANYON ROAD,SEDONA,AZ,86351,2019-08-28,880,D,0,1,Y0DU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on personnel record review, staff interview, and policy review, the facility failed to ensure an employee (staff #18) who has and/or is expected to have direct interaction with a resident for more than 8 hours a week provided evidence of freedom from infectious [MEDICAL CONDITION] (TB). The deficient practice could result in the potential of residents and employees being exposed to TB. Findings include: Review of the personnel record for a Registered Nurse (RN/staff #18) revealed a hire date of (MONTH) 18, (YEAR). The record included a TB testing consent and record form signed by the RN dated (MONTH) 11, 2019 that the RN had been exposed to TB and had a history of [REDACTED]. Continued review of the personnel record revealed a New Hire TB Screen & Annual TB Questionnaire for PPD (purified protein derivative) Converters and Reactors form that the RN exhibited no present symptoms of TB. The form was signed by the infection control nurse, not a medical practitioner, dated (MONTH) 28, 2019. An interview was conducted with the Infection Control Nurse (staff # 53) on (MONTH) 27, 2019 at 9:40 a.m. She stated that employees with a history of a positive TB test complete a yearly questionnaire with the infection control nurse and that if the employee is not exhibiting any signs or symptoms of TB there would be no further action required. Staff #53 stated that she did not realize a medical practitioner is required to sign the questionnaire that an individual is free from infectious TB. Review of the facility's policy for TB testing and chest x-ray requirements for employees revealed that in accordance with state and federal requirements, employees are required to remain free of TB and verify this status through current and yearly TB testing and the conducting of a chest X-ray or TB symptom check. The policy included employees will have their current TB testing status regardless of the form of the testing updated annually either with additional testing, an additional chest x-ray or an additional symptoms check.",2020-09-01
425,HAVEN OF SEDONA,35094,505 JACKS CANYON ROAD,SEDONA,AZ,86351,2019-11-26,689,D,1,0,J72S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews, and facility documentation and policy, the facility failed to provide adequate supervision for two residents (#265 and #31) resulting in a resident to resident altercation between the residents. The sample size was four residents. The deficient practice could result in further incidents between residents. Findings include: -Resident #265 was admitted to the facility on (MONTH) 30, (YEAR) with a [DIAGNOSES REDACTED]. The resident's care plan dated (MONTH) 8, 2019, included that resident #265 resided in a secured unit related to dementia and depression with psychotic symptoms. The goal for this care plan was that the resident's safety would be maintained and the resident would wander about the unit without any occurrence of injury. The interventions included that the resident used a wanderguard, he required monitoring as much as possible to assure his safety, and that staff should keep the environment free of possible hazards. Review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 16, 2019, included a Brief Interview for Mental Status (BIMS) with a score of 3, indicating the resident had severe cognitive impairment. The MDS also included that the resident could be short-tempered, easily annoyed, and exhibited behaviors of pacing and rummaging. Review of a Nurse Practitioner (NP) progress note dated (MONTH) 23, 2019 revealed that resident #265 was roaming on the secured unit with behaviors of ongoing psychotic symptoms including manifestations of a need to stand close to peers on the unit at all times. Review of a progress note dated (MONTH) 4, 2019, revealed that resident #265 had to be constantly redirected away from another resident, who threatened to kick him. A progress note dated (MONTH) 8, 2019, revealed that resident #265 required constant supervision to keep him safe from harm. Review of a progress note dated (MONTH) 13, 2019 at 9:12 p.m., revealed that resident #265 invaded resident #31's personal space and resident #31 verbally threatened resident #265. Review of a Quality Assessment Tool dated (MONTH) 14, 2019, revealed that resident #265 had memory problems and daily behaviors that required maximum staff intervention. -Resident #31 was admitted to the facility on (MONTH) 4, 2019, with [DIAGNOSES REDACTED]. Review of an annual MDS assessment dated (MONTH) 11, 2019, included a BIMS score of 3, indicating the resident had severe cognitive impairment. The MDS did not indicate that the resident had any verbal or physical behaviors toward others. The resident's [MEDICAL CONDITION] medication care plan dated (MONTH) 2019, revealed that the resident had depression, anxiety, and aggression related to a [MEDICAL CONDITION] (TBI) with [MEDICAL CONDITION]. The interventions included discouraging inappropriate behaviors and monitoring and recording any displayed behavior or mood problem. A care plan for cognition showed that the resident had cognitive impairment as evidenced by forgetfulness, confusion, and disorientation. The plan included that the resident believed it was 1986 and had difficulty making decisions. A second care plan for cognitive loss and dementia noted the resident exhibited restlessness and wandering. One of the interventions for this care plan was to increase supervision as necessary. A quarterly MDS dated (MONTH) 16, 2019, revealed that the resident had verbal and physical behaviors directed towards others 1 to 3 days during the 7-day look-back period of the assessment. Review of a facility incident report dated (MONTH) 31, 2019 revealed that resident #31 had an incident with another resident (not resident #265) on (MONTH) 27, 2019, where he had struck the resident on the left cheek leaving a slight pink mark. The report indicated that resident #31 may have felt threatened having the other resident close to him and in an attempt to push her away, his reaction resulted in an incident. The report concluded that there were no further issues or altered behaviors by the resident and that he did not remember the incident. The investigation did not include any further interventions to prevent resident #31 from having future incidents with residents. Review of an Initial Psychiatric Evaluation dated (MONTH) 5, 2019, revealed that resident #31 was agitated, angry, and recently involved in an altercation with another resident. Staff reported that resident was having auditory and visual hallucinations. There was no evidence in resident #31's clinical record that any interventions, including increased supervision, had been put in place after the incident on (MONTH) 27, 2019 to prevent resident #31 from having further incidents with other residents. Review of a facility incident report dated (MONTH) 13, 2019, revealed that resident #265 wandered over to resident #31, who was sitting at a table eating. Resident #31 yelled that he didn't want resident #265 near him. When resident #265 leaned in closer to resident #31, resident #31 grabbed him by the throat leaving a pinkish mark on his neck. On (MONTH) 26, 2019 at 9:14 a.m., an interview was conducted with a Certified Nursing Assistant (CNA/staff #61), who stated that resident #265 wanders and will hold on to the other residents' arms. She said that if the resident tries to get away, resident 265's grip tightens and he will hold up his other hand and make a fist. She said that she and the other staff know that resident #265 is going to grab other residents or their things and that staff are supposed to keep an eye on him to prevent this. On (MONTH) 26, 2019 at 9:40 a.m., an interview was conducted with a Licensed [MEDICATION NAME] Nurse(LPN/staff #67), who stated that in order to prevent incidents, she needs to distract residents or intervene prior to the incident occurring. She said that resident #265 paces all the time and needs to be redirected when he heads toward other residents. She said that some residents are triggered by resident #265 when he comes near them. She said that resident #265 has a prior history of grabbing other residents and making a fist when he is being redirected. During an interview with the interim Director of Nursing (DON/staff #4) on (MONTH) 26, 2019 at 12:10 p.m., she said that wandering behaviors are appropriate on a dementia unit. She said if a resident needs a secured unit, it would be part of the care plan that the resident wanders and the plan may include interventions such as redirection. She said that staff would redirect to keep residents safe and evaluate to determine what might be escalating or triggering the resident. She said that care planned interventions are modified when they do not work. She said the facility looks at triggers to prevent incidents and to ensure that there are staff to intervene quickly when incidents occur or may occur. In an interview with a nurse consultant (staff #72) on (MONTH) 26, 2019 at 12:35 p.m., she said that the residents reside on a wandering unit and staff know resident behaviors on this unit and have interventions for the individual residents. She said that for resident #265, she could not find anything specific in the resident's care plan to address his intrusiveness and entering other resident's spaces but said that there was a general intervention to monitor the resident as close as possible and that this means to be able to see the resident while he is around others so that he can be redirected when needed. During an interview with the administrator (staff #73) on (MONTH) 26, 2019 at 12:35 p.m., he stated that when an incident between residents occurs, he investigates and then based on the results of the investigation, he comes up with an action plan. He said that in this case, he was looking into more appropriate placement for resident #31 since wandering is expected in the secured unit and the resident lashed out when resident #265 wandered near him. Review of the facility's unsafe wandering policy revised (MONTH) 2014, revealed a policy statement that the facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. The policy implementation included that the staff will identify resident who are at risk for harm because of unsafe wandering and assess these resident for potentially correctable risk factors related to unsafe wandering. The policy included that the resident's care plan will indicate the resident is at risk for elopement or other safety issues and interventions to try to maintain safety, such as a detailed monitoring plan, will be included.",2020-09-01
426,DESERT COVE NURSING CENTER,35095,1750 WEST FRYE ROAD,CHANDLER,AZ,85224,2017-01-06,225,D,0,1,GO5211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews and review of the Abuse policy, the facility failed to report an allegation of abuse to the State agency and provide evidence of a thorough investigation for one resident (#138). Findings include: Resident #138 was admitted on (MONTH) 8, (YEAR), with [DIAGNOSES REDACTED]. An interview was conducted with resident #138 on (MONTH) 6, (YEAR) at 12:38 p.m. He stated that there was an incident about 2-3 months ago, where a Certified Nursing Assistant (CNA/ staff #129) abused him, while she was cleaning him after he had been incontinent of urine. He stated that staff #129 pulled his scrotum and yanked on it while cleaning him, until he was yelling in pain. He stated that this incident was witnessed by another CNA (staff #107) who worked on a different hall. The resident stated that he reported this incident to the Director of Nursing (DON) at the time, who stated that if he continued to pursue this accusation, he would be deemed as unfit to live in this facility. A phone interview was conducted on (MONTH) 6, (YEAR) at 1:36 p.m. with the CNA (#107) who the resident stated had witnessed the alleged abuse. Staff #107 stated that he was familiar with the resident, and that he did not recall any incidents where the resident had ever been abused by any CNA, but he stated he did recall one incident where staff #129 was assisting him in cleaning the resident after he had been incontinent. He stated that the resident had feces stuck to his scrotum, so staff #129 had to use more pressure to try to clean him off. He stated the resident said, OW, but did not yell. He stated that the resident was upset and wanted to be left alone. He stated that he and #129 explained to the resident that they were not trying to hurt him, but they needed to clean his scrotum, because there was feces stuck to it. He stated that due to how upset the resident was, they left his room and made him as comfortable as possible. He stated later in the day, a different staff member had come back to finish cleaning the resident. He stated that the resident did indicate to CNA #107 that he felt that staff #129 had abused him. Staff #107 stated that he reported the issue to the nurse, but he could not remember exactly who the nurse was that he reported it to or when exactly the event occurred. He stated that with all allegations of abuse, he would report them to the appropriate nurse. An interview was conducted on (MONTH) 6, (YEAR) at 1:51 p.m. with a Registered Nurse (RN/staff #60), who was the acting DON at the time of the incident. She confirmed that she was acting as the DON at the time of the incident, and was aware that the resident had accused #129 of abusing him, by roughly handling his testicles. She stated that an investigation was performed by the facility, and that a police officer was called by resident #138. She indicated that the police officer could not substantiate the abuse and there was no evidence found through their investigation. She stated that she had received the information regarding the abuse allegation when the police officer came into the building, and that the issue was not directly reported to her by staff until then. She stated that she had called her regional director, but did not call to report the allegation to the state, and that she would get a copy of the investigation. She stated the incident was determined to have occurred around (MONTH) 21, (YEAR). During the survey, two attempts were made to contact staff #129. However, the CNA was unable to be contacted. An interview with the current DON (staff #90), was conducted on (MONTH) 6, (YEAR) at 2:43 p.m. She stated that they were unable to find any documentation regarding the investigation for resident #138. According to the facility's abuse policy, the facility must ensure that all alleged violations of abuse are reported immediately to the Administrator and to the State survey agency. The policy further included that all allegations of abuse are thoroughly investigated, which includes a written summary of the findings no later than five working days after the reported occurrence. According to the facility 'Protection of Residents: Reducing the Threat of Abuse and Neglect' policy, the facility does not condone resident abuse and/ or neglect by anyone, including staff members. All personnel should promptly report any incident or suspected incident of resident abuse or neglect to their immediate supervisor. Also according to the policy, when an incident of resident abuse is suspected, it must be reported to the supervisor regardless of the length of time that has transpired since the incident occurred. Once the incident is reported, the director of nursing, administrator, or designated representative must complete an investigation of the incident, which includes a written summary of the findings no later than five working days after the reported occurrence. Federal requirements state that all allegations of abuse must be reported immediately to the state survey agency.",2020-09-01
427,DESERT COVE NURSING CENTER,35095,1750 WEST FRYE ROAD,CHANDLER,AZ,85224,2017-01-06,226,D,0,1,GO5211,"Based on resident and staff interviews and review of the policy, the facility failed to implement their abuse policy regarding an allegation of abuse. Findings include: An interview was conducted with resident #138 on (MONTH) 6, (YEAR) at 12:38 p.m. He stated that there was an incident about 2-3 months ago, where a Certified Nursing Assistant (CNA/ staff #129) abused him, while she was cleaning him after he had been incontinent of urine. He stated that staff #129 pulled his scrotum and yanked on it while cleaning him, until he was yelling in pain. He stated that this incident was witnessed by another CNA (staff #107) who worked on a different hall. The resident stated that he reported this incident to the Director of Nursing (DON) at the time who stated that if he continued to pursue this accusation, he would be deemed as unfit to live in the facility. A phone interview was conducted on (MONTH) 6, (YEAR) at 1:36 p.m. with the CNA (#107) who the resident stated had witnessed the alleged abuse. Staff #107 stated that he was familiar with the resident, and that he did not recall any incidents where the resident had ever been abused by any CNA, but he said he did recall one incident where staff #129 was assisting him in cleaning the resident after he had been incontinent. He stated that the resident had feces stuck to his scrotum, so staff #129 had to use more pressure to try to clean him off. He stated the resident said, OW, but did not yell. He stated that the resident was upset and wanted to be left alone. He stated that he and #129 explained to the resident that they were not trying to hurt him, but they needed to clean his scrotum, because there was feces stuck to it. He stated that due to how upset the resident was, they left his room and made him as comfortable as possible. He stated later in the day, a different staff member had come back to finish cleaning the resident. He stated that the resident did indicate to CNA #107 that he felt that staff #129 had abused him. Staff #107 stated that he reported the issue to the nurse, but he could not remember exactly who the nurse was that he reported it to or when exactly the event occurred. He stated that with all allegations of abuse, he would report them to the appropriate nurse. An interview was conducted on (MONTH) 6, (YEAR) at 1:51 p.m. with a Registered Nurse (RN/staff #60), who was the acting DON at the time of the incident. She confirmed that she was acting as the DON at the time of the incident, and was aware that the resident had accused #129 of abusing him, by roughly handling his testicles. She stated that an investigation was performed by the facility, and that a police officer was called by resident #138. She indicated that the police officer could not substantiate the abuse and there was no evidence found through their investigation. She said that she had received the information regarding the abuse allegation when the police officer came into the building, and that the issue was not directly reported to her by staff until then. She stated that she had called her regional director, but did not call to report the allegation to the State, and that she would get a copy of the investigation. She stated the incident was determined to have occurred around (MONTH) 21, (YEAR). During the survey, two attempts were made to contact staff #129. However, the CNA was unable to be contacted. An interview with the current DON (staff #90), was conducted on (MONTH) 6, (YEAR) at 2:43 p.m. She stated that they were unable to find any documentation regarding the investigation for resident #138. According to the facility's abuse policy, the facility must ensure that all alleged violations of abuse are reported immediately to the Administrator and to the State survey agency. The policy further included that all allegations of abuse are thoroughly investigated, which includes a written summary of the findings no later than five working days after the reported occurrence.",2020-09-01
428,DESERT COVE NURSING CENTER,35095,1750 WEST FRYE ROAD,CHANDLER,AZ,85224,2017-01-06,281,D,0,1,GO5211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of a clinical record, staff interviews, and review of a policy and procedure, the facility failed to ensure the interim care plan for one resident (#264) included the use of an antipsychotic medication. Findings include: Resident #264 was admitted to the facility on (MONTH) 30, (YEAR), with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A review of the interim care plan revealed no need, goal, or interventions were developed to address the resident's use of the antipsychotic medication. During an interview conducted at 2:37 p.m. on (MONTH) 4, (YEAR), a registered nurse (staff #147) stated that he would expect the nurse admitting the resident to develop an interim care plan to address a resident's use of an antipsychotic medication. The registered nurse also stated that he felt any medication that required obtaining consent and explaining the risk and benefits of the medication to the resident or legal representative should be addressed in the interim care plan. During an interview conducted at 2:40 p.m. on (MONTH) 4, (YEAR), the Director of Nursing (DON/staff #90) stated she would expect an interim care plan should be developed to address the use of an antipsychotic medication. A review of the Resident Care Plan revealed An interim care plan is to be completed upon admission.",2020-09-01
429,DESERT COVE NURSING CENTER,35095,1750 WEST FRYE ROAD,CHANDLER,AZ,85224,2017-01-06,371,E,0,1,GO5211,"Based on observations, staff interviews, and review of a policy and procedure the facility failed to ensure beverages were served under sanitary conditions to multiple residents. Findings include: During a dining observations conducted at 12:01 p.m. on (MONTH) 3, (YEAR), one dietary aid (staff #48) was observed serving beverages off a tray to residents. The dietary aid was picking up the glasses with her bare hand, touching her palm and first finger on her right hand to the outer top rim of the glasses before serving the glasses filled with beverages to multiple residents. During an interview conducted after the observations, the dietary aid stated that she should pick up the glasses lower on the outside of the glasses to avoid touching the surfaces of the glasses that the residents would touch with their mouths. During a second dining observation conducted at 12:00 p.m. on (MONTH) 4, (YEAR), a certified nursing assistant (staff #65) was observed pushing a resident from the dining room to the resident's room. The CNA was carrying a coffee mug with a covered tulip dessert cup on top. She was carrying the cup with her palm above the top of the tulip dessert cup and her fingers and thumb touching the rim of the coffee mug. The resident was carrying a glass of orange juice which was placed on the overhead bed table. The CNA also placed the dessert cup and coffee mug on the overhead bed table. She then picked up the glass of orange juice with her palm over the top of the glass and fingers touching the rim of the glass and moved it in front of the resident and did the same to the coffee cup. During an interview conducted after the CNA exited the resident's room, the CNA stated that she was not supposed to carry cups or glasses in that manner. She stated that her bare hand should not touch the cup or glass where the resident will place their mouth. During an interview conducted at 12:45 p.m. on (MONTH) 4, (YEAR), the dietary manager (staff #49) stated that staff serving resident beverages were supposed to ensure their bare hands do not touch any surface on the dishes, utensils, or glasses that would be touched by the residents' food or mouth. A review of the Safe Food Handling policy and procedure revealed Associates do not touch areas of utensils, dishware, or flatware where the food or mouth is placed.",2020-09-01
430,DESERT COVE NURSING CENTER,35095,1750 WEST FRYE ROAD,CHANDLER,AZ,85224,2017-01-06,411,D,0,1,GO5211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and a review of facility policy, the facility failed to ensure dental services were obtained for one resident (#45). Findings include: Resident #45 was originally admitted on (MONTH) 27, 2012, and was readmitted on (MONTH) 28, (YEAR). The resident's [DIAGNOSES REDACTED]. A review of oral assessments from (MONTH) (YEAR) through (MONTH) 2, (YEAR), revealed documentation that the resident had no dentures and many missing upper and lower teeth. A review of the (MONTH) 10 and (MONTH) 31, (YEAR) oral assessments also include documentation that the resident had no dentures and many missing upper and lower teeth. However, these oral assessments also included documentation that the resident had a broken tooth on the lower jaw. An annual MDS (Minimum Data Set) assessment dated (MONTH) 11, (YEAR), included, Obvious or likely cavity or broken teeth. A care plan was developed to address the resident's dental/mouth problem. The care plan included the resident had broken, loose, missing teeth, was edentulous, was totally dependent on staff for oral care and that she had contractures of both hands. The interventions included the following: -Dental consults as indicated. -Discuss oral concerns with the resident/responsible party. -Report changes in oral status to the physician. -Report changes in oral status to the nurse: teeth broken, loose, cavities, decay, missing teeth. However, a continued review of the clinical record revealed no documented evidence that the resident's dental status (broken lower tooth) had been discussed with her, responsible party, or her physician or that a dental evaluation had been obtained. An interview was conducted on (MONTH) 5, (YEAR) at 8:10 a.m., with the Social Service Director-staff #119, who stated that dental services were available at the facility for residents. She stated that if a resident needs a dental evaluation, the physician or licensed staff sends a referral to social services to obtain the dental evaluation. Staff #119 also stated she did not recall or have any record of a referral for this resident. An interview was conducted on (MONTH) 5, (YEAR) at 8:25 a.m., with MDS staff-#99. Staff #99 stated that she had provided the (MONTH) and (MONTH) (YEAR), oral assessments, including the documentation that a broken lower tooth was present. She stated that she did not send a referral to social services for a dental evaluation because the resident did not complain of any pain and was not having any dental issues. On (MONTH) 5, (YEAR) at 8:30 a.m., a resident interview was conducted. The resident stated that she did have a broken tooth and that sometimes the tooth hurts a little when she is eating or talking. According to the resident, she reported it to the physician and the nurses but that she has not been seen by a dentist in a long time. At this time, the resident stated that she would like to visit people but that she was embarrassed by the tooth. Another interview was conducted on (MONTH) 5, (YEAR) at 10:10 a.m., with the Director of Nursing-staff #90. She stated that the MDS staff, who completed the (MONTH) and (MONTH) (YEAR), oral assessments should have sent a referral to social services to obtain a dental evaluation. A facility policy titled, Dental Services, included, The facility is responsible for assisting the patient in obtaining needed dental services, including routine dental services. The facility will provide or obtain from an outside resource routine and emergency dental services to meet the needs of each resident.",2020-09-01
431,DESERT COVE NURSING CENTER,35095,1750 WEST FRYE ROAD,CHANDLER,AZ,85224,2017-01-06,441,D,0,1,GO5211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of personnel files, staff interviews, and review of policies and procedures, the facility failed to ensure one staff member had documentation of freedom from [DIAGNOSES REDACTED] (TB), and failed to ensure infection control practices were followed in the cleaning of isolation food trays and carts. Findings include: -Review of the personnel file 'Initial and Annual Associate Health Assessment' form for one Dietary staff member (#94),who was hired on (MONTH) 14, (YEAR), revealed an incomplete documentation of freedom from TB. The Purified Protein Derivative (PPD) TB skin test documentation indicated that the result was negative, and the size of the reaction was 0 mm. However, the documentation did not include a date of administration, nor did it include the date which the test was read. An interview was conducted with the DON (staff #90) on (MONTH) 6, (YEAR) at 2:38 p.m. She stated that no one was able to find further documentation regarding the incomplete TB test for staff #94. The facility was unable to provide any documentation that staff #94 was free from TB. Review of the Facility's '[DIAGNOSES REDACTED] Control and Purified Protein Derivative (PPD) Testing' policy revealed that a pre-employment examination of all employees must include a screening for TB. The policy included that all employees must have annual PPD tests, unless exempt. -During an observation of the removal of the lunch trays from one isolation room with confirmed Clostridium Difficile (C-diff) infection and another isolation room with suspected[DIAGNOSES REDACTED] on (MONTH) 5, (YEAR) at 12:20 p.m., the meal trays with non-disposable dishware were observed placed in the tray cart with all other lunch trays and returned to the kitchen. Once in the kitchen, the kitchen worker, (staff #24), was observed to don a disposable plastic apron and gloves. Staff #24 then began to remove each tray from the cart and discard any remaining food and paper products in a trash barrel. It was observed that nearly every tray was held against the staff member's apron as the trays were removed from the tray transport cart. As the staff member cleared each tray, the dishes were either stacked in preparation for adding to the dishwasher racks or added immediately to dishwasher racks. Racks of dishes were then sprayed with water to remove large food debris. Food debris and water splashed onto the staff member's apron. Dish racks were then moved through the dishwasher cycle on the high-temperature dishwasher. The kitchen worker repeated this process until all trays from the cart was removed, including the two trays from the isolation rooms. Once all food trays were removed, the worker removed her gloves and washed her hands. The staff member did not remove or change her apron. The staff member was then observed to empty the freshly washed dish racks. The same dirty/contaminated apron remained on as the worker removed the food trays and dishware. The items were held against the worker's apron. Then the food worker prepared a bucket of sanitizer and bucket of soap and water. Without applying gloves, the worker grossly wiped down the food tray transport cart first with soap and water followed by sanitizer. The sanitizer used was identified as Oasis 146 Multi-Quat Sanitizer. Review of the product specification document from Ecolab on Oasis 146 Multi-Quat Sanitizer revealed an identified list of organisms the sanitizer is effective against at various concentrations;[DIAGNOSES REDACTED] was not included. The kitchen worker then reapplied gloves and began to repeat the process for the next food tray transport cart without changing the apron. In an interview with staff #24 on (MONTH) 5, (YEAR) at 1:10 p.m., staff #24 stated she should have changed her apron when she changed her gloves because of the contamination. In an interview with the Director of Food and Nutrition Services (Director/staff #49) on (MONTH) 5, (YEAR) at 1:20 p.m., the Director stated the apron should have been changed after the isolation tray work was completed. Review of the facility policy titled Transmission-based Precautions and Isolations Procedures included, Contact precautions are used for diseases transmitted by contact with the patient or the patient's environment . The policy further included, Indirect-contact transmission involves contact of a susceptible host with a contaminated object, usually inanimate, in the patient's environment.",2020-09-01
432,DESERT COVE NURSING CENTER,35095,1750 WEST FRYE ROAD,CHANDLER,AZ,85224,2017-01-06,465,D,0,1,GO5211,"Based on observations, staff interviews, and review of facility policy and procedure, the facility failed to ensure bloody bath towels were not left on the floor in a resident bathroom. Findings include: During an observation conducted in room #202 (a private resident room) at 9:55 a.m. on (MONTH) 6, (YEAR), a couple of white bath towels were observed on the floor in the resident bathroom. The towels had large reddish brown spots on them that appeared to be blood. During the observation the Director of Nursing stated that the resident was bleeding during the night and had to be discharged to the hospital. She stated that the night shift staff must have failed to pick up the towels. During an interview conducted at 10:00 a.m. on (MONTH) 6, (YEAR), a certified nursing assistant (staff #65) stated that if a resident was bleeding and soiled towels were on the floor, after the resident was sent to the hospital the CNA was responsible for picking up the bloody towels, double bagging them and placing them in the soiled laundry bin. During a second interview conducted at 10:05 a.m. on (MONTH) 6, (YEAR), the Director of Nursing stated that she picked up the towels, bagged them and placed the two bloody bath towels in the soiled linen bin then informed housekeeping staff regarding the bloody towels that had been placed on the floor in the resident's bathroom and the need to clean the resident's bathroom. She also stated that she would have expected the staff to have picked up the soiled towels before the end of their shift. A review of the Handling of Soiled Linen policy and procedure revealed Soiled linen will be handled in a manner that will provide a sanitary environment for the resident, visitors, and staff in order to reduce the potential for infection. To prevent the spread of infection through proper handling and ensure proper handling of soiled linen .",2020-09-01
433,DESERT COVE NURSING CENTER,35095,1750 WEST FRYE ROAD,CHANDLER,AZ,85224,2018-01-30,602,D,1,1,DW8S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on a review of the clinical record, facility documentation, staff interviews and policy review, the facility failed to ensure that one resident's (#119) money was not misappropriated. Findings include: Resident #119 was admitted on (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. Review of the facility's investigative documentation revealed that on (MONTH) 23, (YEAR), an allegation of misappropriation of resident property was received. Per the report, the resident's checkbook was missing and six checks had been processed by the bank. Three of the checks had been made out to and endorsed by a CNA (Certified Nursing Assistant/staff #137), and three checks were made out to a non-associate of the facility. The memo on three of the checks were for care giving and three for housekeeping services. The check amounts totaled $1,850.00, of which $750.00 went to staff #137 and $1,100.00 went to the non-associate. The facility's report also included that a comparison of the resident's signature and the CNA's printing and signature were made, and it was concluded that it was more likely than not that the CNA had misappropriated the resident's funds. Per the report, the CNA was interviewed on (MONTH) 24, (YEAR) and denied that she had stolen the resident's checks. The CNA was suspended pending the investigation and was subsequently terminated on (MONTH) 25, (YEAR). An interview was conducted on (MONTH) 25, (YEAR) with the Administrator (staff #135), who stated that he was not in the position at the time of the incident and was unable to provide any additional information. During the survey, staff #137 was unable to be reached for an interview. Review of a facility policy titled, Resident Rights revealed that residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.",2020-09-01
434,DESERT COVE NURSING CENTER,35095,1750 WEST FRYE ROAD,CHANDLER,AZ,85224,2018-01-30,607,D,1,1,DW8S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, facility documentation, staff interviews, and policy and procedures, the facility failed to follow their abuse policy regarding allegations of misappropriation of resident property for two residents (#24 and #222). Findings include: -Resident #24 was admitted to the facility on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. Review of the resident's inventory of personal effects dated (MONTH) 9, (YEAR), revealed the resident had a fanny pack, wallet, and a cell phone upon admission. Review of the facility's investigative documentation revealed that on (MONTH) 29, (YEAR), the resident reported that his fanny pack was missing, which contained his wallet, his identification and a debit card. The documentation included that the resident called the bank and that $600 had been withdrawn on (MONTH) 28, and there was an attempt to withdraw another $600 on (MONTH) 29, which was declined. The police were notified and came out to investigate. The fanny pack was unable to be located. Further review of the investigative documentation revealed that it did not include interviews with the resident or interviews with any other residents, and there were no statements from staff regarding the missing fanny pack. In addition, the investigation did not include that the State agency and Adult Protective Services (APS) were notified of the allegation or that the results of the investigation were sent to the State agency. -Resident #222 was admitted to the facility on (MONTH) 15, (YEAR), with [DIAGNOSES REDACTED]. The resident was discharged to home on (MONTH) 1, (YEAR). Review of the resident's inventory of personal effects dated (MONTH) 15, (YEAR) revealed the resident had a wallet, which was listed as a personal item. Review of the facility's investigative documentation revealed that on (MONTH) 18, (YEAR), the resident's family reported to staff that the resident's wallet was missing. The police were notified and came out to investigate. The wallet was unable to be located. Further review of the facility's investigative documentation revealed no evidence that other residents were interviewed, nor did it include any statements from staff. The investigative documentation also did not include that the State agency and APS were notified of the allegation, nor that the results of the investigation were sent to the State agency An interview was conducted with the Administrator (staff #135) at 3:25 p.m. on (MONTH) 25, (YEAR). He stated that both resident #24 and resident #222 had missing items, which were possibly misappropriated. He said that he was not the Administrator at the time of these occurrences. He reviewed the documentation and stated that if they occurred now, he would investigated the allegations and would include much more information, such as interviews with staff and residents. Staff #135 also stated that he would report the allegations to the appropriate agencies, including the State agency and would provide the investigation to the State agency. Review of the facility's Abuse policy revealed that any incident or suspected incident of abuse, neglect, mistreatment, or misappropriation of resident property shall be reported immediately to the Administrator and/or Director of Nursing and to other officials, including the State Survey Agency and APS. Failure to do so will mean that the facility is not in compliance with the Federal regulations. The policy included that the facility must satisfy the Federal requirements to report the results of the investigation within 5 days of the incident. Any report after that time will be considered out of compliance. The policy also included that when an incident of abuse is suspected, the Administrator, Director of Nursing or designated representative will complete an investigation. The information obtained will include the name of the resident involved, the date and time the incident occurred, where the incident took place, the name of the person committing or involved in the incident, if known, the name of any witnesses, and any other pertinent information. Review of a policy titled Abuse Investigation protocol revealed that when there is an allegation that the resident believes their property has been stolen, an investigation is required and the Administrator will lead the investigation. This process includes investigating the alleged victim to determine the details of the concern, interviewing the family and interviewing 10% of the resident population. The policy also included that staff interviews should include those who worked with the alleged victim 48 hours prior to the incident.",2020-09-01
435,DESERT COVE NURSING CENTER,35095,1750 WEST FRYE ROAD,CHANDLER,AZ,85224,2018-01-30,609,D,1,1,DW8S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, facility documentation, staff interviews and policy and procedures, the facility failed to ensure that allegations of misappropriation of resident property for two residents (#24 and #222) were reported to the State agency and that the results of the investigations were submitted to the State agency within 5 days. Findings include: -Resident #24 was admitted to the facility on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. Review of a facility concern and comment form dated (MONTH) 29, (YEAR), revealed the resident told staff that his fanny pack was missing, and that his debit card, wallet, and his identification were all in the fanny pack. The documentation included that the resident called the bank and that $600 had been withdrawn on (MONTH) 28, (YEAR), and there was an attempt to withdraw another $600 on (MONTH) 29, (YEAR), which was declined. Review of the facility's investigative documentation revealed the resident was missing a fanny pack. The facility searched for the fanny pack, but it was not found. The police were contacted and came out to investigate. Further review of the facility's investigation revealed no evidence that the State agency or Adult Protective Services (APS) were notified of the allegation of misappropriation of resident property, and there was no documentation that the results of the investigation were submitted to the State agency, within 5 days. -Resident #222 was admitted to the facility on (MONTH) 15, (YEAR), with [DIAGNOSES REDACTED]. The resident discharged home on (MONTH) 1, (YEAR). Review of the resident's inventory of personal effects dated (MONTH) 15, (YEAR) revealed the resident had a wallet which was listed as a personal item upon admission. According to a facility concern and comment form dated (MONTH) 18, (YEAR), the resident's family reported to staff that the resident's wallet was missing. Per the documentation, the wallet was on the nightstand on (MONTH) 16, and when the family returned to his room on (MONTH) 18, the wallet was missing. Review of the facility's investigation revealed the police had been notified of the missing wallet and had been out to the facility to investigate. The documentation included that the resident had the wallet on admit, as it had been on the inventory sheet. The documentation also included that the wallet was not found. Further review of the facility's investigation revealed it did not include that the State agency or APS were notified of the allegation or that the results of the investigation had been submitted to the State agency, within 5 days. An interview was conducted with the Administrator (staff #135) at 3:25 p.m. on (MONTH) 25, (YEAR). He stated that both resident #24 and resident #222 had missing items and that the police were called, and that they possibly were misappropriated. He said that he was not the Administrator at the time of these occurrences. He reviewed the documentation and stated that if they occurred now, he would report the allegations to the appropriate agencies, including the State agency and would provide the complete investigation to the State agency. Review of the facility's Abuse policy revealed that the facility must ensure that all alleged violations involving abuse, neglect and misappropriation of resident property are reported immediately to other officials including the State Survey Agency and APS. Failure to do so will mean that the facility is not in compliance with the Federal regulations. The policy further noted that the facility must satisfy the Federal requirements and report the results of the investigation within 5 days of the incident to the State agency, and that any report after that time will be considered out of compliance.",2020-09-01
436,DESERT COVE NURSING CENTER,35095,1750 WEST FRYE ROAD,CHANDLER,AZ,85224,2018-01-30,610,D,1,1,DW8S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, facility documentation, family and staff interviews and policies and procedures, the facility failed to ensure that allegations of misappropriation of resident property were thoroughly investigated for two residents (#24 and #222). Findings include: -Resident #24 was admitted to the facility on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. According to the resident's inventory of personal effects form dated (MONTH) 9, (YEAR), the resident had a fanny pack, a wallet and a cell phone, which were listed as personal items that the resident had upon admission. Review of a facility concern and comment form dated (MONTH) 29, (YEAR) revealed the resident told staff that his fanny pack was missing, and that his debit card, wallet, and his identification were all in the fanny pack. The documentation included that the resident called the bank and that $600 had been withdrawn on (MONTH) 28, (YEAR), and there was an attempt to withdraw another $600 on (MONTH) 29, (YEAR), which was declined. Review of the facility's investigative documentation revealed the resident was missing a fanny pack. The documentation included that staff had been interviewed, but none were aware of the missing fanny pack. The facility searched for the fanny pack, but it was not found. The police were contacted and came out to investigate. Further review of the facility's investigative documentation revealed no evidence that the resident was interviewed or that other residents were interviewed regarding any missing items. The investigative documentation also indicated that staff had been interviewed, however, it did not include which staff were interviewed or their statements. -Resident #222 was admitted to the facility on (MONTH) 15, (YEAR), with [DIAGNOSES REDACTED]. The resident was discharged home on (MONTH) 1, (YEAR). Review of the resident's inventory of personal effects dated (MONTH) 15, (YEAR) revealed the resident had a wallet which was listed as a personal item upon admission. According to a facility concern and comment form dated (MONTH) 18, (YEAR), the resident's family reported to staff that the resident's wallet was missing. Per the documentation, the wallet was on the nightstand on (MONTH) 16, and when the family returned to his room on (MONTH) 18, the wallet was missing. Review of the facility's investigation revealed the police had been notified of the missing wallet and had been out to the facility to investigate. The documentation included that the resident had the wallet on admission, as it had been on the inventory sheet. The documentation further included that the wallet was not found. Further review of the facility's investigation revealed it did not include any interviews with staff or other residents. During an interview with the Director of Social Services (staff #109) at 9:20 a.m. on (MONTH) 24, (YEAR), she stated that resident #222's wallet went missing and they looked for it, but could not find it. She stated that her role is to provide the information to the Administrator and the Director of Nursing (DON) and they investigate. A family interview was conducted at 11:45 a.m. on (MONTH) 25, (YEAR). The family member stated that the resident's wallet went missing soon after admission and this was reported to staff and they looked into it. The family member stated that the wallet contained a debit card, a social security identification card and some money. The family member stated that she checked his bank account and someone had used his debit card and tried to take money out of his account twice. Continued review of the facility's investigation revealed that it did not include any specific information regarding the missing wallet such as, what was in the wallet or if the resident's bank had been contacted. An interview was conducted with the Administrator (staff #135) at 3:25 p.m. on (MONTH) 25, (YEAR). He stated that both resident #24 and resident #222 had missing items and that the police were called, and that the items were possibly misappropriated. Staff #135 stated that he was not the Administrator at the time of these occurrences. He reviewed the documentation and stated that if they occurred now, he would investigate the allegations and would include much more information, such as interviews with staff and residents. Review of the facility's Abuse policy revealed that any incident or suspected incident of abuse, neglect, mistreatment and misappropriation of resident property shall be investigated and reported immediately to the Administrator. The policy included that any incident will be reported to a supervisor who will obtain the name of the resident involved, the date and time the incident occurred, where the incident took place, the name of the person committing or involved in the incident, if known, the name of any witnesses, and any other pertinent information. Per the policy, the Administrator will complete an investigation of the incident. Review of a policy titled Abuse Investigation protocol revealed that when there is an allegation that the resident believes their property has been stolen, an investigation is required and the Administrator will lead the investigation. This process includes investigating the alleged victim to determine the details of the concern. The policy noted that family will be interviewed and that 10% of the resident population should be interviewed. The policy also included that staff interviews should include those who worked with the alleged victim 48 hours prior to the incident.",2020-09-01
437,DESERT COVE NURSING CENTER,35095,1750 WEST FRYE ROAD,CHANDLER,AZ,85224,2018-01-30,623,D,0,1,DW8S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, and policy and procedures, the facility failed to notify two residents (#25 and #64) and/or the resident's representatives in writing of the transfers/discharges, and failed to send a copy of the notice to the Ombusdman. Findings include: -Resident #64 was admitted to the facility on (MONTH) 3, (YEAR), with [DIAGNOSES REDACTED]. The clinical record indicated that the resident was his own responsible party. Review of the Minimum Data Set (MDS) assessments revealed the resident had been discharged and readmitted to the facility multiple times as follows: -discharged on (MONTH) 19, (YEAR) and readmitted on (MONTH) 24, (YEAR) -discharged on (MONTH) 11, (YEAR) and readmitted on (MONTH) 21, (YEAR) -discharged on (MONTH) 6, (YEAR) and readmitted on (MONTH) 12, (YEAR) -discharged on (MONTH) 17, (YEAR) and readmitted on (MONTH) 22, (YEAR) -discharged on (MONTH) 10, (YEAR) and readmitted on (MONTH) 11, (YEAR) Review of the corresponding nursing notes revealed the resident had been discharged to the hospital on the above dates. Further review of the clinical record revealed no evidence that the resident was notified in writing of the transfer/discharges or that the ombudsmen was sent copies of the notices of transfers/discharges to the hospital. -Resident #25 was admitted to the facility on (MONTH) 7, (YEAR), with [DIAGNOSES REDACTED]. Review of the admission MDS assessment dated (MONTH) 14, (YEAR) revealed the resident had a Brief Interview for Mental Status score of 10, which indicated the resident had moderate cognitive impairment. According to the MDS assessments, the resident was discharged and readmitted as follows: -discharged on (MONTH) 9, (YEAR) and readmitted on (MONTH) 18, (YEAR) -discharged on (MONTH) 20, (YEAR) and readmitted on (MONTH) 26, (YEAR) Per the clinical record documentation, the resident experienced a change of condition on (MONTH) 9 and 20, (YEAR) and was transferred to the hospital. Further review of the clinical record revealed no evidence that the resident or the resident's representative were notified in writing of the transfer/discharges to the hospital or that the ombudsmen was sent copies of the notices of transfers/discharges to the hospital. In an interview conducted on (MONTH) 26, (YEAR) at 1:49 p.m. with the social worker (staff #134), staff #134 stated she was not responsible for doing the discharges at the facility, so she was not sending any information on discharges to the ombudsman. She further stated she was not aware this had to occur. An interview was conducted on (MONTH) 26, (YEAR) at 1:53 p.m. with a Licensed Practical Nurse (Case Manager/staff #58), who stated that the nurse receives a discharge or transfer order and then lets the family know verbally, but she did not think there was anything in writing. Staff #58 stated the nurses complete the discharges to the hospital. She further stated that she was not aware that the ombudsman needed to be notified. In an interview conducted on (MONTH) 26, (YEAR) at 2:12 p.m., with a registered nurse (interim Director of Nursing/staff #78), staff #78 stated she was not aware of the requirement to notify residents and the ombudsman in writing regarding discharges to the hospital. During an interview conducted with the Corporate Registered Nurse Consultant (staff #133) on (MONTH) 26, (YEAR) at 2:12 p.m., staff #133 stated the facility has a company policy regarding this, however, they are not notifying the resident, family and ombudsman in writing regarding transfers to the hospital. Review of a facility policy titled, Transfers and Discharges revealed that Social Services and Nursing staff will participate in all transfers and discharges, as part of the interdisciplinary team. The policy included that transfers and discharges will be handled appropriately to ensure proper notification and assistance to residents and families, in accordance with Federal and State-specific regulations. The policy also included under the Emergency Transfers section that, When a resident is temporarily transferred on an emergency basis to an acute care facility, notice of the transfer may be provided to the resident and resident representative as soon as practicable. Copies of notices for emergency transfers must also still be sent to the ombudsman, but they may be sent when practicable .",2020-09-01
438,DESERT COVE NURSING CENTER,35095,1750 WEST FRYE ROAD,CHANDLER,AZ,85224,2018-01-30,641,D,0,1,DW8S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, and policy and procedures, the facility failed to ensure that the Minimum Data Set (MDS) assessments were accurate for two residents (#33 and #68). Findings include: -Resident #33 was admitted on (MONTH) 4, (YEAR), with [DIAGNOSES REDACTED]. Review of the (MONTH) and (MONTH) (YEAR) recapitulation of physician's orders [REDACTED]. A physician's note dated (MONTH) 5, (YEAR) revealed documentation that the resident had geriatri[DIAGNOSES REDACTED]s, which included reduced appetite and consumption. The note further stated that the resident's weight change was expected. A quarterly MDS assessment dated (MONTH) 6, (YEAR) indicated in Section K, that the resident had weight loss and was on a physician prescribed weight loss regimen. A care plan identified that the resident was a nutritional risk, as evidenced by significant weight loss, due to disease processes. The care plan included the resident was on a therapeutic diet and to provide diet as ordered. However, a review of the clinical record revealed there was no evidence that the resident was on a physician prescribed weight loss regimen. On (MONTH) 30, (YEAR) at 8:41 a.m., an interview was conducted with the dietician (staff #126). Staff #126 stated that the resident's weight loss was beneficial, due to the resident's BMI (Body Mass Index), however, there was no physician prescribed weight loss regimen for the resident. Staff #126 stated that she was responsible for coding Section K of the resident's MDS assessments, and that she had coded the MDS to reflect the physician prescribed weight loss regimen, because the resident had diabetes and was on a CCHO diet. Staff #126 stated that the CCHO diet did not include any portion control or restrictions regarding calorie consumption. Staff #126 further stated that there were no expected weight loss goals that would indicate a weight loss regimen. -Resident #68 was admitted on (MONTH) 23, (YEAR), with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of the (MONTH) 3, (YEAR) discharge nursing note and the facility's census documentation revealed the resident was discharged to home. However, review of the discharge MDS assessment dated (MONTH) 3, (YEAR), revealed documentation that the resident was discharged to the hospital. An interview was conducted on (MONTH) 25, (YEAR) at 9:05 a.m., with the MDS nurse (staff #52). Following a review of the clinical record, staff #52 stated that the MDS was inaccurate. A facility policy titled, Certification of Accuracy of the MDS included to obtain the signature of all persons who completed any part of the MDS. It is an attestation that to the best of your knowledge, the information you entered on the MDS accurately reflects the patient's status. The primary responsibility for accuracy lies with the person selecting the MDS item response.",2020-09-01
439,DESERT COVE NURSING CENTER,35095,1750 WEST FRYE ROAD,CHANDLER,AZ,85224,2018-01-30,684,D,0,1,DW8S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, staff interviews and policies and procedures, the facility failed to provide the necessary care and services to two residents (#'s 5 and 11). Findings include: -Resident #5 was readmitted on (MONTH) 28, (YEAR), with [DIAGNOSES REDACTED]. A review of the clinical record revealed documentation that the resident had moderate cognitive impairment. Further review of the clinical record revealed the resident had been prescribed and administered aspirin and [MEDICATION NAME] (an anticoagulant) daily, in (MONTH) (YEAR) and (MONTH) (YEAR), for a [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated (MONTH) 13, (YEAR) included a Brief Interview for Mental Status (BIMS) score of 1, which indicated the resident had severe cognitive impairment. The MDS also included there were no skin concerns. A care plan was developed to address the risk for abnormal bleeding, due to the use of [MEDICATION NAME] and included the following: Observe for signs and symptoms of bleeding such as; bleeding gums, nose bleeds, unusual bruising, black tarry stools, pink or discolored urine, and to report to the physician any signs or symptoms of abnormal bleeding or hemorrhage. An observation of the resident was conducted on (MONTH) 23, (YEAR). The resident was observed to have multiple areas of discoloration/bruising on his arms and hands. The bruised areas were a dark purple in color. Additional observations were conducted on (MONTH) 24 and 25, (YEAR), and the resident had the same bruised areas to his arms and hands. However, review of a weekly skin integrity assessment dated (MONTH) 25, (YEAR), revealed there was no documentation of any bruised areas to the resident's arms and hands. There was also no clinical record documentation that the resident had any bruising to the arms and hands in (MONTH) (YEAR). An interview was attempted with the resident, however, the resident was not interviewable. An interview was conducted on (MONTH) 26, (YEAR) at 12:15 p.m., with a LPN (Licensed Practical Nurse/staff #27). Staff #27 stated that the resident's skin was very fragile, because of the blood thinner ([MEDICATION NAME]). Staff #27 stated that the areas of discoloration/bruising on the resident's arms/hands were not new, but was unable to state when they had initially occurred. Staff #27 stated that the resident's skin integrity should be monitored and documented on the weekly skin integrity data collection record. At this time, the weekly skin integrity data collection records from (MONTH) 11 through 25, (YEAR) were reviewed with staff #27. Staff #27 confirmed that the assessments did not reflect the areas of discoloration/bruising on the resident's arms and hands. On (MONTH) 26, (YEAR) at 12:45 p.m., an interview was conducted with the corporate clinical staff (#133). She stated that the weekly skin integrity data collection records were suppose to be used to indicate any skin condition concerns and that the licensed staff should have used this tool to document the areas of discoloration/bruising on the resident's arms and hands. Review of a facility policy titled Evaluations, Screenings and Assessments included, At the time of admission, each patient is evaluated for special needs related to skin care. Additionally, all patients receive a weekly skin integrity check performed by licensed personnel. -Resident #11 was admitted on (MONTH) 16, (YEAR), with [DIAGNOSES REDACTED]. Review of an ADL (Activities of Daily Living) care plan revealed the resident required assistance with ADLs, due to left sided weakness and cognitive impairment. The interventions included to report changes in ADL self performance to the nurse and for the resident to be up in a wheelchair daily. Another care plan identified the resident had cognitive impairment and included an intervention to observe for the need of a consultation and provide an occupational screen as needed. A therapy screen dated (MONTH) 7, (YEAR) included the resident was screened, due to excessive forward lean. Per the documentation, recommendations were made to address the forward lean. Clinical record documentation included that therapy was provided to the resident, addressing the forward lean. A quarterly MDS assessment dated (MONTH) 25, (YEAR) included the resident had long and short term memory deficits. The MDS identified that the resident required extensive assistance of two persons for bed mobility and transfers, and extensive assistance of one person with dressing, eating and personal hygiene. The MDS also included that the resident was non-ambulatory. Review of a Nurse Practitioner's progress note dated (MONTH) 6, (YEAR) revealed the resident was alert, but only oriented to self and at times to situation, and that the resident's spine had mild [MEDICATION NAME] kyphosis. An observation was conducted on (MONTH) 23, (YEAR) at 9:28 a.m., of the resident in a wheelchair. The resident was observed leaning to the left, with her left arm pressed up against the arm rest of the wheelchair. Staff were not observed to reposition the resident, and there were no supportive devices to help the resident maintain a more upright position. Additional observations of the resident were conducted on (MONTH) 24 and 25, (YEAR). During these observations, the resident was in her wheelchair and continued to lean to the left, without any devices in place to help maintain a more upright position. An observation was conducted on (MONTH) 26, (YEAR) at 8:15 a.m., of the resident seated in her wheelchair in the main dining room for breakfast. Again, the resident was observed to be leaning to the left side, with her left arm pressed against the arm rest of the wheelchair. At this time, a staff person was feeding the resident, however, the staff person did not reposition the resident. Further review of the clinical record revealed no documented evidence that the resident's lean to the left had been identified or addressed by nursing or therapy. On (MONTH) 26, (YEAR) at 8:30 a.m., an interview was conducted with an Occupational Therapist/Therapy Director (staff #136). Staff #136 stated that the left sided lean for this resident was new, and that she had not been made aware of it by the nursing staff. Staff #136 stated that therapy screens are provided quarterly and as needed. Staff #136 stated that a therapy screen for positioning could have been provided, if nursing staff had provided a referral. Immediately following this interview, a resident observation was conducted with staff #136. At this time, staff #136 confirmed that the resident had a lateral lean to the left and that her arm was pressed up against the arm rest of the wheelchair. Staff #136 stated that a lateral supportive device could be appropriate to use and that a screen would be conducted today. Review of an Occupational Therapy Screen dated (MONTH) 26, (YEAR) revealed the resident had a lateral lean to the left side, decreased left upper extremity positioning and decreased upright sitting posture, while seated in a wheelchair, and had decreased self feeding participation. Per the documentation, a recommendation for an occupational evaluation related to seating, positioning, strengthening, self feeding and transfers was made. An interview was conducted on (MONTH) 26, (YEAR) at 9:15 a.m., with a LPN (Licensed Practical Nurse/staff #27), who stated that the resident has had the left side lean for awhile, but could not specify the time frame. On (MONTH) 26, (YEAR) at 9:45 a.m., an interview was conducted with a CNA (Certified Nursing Assistant/staff #124). Staff #124 stated that the resident does lean to the left off and on throughout the day, when seated in her wheelchair. On (MONTH) 29, (YEAR), an occupational therapy evaluation was conducted and a plan of treatment was developed for the resident to address positioning, when seated in a wheelchair. A facility policy titled, Patient Screening included the following: Rehabilitation disciplines screen patients in order to determine if the delivery of therapy services is indicated by the patients's condition. Patients may be screened during admission, by referral, and on a quarterly basis to determine the need for skilled intervention.",2020-09-01
440,DESERT COVE NURSING CENTER,35095,1750 WEST FRYE ROAD,CHANDLER,AZ,85224,2018-01-30,689,J,0,1,DW8S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, staff and resident interviews and policy and procedures, the facility failed to implement their non smoking policy and failed to ensure two residents (#35 and #62) who were assessed to be unsafe to smoke independently were provided supervision while smoking. The facility also failed to ensure that safety equipment was in place in the areas where the residents smoked outside. As a result, the Condition of Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified. Findings include: On (MONTH) 23, (YEAR) at 1:44 p.m., the Condition of Immediate Jeopardy (IJ) and SQC were identified. The Administrator (staff #135) was informed of the facility's failure to ensure that supervision was provided for two residents who were assessed to be unsafe to smoke independently, and that smoking materials were being kept by the residents. In addition, there was no safety equipment in place in the areas where the residents smoked outside. The Administrator presented a plan of correction on (MONTH) 23, (YEAR) at 3:58 p.m. The Administrator was informed that the plan of correction did not include all of the components to ensure resident safety. The Administrator presented another plan of correction on (MONTH) 23, (YEAR) at 5:25 p.m., and was returned for additional information. At 6:34 p.m., a revised plan of correction was presented and was accepted. Multiple observations of the facility implementing their plan of correction were conducted on (MONTH) 23 and 24, (YEAR), which included implementation of their non smoking policy, there were no observations of residents smoking, verification that residents did not have possession of any smoking materials, documentation of staff in-services, and staff interviewed were knowledgeable of the non smoking policy. As a result, the condition of Immediate Jeopardy was abated on (MONTH) 24, (YEAR) at 9:42 a.m. -Resident #62 was admitted to the facility on (MONTH) 29, (YEAR), with [DIAGNOSES REDACTED]. An admission assessment dated (MONTH) 29, (YEAR), included the resident denied tobacco use. Review of an admission Minimum Data Set (MDS) assessment dated (MONTH) 4, (YEAR), revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15, which indicated the resident was cognitively intact. The MDS included the resident had upper and lower extremity impairment on both sides, and was totally dependent on staff for eating and required extensive assistance with personal hygiene. The MDS also included the resident did not currently use tobacco. A physician's progress note dated (MONTH) 5, (YEAR) included the resident had minimal movement of his upper extremities, related to a [DIAGNOSES REDACTED]. Review of the Resident Admission Agreement which was signed by the resident on (MONTH) 10, (YEAR), revealed documentation that the facility was a non smoking facility. By signing the admission agreement, the resident acknowledged that he was legally bound by this agreement. In Section 10: Rules and Regulations the following was included: The Resident/Representative understands and agrees that the Resident will refrain from smoking while in the Facility except in designated smoking areas, if any. In addition, the Resident may only smoke if this action does not threaten the health or welfare of others as defined by individual facility policy. The agreement further included, The Resident/Representative understands and agrees that smoking is never permitted in Resident rooms nor any other areas not specifically designated as a smoking permitted area of the Facility. The Resident/Representative also understands and agrees that the Facility may impose additional smoking procedures and/or restrictions to protect the health and safety of Residents and others or as required by law. The facility did not have any designated smoking areas. A nursing progress note dated (MONTH) 10, (YEAR) included that on (MONTH) 9, a resident's family member requested to have the resident's oxygen removed, so the resident could go across the street to smoke a cigar. The note included that the resident's family member was educated on the non smoking policy. The resident was noted to be out of the facility for approximately 30 minutes without oxygen. His oxygen level was obtained upon return to the facility and it was 83% (per the nursing progress notes the resident's oxygen levels were usually between 93-97%). A nursing progress note dated (MONTH) 25, (YEAR), revealed the resident was outside of the facility in his power chair and fell on the side walk and no injury was sustained, and that the resident will continue to be monitored. A rehabilitation services post fall screening tool dated (MONTH) 25, (YEAR), revealed the resident had a fall off property. The resident was across the street in his power wheelchair smoking. The resident appears to have fallen out of the wheelchair to the ground. No change in status was reported. Per the note, the resident was non-compliant. Review of a nursing progress note dated (MONTH) 29, (YEAR) revealed the resident was non compliant with informing staff when leaving the facility. A smoking care plan dated (MONTH) 13, (YEAR) included that the resident wishes to smoke and was non compliant with the facility's non smoking policy. Interventions included the resident was to ask for smoking materials which the facility would store and dispense, the resident will utilize a smoking apron, the resident will smoke off grounds, and will utilize a log to sign in and out, when going off site to smoke. Review of a document dated (MONTH) 13, (YEAR), which was located in the resident's clinical record stated, This document serves as a risk agreement for resident .Resident chooses to ignore medical advice and engage in tobacco use while he is a resident . The facility is a non smoking facility and the resident has been offered and encouraged by facility staff to transfer to a facility that allows smoking. Resident declines to transfer and chooses to remain. In addition, he accepts that smoking is not allowed on the premises and he will have to leave facility grounds on his own accord in order to smoke off of the property. He has obtained an order from the physician to leave facility grounds. To minimize the risk for harm the resident agrees to abide by the following procedures when he chooses to smoke: 1. Resident must sign himself out when he leaves and back in when he returns. 2. Resident cannot smoke while using oxygen and will leave his oxygen tank at the facility. 3. Resident's vitals will be taken before he leaves grounds to assure he is in stable medical condition. 4. Resident will wear a smoking apron when he leaves the grounds for the purpose of smoking. The document further included, I (resident #62) understand the above mentioned procedures and assume full responsibility for the risks and liability associated with choosing to go off facility grounds to smoke. I understand that I am not allowed to smoke on facility property. I know that I am able to transfer to another location that allows smoking on their premise, but I choose not to. I understand that smoking is not encouraged by my physician and other medical providers .I understand that I expose myself to avoidable risks by leaving the facility grounds to smoke and accept the possible consequences associated with this behavior. The document was signed by the resident, the social worker, an Licensed Practical Nurse (LPN) the Executive Director, and the Long Term Care Case Manager. Review of a smoking safety assessment dated (MONTH) 29, (YEAR), identified the resident exhibited poor safety awareness when smoking, and that interventions must be placed to promote safe smoking. The assessment included the resident was able to self-extinguish cigarettes. However, the assessment also included the resident fails to properly utilize an ashtray, the resident drops ashes on self, the resident attempts to keep smoking paraphernalia on self or in room, the resident has [MEDICAL CONDITION] self or clothing related to cigarette smoking, and the resident is non compliant with smoking regulations in the facility. The documentation included that this assessment was to be completed for all residents who smoke, to determine any potential safety risks upon admission, quarterly and upon a significant change in the resident's status. This assessment was not signed by anyone. A nursing progress note dated (MONTH) 31, (YEAR) stated the resident continues to go outside to smoke, with a smoking apron on. The note included the resident went outside to smoke at 12:50 p.m., and at 1:45 p.m., the resident was found leaning too far to the right side, almost falling out of the power chair. The resident was able to be repositioned and was then accompanied back into the facility. The note indicated the resident was educated about the risks of smoking and smoking alone, and his inability to straighten himself in the power chair. Review of a rehabilitation services post fall screening tool dated (MONTH) 31, (YEAR), revealed the resident had a fall out of power chair outside the facility near a shed. An environmental factor listed as contributing to the fall was leaning out of chair. Interventions included that the resident was educated in maneuvering on sidewalk and staying close to staff support when smoking. The note also included a recommendation that the resident should ask staff for repositioning assistance throughout the day. A quarterly MDS assessment dated (MONTH) 4, (YEAR) included the resident had a BIMS score of 15, which indicated the resident was cognitively intact. The MDS included the resident had upper and lower extremity impairment on both sides, and required extensive assistance with eating and was total dependent on staff with personal hygiene. A nursing progress note dated (MONTH) 5, (YEAR) included the resident still continues to smoke outside of the facility, and that this was a smoke free facility. The nurse informed the resident of the risks of smoking, precautions and using an apron to ensure safety and understanding of risks. A nursing progress note dated (MONTH) 7, (YEAR), included the resident continues to smoke even though this is a smoke free facility. Informed patient of the risks, remove O2 whenever patient leaves to smoke and place apron. An observation was conducted on (MONTH) 23, (YEAR) at 11:50 a.m., of resident #62 outside of the facility on a sidewalk, which was next to the parking lot. Resident #62 was observed smoking a cigar in his power chair and there were no staff present. The resident was wearing a smoking apron and was holding a cigar in his left hand. The resident was not wearing any oxygen at this time. The resident was positioned upright in the power chair and was able to move his arm up and down to smoke the cigar. During this observation, the resident stated that he comes out to smoke maybe twice a day and staff are not present. The resident stated he is able to light his own cigar and keeps his smoking materials with him, which includes cigars and a lighter. He stated that when he is ready to go out to smoke, he lets the staff know and they take off his oxygen and give him the smoking apron. While speaking with the resident, it was observed that ashes were accumulating on the end of the cigar (about an inch in length), and the resident then inadvertently brushed the ashes on to the smoking apron and the ashes fell on to the ground. Additional observations were conducted at this time and there was no safety equipment (i.e. fire extinguisher, fire blanket, ash container) in the area where the resident was smoking. Review of the sign out log for resident #62 revealed sections to document the date, the time out/in, oxygen was off, vitals were taken, smoking apron, resident informed of risk, resident signature/initials, and staff initials. Review of the log revealed the resident was signed out anywhere from one to four times a day between (MONTH) 13, (YEAR), through (MONTH) 23, (YEAR). An interview with a LPN (Licensed Practical Nurse/staff #70) was conducted on (MONTH) 23, (YEAR) at 1:28 p.m. She stated resident #62 keeps his smoking material with him in a bag and that he is able to light his own cigarette. She stated the resident has to have his vitals taken and has to get a smoking apron from the staff, before signing himself out to smoke. Staff #70 stated that the resident tells them when he goes out to smoke and staff sign him out on his smoking log. In an interview with the Social Services Director (staff #109) on (MONTH) 26, (YEAR) at 12:52 p.m., she stated the resident did not indicate he was a smoker until he was switched from skilled care to long term care. She stated when the facility found out about his smoking habit, an attempt was made to keep the resident safe when he is off grounds smoking. Further, she stated the resident was offered help to transfer to a facility which allows smoking, but the resident declined. In an interview with the Executive Director (staff #135) on (MONTH) 26, (YEAR) at 1:32 p.m., he stated that he thought the facility was doing the right thing by protecting the resident while he was smoking. He stated the facility put things in place to try and keep the resident safe, such as giving him a smoking apron, so he would not burn himself. -Resident #35 was admitted to the facility on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. An admission nursing progress note dated (MONTH) 2, (YEAR) included the resident wanted to go out and smoke, as soon as he arrived at the facility. Per the note, the nursing staff explained that they were a non smoking facility, thus he would not be allowed to go outside and smoke. The note further included that the resident was non compliant with signing the admission papers. According to a social services note dated (MONTH) 7, (YEAR), the resident was a smoker and was aware prior to his arrival that they were a non smoking facility, and that he would be unable to smoke. The resident was offered a Nicotine patch which he refused. The note further included the resident continues to display poor insight into deficits in physical strength and functional ability. Review of a social service addendum note dated (MONTH) 7, (YEAR) revealed that staff provided extensive and frequent redirection and education regarding their non smoking policy. A MDS assessment dated (MONTH) 8, (YEAR) included the resident had a BIMS score of 14, which indicated the resident was cognitively intact. The MDS further included the resident required two person assistance for transfers and required supervision with locomotion off of the unit. A physician's orders [REDACTED]. A smoking safety assessment was completed on (MONTH) 29, (YEAR), which indicated that the resident attempts to keep smoking paraphernalia on his self or in his room, and that the resident was not safe to smoke, without supervision. A care plan dated (MONTH) 29, (YEAR) included the resident wishes to smoke and was non compliant with the non smoking policy. A goal included that the resident would remain safe while smoking off the facility grounds. Under approaches it stated to provide the resident with the following while smoking: resident will utilize a smoking apron and smoke off of facility grounds, resident will allow facility staff to store and dispense smoking paraphernalia and ask for smoking materials, and resident will sign himself in an out when going outside to smoke. Review of a log that the facility had developed to track when resident #35 went out on pass to smoke revealed the resident had signed himself out and left the facility twenty three times between (MONTH) 30, (YEAR) and (MONTH) 23, (YEAR), and had consistently refused a smoking apron. An interview was conducted on (MONTH) 23, (YEAR) at 12:06 p.m., with resident #35. He stated that he is a one pack per day smoker for the past twenty years. The resident stated that he was assessed to be allowed to smoke, and goes off the property on the sidewalk to smoke, unescorted in an electric wheelchair. He also stated that he is allowed to keep a lighter and cigarettes in a pouch with him. An observation of the resident was conducted on (MONTH) 23, (YEAR) at 2:10 p.m. At this time, a small burn hole on the cuff of the resident's left sleeve was visible. The resident stated it was an old burn hole from home. The resident's smoking paraphernalia was visible and was stored in a lap pouch. Following the identification of IJ, another smoking assessment was completed on (MONTH) 23, (YEAR) for resident #35. The assessment included that the resident had not demonstrated the ability to smoke safely, due to the resident failing to utilize ashtrays, dropping ashes on self, keeps smoking paraphernalia on his self or in his room, and has [MEDICAL CONDITION] self or clothing related to cigarette smoking. An interview with a RN (Registered Nurse/staff #90) was conducted on (MONTH) 23, (YEAR) at 1:55 p.m. She stated the resident was non compliant with smoking restrictions. She stated he has a physicians order to go out on pass and will often leave to go out to smoke cigarettes. She stated there is a special sign out book for him to sign out and sign in when he returns. She stated the resident has refused to wear a smoking apron when he smokes. Review of the facility's non smoking policy revealed that smoking is not allowed at any time, inside or outside of the building or on the property by residents, staff or visitors. Residents, families and/or responsible parties will be provided information on the facility's non smoking policy upon admission, and as indicated thereafter. All staff will be provided education on the facility's smoking policy during orientation and as indicated thereafter. Upon identification of a resident's non compliance to the smoking policy, the resident's physician, family, or responsible party will be notified. In the event that the resident continues to be non compliant, with the smoking policy, the facility will notify the resident, family and/or responsible party of potential discharge, due to the potential for harm of self and/or others. Upon identification of smoking non compliance, by the resident, family or visitors, staff will intervene immediately, providing instruction on the facility's non smoking policy. In the event of ongoing non compliance by the resident, family or visitors, the facility will consider supervised visitation and/or revocation of visiting privileges. Any and all smoking paraphernalia will be confiscated by the facility and stored until discharge.",2020-09-01
441,DESERT COVE NURSING CENTER,35095,1750 WEST FRYE ROAD,CHANDLER,AZ,85224,2018-01-30,698,D,0,1,DW8S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure that post [MEDICAL TREATMENT] assessments were consistently performed for one resident (#118). Findings include: Resident #118 was admitted on (MONTH) 11, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident had an arteriovenous (AV) shunt on the right forearm. The physician's orders dated (MONTH) 11, (YEAR) included for [MEDICAL TREATMENT] on Tuesday, Thursday and Saturday. The orders also included to check vital signs before and after [MEDICAL TREATMENT] and to document on the [MEDICAL TREATMENT] form. According to the admission Minimum Data Set (MDS) assessment dated (MONTH) 18, (YEAR), the resident scored a 15 on the Brief Interview for Mental Status section, which indicated the resident was cognitively intact. Review of the pre and post [MEDICAL TREATMENT] form revealed areas to document vital signs, the condition of the AV shunt site and assessing for the presence of thrill and bruit. Per the pre and post [MEDICAL TREATMENT] forms, the resident had gone to [MEDICAL TREATMENT] six times between (MONTH) 13 through 25, (YEAR). However, Review of the POS [REDACTED]. There was no corresponding clinical record documentation for (MONTH) 16, 18, and 25, which included that the resident's vital signs were taken after [MEDICAL TREATMENT], or that the AV shunt site was assessed for bleeding and for thrill and bruit. An interview with a Licensed Practical Nurse (LPN/staff #80) was conducted on (MONTH) 25, (YEAR) at 12:07 p.m. She stated that on [MEDICAL TREATMENT] days the nursing staff are to monitor the AV site and check for thrill and bruit, obtain vital signs and then document the findings on the pre and post [MEDICAL TREATMENT] form. An interview with a Licensed Practical Nurse (LPN/staff #113) was conducted on (MONTH) 26, (YEAR) at 8:57 a.m. He stated that the nurse's are to assess the resident's AV site for thrill and bruit and take vital signs pre and post [MEDICAL TREATMENT]. He stated that the vitals and assessments are to be documented on the [MEDICAL TREATMENT] form. An interview with the acting Assistant Director of Nursing (ADON/staff #78) was conducted on (MONTH) 26, (YEAR) at 9:02 a.m. She stated that before and after [MEDICAL TREATMENT], vital signs are to be taken and the AV site is to be checked and documented on the [MEDICAL TREATMENT] transfer form. After reviewing the post [MEDICAL TREATMENT] forms dated (MONTH) 16, 18, and 25, the ADON stated that the post [MEDICAL TREATMENT] assessments which include vital signs, condition of the AV site, and the presence of thrill and bruit should have been completed. Review of the facility policy regarding [MEDICAL TREATMENT] revealed that the [MEDICAL TREATMENT] patient shall receive consistent care pre and post [MEDICAL TREATMENT]. The shunt site shall be checked with physician notification for any known or suspected problem. On the day of [MEDICAL TREATMENT], the facility required forms are to be filled out and sent with patient. Vital signs of the patient are to be obtained and the shunt site monitored upon returning from [MEDICAL TREATMENT], and that staff are to follow the [MEDICAL TREATMENT] instructions on the [MEDICAL TREATMENT] form.",2020-09-01
442,DESERT COVE NURSING CENTER,35095,1750 WEST FRYE ROAD,CHANDLER,AZ,85224,2018-01-30,732,E,0,1,DW8S11,"Based on review of facility documentation and staff interviews, the facility failed to ensure that the daily nurse staffing data information was complete. Findings include: Review of the daily nurse staffing and census information records revealed the following: -On (MONTH) 6, 8, and 9, (YEAR) and on (MONTH) 19, (YEAR) and on (MONTH) 4 and 5, (YEAR), there was no census documented. -There were no evening or night shift hours for registered nurses (RN), licensed practical nurses (LPN) and certified nursing assistants (CNA) on (MONTH) 15, (YEAR). -There were no staff hours for RNs, LPNs and CNAs and there was no census on (MONTH) 19 and 25, (YEAR) and on (MONTH) 22, (YEAR). -There were no staff hours for RNs, LPNs and CNAs on (MONTH) 26, (YEAR), on (MONTH) 18 and 19, (YEAR) and on (MONTH) 31, (YEAR). -There were no RN hours on (MONTH) 11 and 25, (YEAR). Also, none of the above documents contained the facility's name. An interview was conducted with a CNA (Staffing Coordinator/staff #53) on (MONTH) 25, (YEAR) at 10:19 a.m. Staff #53 stated that she prints out the staffing schedule each day and gives it to the receptionist, who then calculates the number of staffing hours. Staff #53 stated the receptionist will then write the staffing hours and the census on the daily nurse staffing records. An interview was conducted on (MONTH) 25, (YEAR) at 11:17 a.m. with the Interim Director of Nursing (staff #78), who stated the daily posting is completed by the front desk staff and possibly the business office manager. Staff #78 stated the posting should include how many RNs, LPNs and CNAs are on the floor working. Staff #78 stated that the information should have been completed according to regulations. She further stated that the facility did not have a specific policy related to the daily nurse staff posting.",2020-09-01
443,DESERT COVE NURSING CENTER,35095,1750 WEST FRYE ROAD,CHANDLER,AZ,85224,2018-01-30,758,D,0,1,DW8S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policies and procedures, the facility failed to ensure one resident (#43) had adequate indications for the administration of a [MEDICAL CONDITION] medication, and failed to assess the effectiveness of the medication after being administered. Findings include: Resident #43 was admitted on (MONTH) 18, (YEAR), with [DIAGNOSES REDACTED]. Review of the (MONTH) (YEAR) recapitulation of physicians orders revealed for [MEDICATION NAME] (an anti-anxiety medication) 0.5 mg (milligrams) by mouth every six hours as needed for anxiety, as evidenced by shortness of breath. A care plan for [MEDICAL CONDITION] medication included the resident received [MEDICATION NAME], as evidence by shortness of breath and a history of agoraphobia. An intervention included to monitor for the effectiveness of the [MEDICAL CONDITION] drug. Review of the (MONTH) (YEAR) MAR (Medication Administration Record) revealed the resident was administered [MEDICATION NAME] on (MONTH) 15, (YEAR) at 3:15 a.m. The documentation on the MAR indicated [REDACTED]. According to the Behavior/Intervention Monthly Flow Record for (MONTH) (YEAR), the resident was being monitored for episodes of restlessness. However, there was no documentation on (MONTH) 15 of any episodes of restlessness. There was also no documentation for the entire month of (MONTH) of any episodes of restlessness. In addition, there was no clinical record documentation as to why the resident was administered [MEDICATION NAME] on (MONTH) 15, nor was there documentation of the effectiveness of the medication. Review of the recapitulation of physicians orders for (MONTH) (YEAR) revealed an order for [REDACTED]. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. The Behavior/Intervention Monthly Flow Record for (MONTH) (YEAR) included the resident was being monitored for shortness of breath. There was no documentation on the Monthly Flow Record that the resident had experienced any episodes of shortness of breath on (MONTH) 9, or on (MONTH) 23. There was also no documentation of any episodes of shortness of breath from (MONTH) 1 through 25. In addition, there was no clinical record documentation as to why the resident was administered [MEDICATION NAME] on (MONTH) 9 and 23, and no documentation of the effectiveness of the medication. An interview was conducted with a LPN (Licensed Practical Nurse/staff #27) on (MONTH) 25, (YEAR) at 1:55 p.m. Staff #27 stated that the resident had an order for [REDACTED].#27 stated there is a behavior flow sheet in the MAR indicated [REDACTED]. After reviewing the (MONTH) (YEAR) MAR, the Behavior/Intervention Monthly Flow Records, and the progress notes, staff #27 stated that there was no documentation regarding the reasons why the resident was administered [MEDICATION NAME] on (MONTH) 9 and 23, (YEAR), nor documentation of it's effectiveness. On (MONTH) 26, (YEAR) at 11:06 a.m., an interview was conducted with the DON (Director of Nursing/staff #78). Staff #78 stated that when a resident displays identified behaviors for the administration of a as needed psychoactive medications such as [MEDICATION NAME], the nurse who will be administering the medication should document the identified behavior and document the effectiveness of the medication on the behavior flow sheet, and may document it in the progress notes. Staff #78 reviewed the clinical record for resident #43 and stated there was no additional documentation regarding why [MEDICATION NAME] was administered in (MONTH) and January. A policy titled, Psychopharmacological Medication Management included that an unnecessary drug was any drug when used without adequate monitoring and without adequate indications for it's use. The policy further included that the resident's clinical record should include documentation of observed behaviors and frequency, of any interventions provided and the resident's response to the medication.",2020-09-01
444,DESERT COVE NURSING CENTER,35095,1750 WEST FRYE ROAD,CHANDLER,AZ,85224,2018-01-30,835,E,0,1,DW8S11,"Based on concerns identified during the survey, facility documentation and staff interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively to maintain the highest practicable well-being for residents. Findings include: According to the facility admission agreement and non smoking policies, the facility had been deemed as a non smoking facility. Per the agreement, if residents were identified as desiring to smoke, they would be screened to determine if the residents would be willing to accept the non smoking status, prior to admission. By signing the admission agreement, the resident acknowledges that he is legally bound by this agreement and the Resident/Representative understands and agrees that the Resident will refrain from smoking while in the Facility, except in designated smoking areas, if any. In addition, the Resident may only smoke if this action does not threaten the health or welfare of others as defined by individual facility policy. Although the facility had determined that they were a non smoking facility, concerns were identified during the survey regarding two residents who smoked outside on the sidewalk of the building. The two residents were assessed by the facility to be unsafe to smoke independently, and were also allowed to keep their smoking paraphernalia. One of the residents was observed smoking outside, without any supervision. Multiple staff were interviewed and confirmed that both residents smoked outside, without supervision. Also, there was no safety equipment such as a (smoking blanket, fire extinguisher, ash receptacle) in the area where the resident was observed smoking. As a result, the Condition Immediate Jeopardy was identified on (MONTH) 23, (YEAR). According to the facility's non smoking policy, smoking is not allowed at any time, inside or outside of the building or on the property by residents, staff or visitors. Residents, families and/or responsible parties will be provided information on the facility's non smoking policy upon admission, and as indicated thereafter. All staff will be provided education on the facility's smoking policy during orientation and as indicated thereafter. Upon identification of a resident's non compliance to the smoking policy, the resident's physician, family, or responsible party will be notified. In the event that the resident continues to be non compliant with the smoking policy, the facility will notify the resident, family and/or responsible party of potential discharge, due to the potential for harm of self and/or others. Upon identification of smoking non compliance, by the resident, family or visitors, staff will intervene immediately, providing instruction on the facility's non smoking policy. In the event of ongoing non compliance by the resident, family or visitors, the facility will consider supervised visitation and/or revocation of visiting privileges. Any and all smoking paraphernalia will be confiscated by the facility and stored until discharge. Despite the facility's non smoking policy, the facility was aware that two residents continued to go outside and smoke on the sidewalk unsupervised, and no additional interventions were implemented to address this issue to ensure resident safety. An interview was conducted with the Administrator (staff #135) on (MONTH) 30, (YEAR) at 2:40 p.m. Staff #135 stated that the facility had a Quality Assurance/Quality Assessment Performance Improvement Plan (QA/QAPI) that met monthly to identify quality and/or process improvement concerns. Staff #135 stated there had been no action taken by the QA/QAPI committee to address the issue of residents smoking outside, when they were assessed to be unsafe to do so.",2020-09-01
445,DESERT COVE NURSING CENTER,35095,1750 WEST FRYE ROAD,CHANDLER,AZ,85224,2018-01-30,838,E,0,1,DW8S11,"Based on facility documentation, staff interview and policy review, the facility failed to ensure that their Facility Assessment addressed the issue that two residents smoked outside of the building, despite being a non smoking facility, per their policy. Findings include: During the entrance conference on (MONTH) 23, (YEAR) at 8:40 a.m., the Administrator (staff #135) stated the facility was a non smoking facility, but they did have two residents who smoked outside. Review of the Facility assessment dated (MONTH) 17, (YEAR) revealed the resident population included for any ethnic, cultural or religious factors, that may potentially affect the care provided by the facility, including activities. The assessment further included that the resident population must be taken into account when determining staffing and resource needs (e.g., residents' preferences with regard to daily schedules, activities). However, the Facility Assessment did not include that it was a non smoking facility, but had two residents who smoked. The assessment also did not identify the resources needed to ensure resident safety, such as staffing and equipment (fire blanket, ash receptacles, fire extinguisher) for residents who smoked outside. During an interview with the Administrator (staff 135) on (MONTH) 26, (YEAR) at 2:00 p.m., staff #135 stated that the facility had not included smoking residents in their Facility Assessment, because the facility was a non smoking facility. Staff #135 stated the facility had not revised their Facility Assessment to include the care and provisions for residents who smoked. Review of a policy regarding the Facility Assessment revealed that the facility must address or include but is not limited to: any ethical, cultural, or religious factors that may potentially affect the care provided by the facility, including but not limited to activities.",2020-09-01
446,DESERT COVE NURSING CENTER,35095,1750 WEST FRYE ROAD,CHANDLER,AZ,85224,2018-01-30,880,E,0,1,DW8S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and policy review, the facility failed to ensure that infection control procedures were followed during a wound care observation. Findings include: A wound care observation was conducted on (MONTH) 26, (YEAR) at 10:00 a.m., with a Licensed Practical Nurse (LPN/staff #39). As staff #39 was setting up the supplies in the resident's room, she realized that she did not have any scissors and called down the hall for a Certified Nursing Assistant (CNA) to bring her some. The CNA brought staff #39 a pair of scissors. Staff #39 then placed the scissors directly on the resident's bed. Staff #39 was not observed to sanitize the scissors. The nurse then washed her hands and donned gloves. The nurse removed the dirty dressing and then removed her gloves, however, she did not wash or sanitize her hands. Staff #39 then donned a clean pair of gloves, cleansed the wound and removed her gloves. Staff #39 then retrieved a tongue blade from a plastic bin which contained wound supplies, and picked up a plastic package which contained a Dakin's soaked Kerlix roll. Staff #39 then dropped the tongue blade on the resident's bed, picked it up and then began to pull the Kerlix roll from the package and fed it into the wound, using the same tongue blade. After packing the wound with the soaked Kerlix, staff #39 set the tongue blade on the bed. She then cut the Kerlix with scissors and picked up the same tongue blade and pushed the cut end of the Kerlix into the wound, then placed the tongue blade back onto the bed. She then picked up the tongue blade again and used the other end of it to apply [MEDICATION NAME] to a second wound. In an interview with staff #39 on (MONTH) 26, (YEAR) at 10:20 a.m., staff #39 stated that she should have cleaned the scissors prior to using them. Staff #39 also acknowledged that the tongue blade was placed directly on the bed and then used, and that it was used for another wound. Staff #39 stated she should not have done that. An interview was conducted on (MONTH) 26, (YEAR) at 11:17 a.m., with a registered nurse (interim Director of Nursing/staff #78). Staff #78 stated that during the provision of wound care, the nurses should wash their hands before starting the procedure and when gloves are changed. Staff #78 stated the nurse should clean the bedside table with wipes and then set the equipment on it. Staff #78 further stated that if a tongue blade is needed for more than one step in the wound care, a different tongue blade should be used for each step. Staff #78 also stated the scissors should have been cleaned with disinfectant wipes, prior to and after use. Review of a facility policy titled, Wound Care/Treatment Clean Dressing Change revealed the following procedures: -Follow hand hygiene protocol -Prepare a clean field with the necessary equipment. -Put on gloves -Remove the soiled dressing and place in a bag for disposal -Remove gloves and discard them -Follow hand hygiene protocol -Put on new gloves -Cleanse the wound as directed. -Remove gloves and discard them -Follow hand hygiene protocol -Put on new gloves and perform wound care as ordered -Remove gloves and discard them -Disinfect or clean the work area as required -Follow hand hygiene protocol The policy regarding Hand Hygiene included that the purpose of the policy was to decrease the risk of transmission of infection. The policy included that hand washing and hand hygiene is generally considered the most important single procedure for preventing nosocomial infections. Although antiseptics and other hand washing agents do not sterilize the skin, they can reduce microbial contamination depending on the type and the amount of contamination, the agent used, the presence of residual activity and the hand washing technique followed.",2020-09-01
447,DESERT COVE NURSING CENTER,35095,1750 WEST FRYE ROAD,CHANDLER,AZ,85224,2019-04-04,550,D,0,1,M6IO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interview, and policy, the facility failed to ensure one resident's (#20) urinary catheter bag was covered. There were 12 residents with urinary catheters. This deficient practice resulted in the resident's dignity not being maintained. Findings include: Resident #20 was admitted (MONTH) 14, 2014, with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated (MONTH) 17, 2019, revealed the resident had an indwelling urinary catheter in place. During a random observation conducted (MONTH) 4, 2019 at 11:52 a.m., the resident was observed being pushing in a wheelchair down the hall to the dining room by a Certified Nursing Assistant (CNA/staff #69) with the urinary catheter bag uncovered. An interview was conducted immediately with staff #69. The CNA stated that the urinary catheter bag needed a privacy bag and that she was going to go get one. The facility's policy titled Dignity revealed assisting residents in a dignified manner included covering appliances attached to residents.",2020-09-01
448,DESERT COVE NURSING CENTER,35095,1750 WEST FRYE ROAD,CHANDLER,AZ,85224,2019-04-04,600,D,1,1,M6IO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure 1 of 2 sampled residents (#258) was free from verbal abuse by a staff member. The deficient practice could result in other residents being verbally abuse. Findings include: Resident #258 was admitted to the facility on (MONTH) 25, (YEAR) with a [DIAGNOSES REDACTED]. The resident was discharged (MONTH) 6, (YEAR). Review of the care plan initiated (MONTH) 25, (YEAR) revealed the resident had urinary and bowel incontinence. Interventions included assisting with toileting as needed and pericare as needed. A nursing note dated (MONTH) 27, (YEAR) revealed the resident was alert and able to make needs known verbally and needed the assistance of 1-2 staff. Review of the facility's investigation report dated (MONTH) 30, (YEAR), revealed that on (MONTH) 28, (YEAR) at approximately 5:20 PM resident #258 reported to the Assistant Director of Nursing (ADON) that she felt verbally abused by a Certified Nursing Assistant (CNA/staff #134) who was caring for her that evening. Resident #258 stated that she called the CNA a [***] when she was told that she would need to wait for care. The CNA answered the resident by stating if she needed to see a [***] all she needed to do was look in the mirror. The report included a CNA (staff #41) was working with staff #134. Staff #134 was placed on suspension pending investigation. The report also included the resident was alert and oriented to time, person and place. The facility's report revealed staff #134 employment was terminated after completion of the investigation. A written statement by staff #134 dated November, 28, (YEAR) revealed that after the resident called her a [***] she replied, if you looked in the mirror you would see the same thing. A written statement by staff #41 dated (MONTH) 29, (YEAR) revealed resident #258 was wet when she and staff #134 answered the resident's call light. Staff #134 asked the resident to please give them a few minutes because they were passing dinner trays. Resident #258 responded, You're a [***] . The statement included the resident was clearly agitated so they left the room. The statement also included staff #41 returned alone to change the resident after the dinner trays were passed. An interview was conducted with staff #41 on (MONTH) 2, 2019 at 9:09 AM. She stated that after the resident called staff #134 a [***] , she immediately went and reported it to the nurse and the ADON. She stated that she did not hear a response from staff #134. She stated that she felt very uncomfortable when the resident called the CNA a name. Staff #41 stated that it made her feel like there had been a previous confrontation between the two. An attempt to contact staff #134 by telephone for an interview was unsuccessful. An interview was conducted with the Director of Nursing (DON/staff #32) on (MONTH) 4, 2019 at 12:51 PM. She stated that if abuse is witnessed, it needs to be reported immediately to a supervisor. The DON stated that if the alleged perpetrator is a staff member, the staff member would be removed from providing care for residents. She stated they would make sure the resident was okay and would contact the family, doctor and the proper agencies. The DON stated that verbal abuse by staff to a resident is not tolerated. The facility's policy for Protection of Resident: Reducing the Threat of Abuse and Neglect, revised on (MONTH) (YEAR) revealed that each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation of any type by anyone. This includes but is not limited to staff, other residents, consultants, volunteers, staff from other agencies serving our resident, family members, the resident representative, friends or any other individuals. The policy included verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance, regardless of age, ability to comprehend, or disability.",2020-09-01
449,DESERT COVE NURSING CENTER,35095,1750 WEST FRYE ROAD,CHANDLER,AZ,85224,2019-04-04,607,D,0,1,M6IO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a clinical record review, staff interviews, and policy review, the facility failed to implement their policy, by failing to report an allegation of injury of unknown source, conduct a thorough investigation, and report the results of the investigation to the State Agency for one of two sampled residents (#15). This deficient practice could result in the potential for further abuse. Findings include: Resident #15 was admitted to the facility on (MONTH) 5, (YEAR), with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 12, (YEAR) revealed the resident had severely impaired cognitive skills for daily decision making and required extensive assistance with all activities of daily living (ADLs). Review of the weekly skin check dated (MONTH) 8, (YEAR) revealed the resident's skin was intact. A nursing note dated (MONTH) 9, 2019 revealed a bruise was noted to the resident's inner left thigh with mild swelling. The note included the nurse practitioner (NP) was notified and an order was obtained for an x-ray to the left lower extremity. The results of the x-ray dated (MONTH) 9, (YEAR) revealed mild [MEDICAL CONDITION] changes. Review of the NP's progress note dated (MONTH) 9, (YEAR) revealed the chief complaint was left hip pain and swelling. The note included the nurses were concerned about the left hip pain and the bruising noted to the internal thigh. The nursing staff reported the resident was experiencing more pain than usual with the left leg movement. The resident was crying out or moaning when passive range of motion was conducted to the left leg. The nursing staff reported that there was no recent trauma to the leg or a fall. The progress note revealed the resident was noted to have [MEDICAL CONDITION] to the left thigh, bruising to the left groin area, and that there was slight joint contraction noted to the left side. The resident seemed more swollen on the left side and the left leg was contracted up and turned outward. The progress note also included the bruising may have been from the use of aspirin and [MEDICATION NAME]. A nursing note dated (MONTH) 29, (YEAR) revealed a Certified Nursing Assistant (CNA) notified the nurse of an old bruise to the left inner thigh. Review of the clinical record and the State Data base revealed no evidence this injury of unknown source was reported to the State Agency or Adult Protective Services (APS). An interview was conducted with a CNA (staff #27) on (MONTH) 3, 2019 at 8:08 a.m. Staff #27 stated that CNAs are to observe the resident's skin during routine care and showers. Staff #27 stated that if bruising is identified, the nurse is to be notified as soon as possible. An interview was conducted on (MONTH) 3, 2019 at 10:25 a.m. with a Registered Nurse (RN/staff #74). Staff #74 stated that if a bruise is identified, the resident is immediately questioned as to how the bruise occurred. Staff #74 stated that if the resident is unable to say how the bruise occurred, the Direct of Nursing (DON) is notified and an investigation is conducted. Staff #74 stated that the bruise is assessed which may include the location of the bruise, size and shape, and if swelling or pain is present. Staff #74 stated that bruises can be a sign of abuse. An interview was conducted on (MONTH) 3, 2019 at 3:17 p.m. with the Director of Nursing (DON/staff #32). The DON stated the CNAs complete skin checks during routine care and the nursing staff complete weekly skin checks. The DON stated that if a new skin condition is identified, the nurse will notify the family and the provider. She stated that the nurse will further investigate the origin of the skin condition which may be a bruise. The DON stated the nurse will ask the resident how the bruise occurred and that if the resident is unable to say, an investigation is initiated. She stated that the nurse will also ask the staff caring for the resident about the bruise. The DON further stated that if the cause is unable to be determined via the investigation, the injury or bruise is considered to be an injury of unknown source. The DON stated that if it is an injury of unknown source then the family, Adult Protective Services (APS), the State Agency, and the provider are notified within two hours. She stated that the investigation will include staff and family interviews. She stated that the results of the investigation are then reported to the State Agency within 5 days. On (MONTH) 3, 2019 at 3:45 p.m. the DON (staff #32) stated that there were no incident reports or investigations conducted for the bruise identified on the resident's inner thigh. A follow up interview was conducted on (MONTH) 4, 2019 at 12:34 p.m. with the DON (staff #32). The DON stated the NP evaluated the resident after the bruise was identified and noted a contracture with weakness to the left side and joint swelling. The DON stated that due to the NP's evaluation, it was determined no additional investigation was needed. Review of the facility's policy dated (MONTH) 20, (YEAR) titled Protection of Residents: Reducing the Threat of Abuse and Neglect revealed the purpose of the policy is to minimize the threat of abuse and neglect by incorporating clear-out policies and practices that demonstrate a hardline, zero tolerance approach to resident abuse. Per policy, the facility is to identify abuse and exploitation of residents including but not limited to identifying and understanding the different types of abuse and possible indicators, such as; injury that is suspicious because the source of injury is not observed or the extent or location of the injury is unusual. The policy included possible signs of sexual abuse include an unexplained pelvic injury and/or bruising of the genitals or inner thighs. The policy defines injuries of unknown source when both of the following criteria are met; the injury that was not observed by anyone or the source of the injury could not be explained by the resident and the injury is suspicious because of the extent of the injury or the location of the injury, such as, the injury is located in an area not generally vulnerable to trauma or the number of injuries observed at one particular point in time or incidences of injuries over time. The policy further revealed all personnel are to promptly report any incident or suspected incident of resident abuse, neglect, and injuries of unknown source to their immediate supervisor or facility representative. In addition, it is the facilities policy that reports of abuse including injuries of unknown source are promptly and thoroughly investigated and the administrator or director of nursing will complete a written summary of the findings of the investigation and report the findings to the State Agency within 5 days.",2020-09-01
450,DESERT COVE NURSING CENTER,35095,1750 WEST FRYE ROAD,CHANDLER,AZ,85224,2019-04-04,609,D,0,1,M6IO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a clinical record review, staff interviews, and policy review, the facility failed to ensure an allegation of injury of unknown source was reported to the required agencies within the required timeframes for one of two sampled residents (#15). This deficient practice could result in the potential for further abuse. Findings include: Resident #15 was admitted to the facility on (MONTH) 5, (YEAR), with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 12, (YEAR) revealed the resident had severely impaired cognitive skills for daily decision making and required extensive assistance with all activities of daily living (ADLs). A nursing note dated (MONTH) 9, 2019 revealed a bruise was noted to the resident's inner left thigh with mild swelling. The note included the Nurse Practitioner (NP) was notified and an order for [REDACTED]. Review of the NP's progress note dated (MONTH) 9, (YEAR) revealed the chief complaint was left hip pain and swelling. The note included the nurses were concerned about the left hip pain and the bruising noted to the internal thigh. The nursing staff reported the resident was experiencing more pain than usual with the left leg movement. The resident was crying out or moaning when passive range of motion was conducted to the left leg. The nursing staff reported that there was no recent trauma to the leg or a fall. The progress note revealed the resident was noted to have [MEDICAL CONDITION] to the left thigh, bruising to the left groin area, and that there was slight joint contraction noted to the left side. The resident seemed more swollen on the left side and the left leg was contracted up and turned outward. The progress note also included the bruising may have been from the use of aspirin and [MEDICATION NAME]. The results of the x-ray dated (MONTH) 9, (YEAR) revealed mild [MEDICAL CONDITION] changes. A nursing note dated (MONTH) 29, (YEAR) revealed a Certified Nursing Assistant (CNA) notified the nurse of an old bruise to the left inner thigh. Review of the clinical record and the State Data base revealed no evidence this injury of unknown source was reported to the State Agency or Adult Protective Services (APS). An interview was conducted with a certified nursing assistant on (MONTH) 3, 2019 at 8:08 a.m. (CNA/staff #27). Staff #27 stated CNAs are to observe the resident's skin during routine care and showers. Staff #27 stated if bruising is identified the nurse is to be notified as soon as possible. An interview was conducted on (MONTH) 3, 2019 at 10:25 a.m. with a Registered Nurse (RN/staff #74). Staff #74 stated if a bruise is identified, the resident is immediately questioned as to how the bruise occurred. Staff #74 stated that if the resident is unable to say how the bruise occurred, the Direct of Nursing (DON) is notified. An interview was conducted on (MONTH) 3, 2019 at 3:17 p.m. with the DON (staff #32). The DON stated that if a new skin condition is identified, the nurse will notify the family and the provider. She stated that the nurse will further investigate the origin of the skin condition which may be a bruise. The DON stated the nurse will ask staff and the resident how the bruise occurred and that if the resident is unable to say, an investigation is initiated. The DON further stated that if the cause is unable to be determined via the investigation, the injury or bruise is considered to be an injury of unknown source. The DON stated that if it is an injury of unknown source then the family, Adult Protective Services (APS), the State Agency, and the provider are notified within two hours. A follow up interview was conducted on (MONTH) 4, 2019 at 12:34 p.m. with the DON. The DON stated the nurse practitioner (NP) evaluated the resident after the bruise was identified and that due to the NP's evaluation, it was determined no additional investigation was needed. Review of the facility's policy dated (MONTH) 20, (YEAR) titled Protection of Residents: Reducing the Threat of Abuse and Neglect revealed the facility is to identify abuse and exploitation of residents including but not limited to identifying and understanding the different types of abuse and possible indicators, such as; an injury that is suspicious because the source of injury is not observed or the extent or location of the injury is unusual. The policy included possible signs of sexual abuse may include unexplained pelvic injury and/or bruising of the genitals or inner thighs. The policy defines injuries of unknown source when both of the following criteria are met; the injury that was not observed by anyone or the source of the injury could not be explained by the resident and the injury is suspicious because of the extent of the injury or the location of the injury, such as, the injury is located in an area not generally vulnerable to trauma or the number of injuries observed at one particular point in time or incidences of injuries over time. The policy further revealed all personnel are to promptly report any incident or suspected incident of resident abuse, neglect, and injuries of unknown source to their immediate supervisor or facility representative. The policy revealed the facility must ensure that all alleged violations involving abuse, neglect, including injuries of unknown source are to be reported to the State Agency immediately, but not later than 2 hours after the allegation is made and the allegation is to be reported to APS where state law provides jurisdiction. The policy further revealed failure to do so will mean that the facility is not in compliance with the federal regulations.",2020-09-01
451,DESERT COVE NURSING CENTER,35095,1750 WEST FRYE ROAD,CHANDLER,AZ,85224,2019-04-04,610,D,0,1,M6IO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a clinical record review, staff interviews, and policy review, the facility failed to ensure an injury of unknown source was thoroughly investigated and the results of the investigation were reported to the State Agency within the required timeframe for one of two sampled residents (#15). The deficient practice could result in the potential for further abuse. Findings include: Resident #15 was admitted to the facility on (MONTH) 5, (YEAR), with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 12, (YEAR) revealed the resident had severely impaired cognitive skills for daily decision making and required extensive assistance with all activities of daily living (ADLs). A nursing note dated (MONTH) 9, 2019 revealed a bruise was noted to the resident's inner left thigh with mild swelling. The note included the nurse practitioner (NP) was notified and an order for [REDACTED]. Review of the NP's progress note dated (MONTH) 9, (YEAR) revealed the chief complaint was left hip pain and swelling. The note included the nurses were concerned about the left hip pain and the bruising noted to the internal thigh. The nursing staff reported the resident was experiencing more pain than usual with the left leg movement. The resident was crying out or moaning when passive range of motion was conducted to the left leg. The nursing staff reported that there was no recent trauma to the leg or a fall. The progress note revealed the resident was noted to have [MEDICAL CONDITION] to the left thigh, bruising to the left groin area, and that there was slight joint contraction noted to the left side. The resident seemed more swollen on the left side and the left leg was contracted up and turned outward. The progress note also included the bruising may have been from the use of aspirin and [MEDICATION NAME]. The results of the x-ray dated (MONTH) 9, (YEAR) revealed mild [MEDICAL CONDITION] changes. A nursing note dated (MONTH) 29, (YEAR) revealed a Certified Nursing Assistant (CNA) notified the nurse of an old bruise to the left inner thigh. An interview was conducted on (MONTH) 3, 2019 at 10:25 a.m. with a Registered Nurse (RN/staff #74). Staff #74 stated that if a bruise is identified, the resident is immediately questioned as to how the bruise occurred. Staff #74 stated that if the resident is unable to say how the bruise occurred, the Direct of Nursing (DON) is notified and an investigation is conducted. Staff #74 stated that bruises can be a sign of abuse. An interview was conducted on (MONTH) 3, 2019 at 3:17 p.m. with the Director of Nursing (DON/staff #32). The DON stated the CNAs complete skin checks during routine care and the nursing staff complete weekly skin checks. The DON stated that if a new skin condition is identified, the nurse will notify the family and the provider. She stated that the nurse will further investigate the origin of the skin condition which may be a bruise. The DON stated the nurse will ask staff and the resident how the bruise occurred and that if the resident is unable to say, an investigation is initiated. The DON further stated that if the cause is unable to be determined via the investigation, the injury or bruise is considered to be an injury of unknown source. She stated that the investigation will include staff and family interviews. She stated that the results of the investigation are then reported to the State Agency within 5 days. On (MONTH) 3, 2019 at 3:45 p.m. the DON (staff #32) stated that there were no incident reports or investigations conducted for the bruise identified on the resident's inner thigh. A follow up interview was conducted on (MONTH) 4, 2019 at 12:34 p.m. with the DON. The DON stated the nurse practitioner (NP) evaluated the resident after the bruise was identified and that due to the NP's evaluation, it was determined no additional investigation was needed. Review of the facility's policy dated (MONTH) 20, (YEAR) titled Protection of Residents: Reducing the Threat of Abuse and Neglect revealed the purpose of the policy is to minimize the threat of abuse and neglect by incorporating clear-cut policies and practices that demonstrate a hardline, zero tolerance approach to resident abuse. Per policy, the facility is to denitrify abuse and exploitation of residents including but not limited to identifying and understanding the different types of abuse and possible indicators, such as; injury that is suspicious because the source of injury is not observed or the extent or location of the injury is unusual and possible signs of sexual abuse include an unexplained pelvic injury, bruising of the genitals or inner thighs. The policy defines injuries of unknown source when both of the following criteria are met; the injury that was not observed by anyone or the source of the injury could not be explained by the resident and the injury is suspicious because of the extent of the injury or the location of the injury, such as, the injury is located in an area not generally vulnerable to trauma or the number of injuries observed at one particular point in time or incidences of injuries over time. The policy further revealed reports of abuse including injuries of unknown source are promptly and thoroughly investigated and the administrator or director of nursing will complete an incident report and a written summary of the findings of the investigation including but not limited to review of the incident report, an interview with the person reporting the incident, interviews with witnesses, an interview with the resident, review of the medical record, interviews with staff members on all shifts having contact with the resident at the time of incident, an interview with the roommate, and all circumstances surrounding the incident and report the findings to the State Agency within 5 days.",2020-09-01
452,DESERT COVE NURSING CENTER,35095,1750 WEST FRYE ROAD,CHANDLER,AZ,85224,2019-04-04,641,D,0,1,M6IO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for two residents (#58 and #208). The census was 66. The deficient practice could affect residents' continuity of care. Findings include: -Resident #58 was admitted on (MONTH) 12, 2019, with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. A review of the nursing discharge summary progress notes dated (MONTH) 2, 2019 revealed the resident was discharged home. Review of the discharge MDS assessment dated (MONTH) 2, 2019, revealed the resident was discharged to an acute hospital. An interview was conducted with the MDS coordinator (staff #51) on 04/04/19 at 08:53 AM. Staff #51 stated that she obtains information for the MDS assessment from the nurses, certified nursing assistants, therapy, residents and families. She stated that resident #58 was discharged home and that the discharge MDS assessment was an error. During an interview conducted with the Administrator (staff #132) on 04/04/19 at 09:24 AM, the Administrator stated that the expectation is that the MDS assessments are accurate and that an inaccurate assessment is not acceptable. -Resident #208 was admitted to the facility on (MONTH) 6, (YEAR), with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. A nursing note dated (MONTH) 16, (YEAR), revealed the resident was discharged to another nursing facility. However, the discharge MDS assessment dated (MONTH) 16, (YEAR), revealed the resident was discharged to the community. An interview was conducted on (MONTH) 3, 2019 at 8:42 a.m. with the MDS Coordinators (staff #51 and staff #88). The coordinators stated that they worked together and shared duties to complete the MDS assessments. They stated that they followed the RAI manual to code the MDS assessments. Staff #51 stated that the resident's discharge MDS assessment should have been coded that the resident went to another facility not to the community. The RAI manual instructs to review the resident's clinical record for documentation of the discharge location. The RAI manual also includes that it is required that the assessment accurately reflects the resident's status and that the importance of accurately completing and submitting the MDS assessment cannot be over emphasized.",2020-09-01
453,DESERT COVE NURSING CENTER,35095,1750 WEST FRYE ROAD,CHANDLER,AZ,85224,2019-04-04,655,E,1,1,M6IO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, resident and staff interviews, and policy review, the facility failed to ensure a summary of the baseline care plan was provided to three residents (#15, #38, #25) and/or the residents' representatives and failed to ensure a baseline care plan was developed within 48 hours for three residents (#59, #209, #317). The sample size was 20. The deficient practice could result in residents' care needs not being met. Findings include: -Resident #15 was admitted to the facility on (MONTH) 5, (YEAR), with [DIAGNOSES REDACTED]. Review of the baseline care plan revealed the care plan was developed on (MONTH) 5, (YEAR), which included the resident's advance directive status, communication status, Activities of Daily Living (ADL) status, fall risk status, and the resident's impaired cognitive ability related to dementia. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 12, (YEAR) revealed the resident scored a 5 on the Brief Interview for Mental Status (BIMS), indicating the resident had severe cognitive impairment. Review of the clinical record revealed no evidence that a summary of the resident's baseline care plan had been provided to the resident's legal representative. -Resident #38 was admitted to the facility on (MONTH) 6, (YEAR), with [DIAGNOSES REDACTED]. The baseline care plan included the resident's communication status, ADL status, fall risk, hydration, and nutritional status. Review if the admission MDS assessment dated (MONTH) 13, (YEAR) revealed the resident scored a 13 on the BIMS, indicating the resident was cognitively intact. Review of the clinical record revealed no evidence that a summary of the resident's baseline care plan had been provided to the resident. An interview was conducted on (MONTH) 4, 2019 at 11:40 a.m. with a licensed practical nurse (LPN/staff #128). Staff #128 stated the admission nurse will develop a baseline care plan upon admission. Staff #128 stated the baseline care plan includes diagnoses, wounds, ADLs, and other care needs. Staff #128 stated the care plan is developed within 24-48 hours of admission. Staff #128 further stated the charge nurse or Director of Nursing (DON) will print a copy of the baseline care plan and review it with the resident or resident representative. The LPN stated the resident or representative will then sign a copy which will be kept in the medical record and a copy will be given to the resident or the resident's representative. An interview was conducted on (MONTH) 4, 2019 at 12:34 p.m. with the DON (staff #32). The DON stated that on admission, the admitting nurse is responsible for developing a baseline care plan inclusive of advance directives, diagnoses, potential and actual skin breakdown, and falls. The DON further stated a copy of the baseline care plan is reviewed and given to the resident or representative within 48 hours and a signed copy is kept for the clinical record. A copy of the signed baseline care plan was requested for residents (#15 and #38). At 2:11 p.m., the DON stated the signed copies of the baseline care plans for the two residents (#15 and #38) were unable to be located. -Resident #25 was admitted on (MONTH) 24, (YEAR), with [DIAGNOSES REDACTED]. Review of the baseline care plan dated (MONTH) 24, (YEAR), included the resident's advance directive status, ADL status, communication status, medications, fall risk status, and oxygen therapy. Review of the admission MDS assessment dated (MONTH) 31, (YEAR) revealed a score of 10 on the BIMS which indicated the resident had moderate impaired cognition. The nurse progress note dated (MONTH) 12, (YEAR), revealed the resident had a medical power of attorney (MPOA). Continued review of the clinical record revealed no evidence that a summary of the resident's baseline care plan had been provided to the resident's legal representative. During an interview conducted with the resident's MPOA on (MONTH) 2, 2019 at 1:18 p.m., the MPOA stated that even after multiple requests, no information had been provided regarding the resident's care plan. An interview was conducted with Director of Social Services (staff #112) on (MONTH) 3, 2019 at 1:37 p.m. Staff #112 stated the baseline care plans are initiated upon admission by the nurse. She stated that the case managers and nurses review the care plans with the residents' representatives. An interview was conducted with the Director of Nursing (DON/staff #32) on (MONTH) 3, 2019 at 2:02 p.m. The DON stated that the Assistant Director of Nursing (ADON) was the one responsible for making sure the baseline care plans were complete and reviewing the care plans with the resident and/or the resident's representative. Staff #32 stated the ADON was no longer at the facility. -Resident #59 was admitted to the facility on (MONTH) 14, 2019 with a [DIAGNOSES REDACTED]. Review of the clinical record did not reveal a baseline care plan for resident #59. An interview was conducted with the Medical Records Director (staff #56) on (MONTH) 3, 2019 at 11:40 AM. Staff #56 stated a baseline care plan was never developed for resident #59 and that the resident was not there long enough for the comprehensive care plan. An interview was immediately conducted with a Licensed Practical Nurse (LPN/staff #106). She stated the floor nurse develops the baseline care plan on admission and that it should be completed in 24 hours. An interview was conducted with the Director of Nursing (DON/staff #32) on (MONTH) 3, 2019 at 1:44 PM. The DON stated the baseline care plan is developed by the floor nurse on admission and should be completed within 24 hours. She stated that she did not know what had happened with the baseline care plan for resident #59. The DON stated she was very involved with the family and actually thought she had completed that one herself. -Resident #209 was admitted to the facility on (MONTH) 27, 2019 with [DIAGNOSES REDACTED]. Review of the baseline care plan revealed the resident's care plan had been initiated but not completed. The focus for pain was left blank in the area of the specific type of pain. It was also left blank in the area that states what the pain is related to. No goals were in place and the care plan contained only one intervention which included evaluating the effectiveness of pain interventions. An interview was conducted with the DON on (MONTH) 4, 2019 at 12:51 PM. The DON stated the nurse that does the admission is responsible for making sure the baseline care plan is complete. She also stated that chart reviews are regularly conducted. After viewing the care plan for resident #209, the DON stated that the care plan was not complete. -Resident #317 was admitted (MONTH) 24, 2019, with [DIAGNOSES REDACTED]. During an initial observation conducted of the resident on (MONTH) 1, 2019 at 11:09 a.m., the resident was observed to have oxygen on at 2 liters per nasal cannula. Review of the clinical record did not reveal a physician's orders [REDACTED]. Further review of the clinical record did not reveal a baseline care plan had been developed for oxygen therapy. An interview was conducted with a Licensed Practical Nurse (LPN/staff #120) on (MONTH) 4, 2019 at 1:25 p.m. The LPN stated that a physician's orders [REDACTED]. Review of facility's policy regarding baseline care plan revealed the baseline care plan will be developed for every resident within 48 hours of admission to provide an initial set of instructions needed to provide effective and person-centered care of the resident that meet professional standards of care. The policy also included reviewing the baseline care plan and the physician orders [REDACTED].",2020-09-01
454,DESERT COVE NURSING CENTER,35095,1750 WEST FRYE ROAD,CHANDLER,AZ,85224,2019-04-04,686,E,1,1,M6IO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews, and policy review, the facility failed to ensure barrier cream was consistently applied to one of three sampled residents (#15) and failed to ensure three of three sampled residents (#15, #208, and #308) with pressure ulcers consistently received treatment and services consistent with professional standards of practice. The deficient practice could result in the development and worsening of pressure ulcers. Findings include: -Resident #15 was admitted to the facility on (MONTH) 5, (YEAR), with [DIAGNOSES REDACTED]. Review of the baseline care plan initiated on (MONTH) 5, (YEAR) revealed the resident was at risk for skin break down related to immobility and incontinence. The goal was for the resident to maintain intact skin. Interventions included keeping the skin clean and dry after each incontinence episode, a pressure reducing mattress, completing weekly skin checks, and providing treatments as ordered. Review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 12, (YEAR) revealed the resident had severely impaired cognitive skills for daily decision making and required extensive assistance with all activities of daily living (ADLs). The MDS assessment included the resident had no unhealed pressure ulcers but was at risk for pressure ulcer development. The Braden Scale dated (MONTH) 22, (YEAR) revealed a score of 15 indicating the resident was at mild risk for pressure ulcer development. Review of the weekly skin checks revealed no evidence of pressure ulcers prior to (MONTH) 24, (YEAR). A weekly skin check dated (MONTH) 25, (YEAR) revealed the resident's skin remained intact, however, there was a non-blanchable area noted to the sacrum. Review of the physician orders [REDACTED]. A weekly skin check dated (MONTH) 15, (YEAR) revealed the sacrum was red and barrier cream was applied. The Treatment Administration Record (TAR) for (MONTH) (YEAR) revealed no evidence [MEDICATION NAME] cream was applied during the day shift on (MONTH) 20, (YEAR). Review of the progress notes for (MONTH) 20, (YEAR) revealed no evidence the cream was administered or refused by the resident. A weekly skin check dated (MONTH) 22, (YEAR) revealed there was redness to the left and right buttock. Review of the weekly skin checks for (MONTH) (YEAR) revealed the resident's skin remained intact with no new findings. Review of the TAR for (MONTH) (YEAR) revealed the [MEDICATION NAME] cream was applied as ordered. A communication note dated (MONTH) 29, (YEAR) revealed that while changing the resident's brief, the resident's family identified and notified the nurse of an opening to the resident's left buttock. The note included the Assistant Director of Nursing (ADON) was notified and an order for [REDACTED].>Review of the physician orders [REDACTED]. The first documentation of the wound measurements was a health status note dated (MONTH) 3, 2019 that the open area to the left buttock measured 0.5 centimeters (cm) in length by 0.4 cm in width and 0.2 cm in depth. The note included the wound treatment was provided and the wound nurse was notified. However, the note did not include a description of the wound. Review of the weekly skin check for (MONTH) 6, 2019, revealed the resident had an open area to the left gluteal fold. A health status note dated (MONTH) 9, 2019 revealed the Nurse Practitioner (NP) communicated to the wound nurse to have the wound care team follow the resident for the stage two pressure ulcer to the left buttock. Review of the nursing health status notes for (MONTH) 9, 2019 revealed the family refused to let staff reposition and change the resident. The notes included the nurse was concerned and spoke to the family about the wound and repositioning the resident and that the family showed no concern for the wound. A care plan was initiated on (MONTH) 9, 2019 and revised on (MONTH) 22, 2019 for the stage two pressure ulcer to the left ischium. The goal was for the resident to have intact skin, be free from redness, and for the pressure ulcer to show signs of healing and remain free from infections. Interventions included using two staff with repositioning, keeping the bed flat to reduce shearing, observing and reporting changes in skin status, and following policies for prevention and treatment of [REDACTED]. Review of the Care conference notes dated (MONTH) 11, 2019 revealed the family was upset that the CNAs were coming into the resident's room in the middle of the night to reposition and change the resident. The note included the family was informed of the increased risk to the skin and the detrimental effect of not changing positions. The weekly skin check for (MONTH) 12, 2019 revealed there was an open area to the left gluteal fold. Review of the quarterly MDS assessment dated (MONTH) 12, 2019 revealed the resident had severely impaired cognitive skills for daily decision making and required extensive assistance with all ADLs. The assessment included the resident had a stage two unhealed pressure ulcer. Further review of the clinical record from (MONTH) 29, (YEAR) through (MONTH) 14, 2019 revealed no thorough assessment of the pressure ulcer which included a description of the wound bed, any drainage, the surrounding skin, or any odor. A skin/wound note dated (MONTH) 15, 2019 revealed the resident had a stage three left ischium ulcer measuring 0.6 cm in length by 0.7 cm in width with minimal slough with mild drainage. The note included the resident had an alternating pressure mattress present on the bed and a Roho cushion in the wheelchair. Review of the provider's progress note dated (MONTH) 15, 2019, revealed the wound was a ischial ulceration with an irregular shaped superficial ulceration extending to the subcutaneous tissue with minimal slough, mild granulation, mild serous drainage, and no peri-wound inflammation. Review of the weekly skin check for (MONTH) 20, 2019 revealed the resident had an open area/wound. The weekly skin check for (MONTH) 25, 2019 revealed there was no new finding. Review of the TAR for (MONTH) 2019 revealed no evidence the [MEDICATION NAME] cream was applied on the day shift on (MONTH) 14,16, 25, and 28 and the evening shift of (MONTH) 25, 2019. Review of the progress notes for these dates revealed no evidence the cream was administered or refused by the resident. Additional review of the TAR for (MONTH) 2019 revealed no evidence the left ischium treatment was provided as ordered on (MONTH) 14, 16, 21, 23, and 25, 2019. Review of the progress notes for these dates revealed no evidence treatment was administered or refused by the resident. The weekly pressure ulcer tracking report dated (MONTH) 29, 2019 revealed the pressure ulcer to the left ischium measured 0.4 cm in length by 0.3 cm in width by 0.1 cm in depth. The report included the wound was a superficial ulceration extending through the subcutaneous tissue with no odor, minimal slough, and mild drainage. Review of the provider's progress note dated (MONTH) 5, 2019 revealed the bilateral ischial ulceration was 100 percent re-[MEDICATION NAME] and had resolved. Review of a wound note dated (MONTH) 5, 2019, revealed the ulcer had resolved and to continue applying the cream to the buttock as ordered. The TAR dated (MONTH) 2019 revealed no evidence the [MEDICATION NAME] cream was applied on the day shift on (MONTH) 1, 7, and the 22, 2019. Review of the progress notes for the corresponding dates revealed no evidence the cream was administered or refused by the resident. The TAR dated (MONTH) 2019 revealed no evidence the [MEDICATION NAME] cream was applied on the day shift on (MONTH) 11, 2019. Review of the progress notes for (MONTH) 11, 2019 revealed no evidence the cream was administered or refused by the resident. An interview was conducted on (MONTH) 3, 2019 at 10:25 a.m. with a Register Nurse (RN/staff #74). Staff #74 stated that once a wound is identified, the nurse will notify the doctor and obtain a treatment order. Staff #74 stated the wound nurse will stage, measure, and assess the wound weekly. The RN stated that the nurses complete the weekly skin assessments and administer the treatments. She also stated that the nurses are to document wound treatment on the TAR and that if it is not documented on the TAR, it is assumed the treatment was not provided. An interview was conducted on (MONTH) 4, 2019 at 8:20 a.m. with the wound nurse (staff #107). Staff #107 stated that the wound nurse is notified when a new skin opening is identified. Staff #107 stated that the wound nurse will obtain a treatment order and assess and measure the wound weekly. Staff #107 also stated that the wound provider will assess and determine the stage of a pressure ulcer. Staff #107 stated the administration of a treatment is record on the TAR by the nurse. On (MONTH) 4, 2019 at 10:37 a.m., the Director of Nursing (DON/staff #32) stated that all copies of the wound assessments and documentation for this resident had been provided. During an interview conducted on (MONTH) 4, 2019 at 12:34 p.m. with the DON (staff #32), the DON stated that the nurses complete the weekly skin checks and the wound nurse completes the weekly pressure ulcer measurements and assessments along with the wound doctor. The DON further stated treatments administered to the resident are documented on the TAR. -Resident #208 was admitted to the facility on (MONTH) 6, (YEAR), with [DIAGNOSES REDACTED]. The resident was discharged on (MONTH) 16, (YEAR). Review of the admission nursing assessment dated (MONTH) 7, (YEAR), revealed the resident had skin tears on the right elbow, right trochanter, and left and right shoulders. The assessment also included the resident had a wound on the coccyx and scars on the front of the right and left knees. The admission assessment did not include any documentation of skin breakdown on the resident's heels. Review of the care plan dated (MONTH) 8, (YEAR), revealed the resident was at risk for skin integrity breakdown. The goal was for the resident to maintain intact skin with no skin breaks. Interventions included a pressure reducing mattress, treatments as ordered, and weekly skin checks. Review of the resident's wound assessments revealed an assessment described as a first observation dated (MONTH) 8, (YEAR) which described a stage 2 pressure ulcer located on the resident's sacrum. The assessment did not include any wounds on the resident's heels. A skin/wound note dated (MONTH) 9, (YEAR), stated, Patient's skin checked for a second time .a stage 2 ulcer to the right heel noted. New orders put in place . Review of the clinical record revealed no evidence of an initial wound assessment for the resident's right heel wound. The physician's orders [REDACTED]. heel to be cleansed and dressed daily. Review of the Treatment Administration Record (TAR) for (MONTH) (YEAR), revealed the resident received treatments for the right heel wound daily from (MONTH) 9 through (MONTH) 14, (YEAR), and on (MONTH) 16, (YEAR). The treatment was not documented on the TAR as being provided to the resident's right heel on (MONTH) 15, (YEAR). Review of the 5 day MDS assessment dated (MONTH) 13, (YEAR), revealed the resident had one stage 2 unhealed pressure ulcer present on admission. A provider's progress note dated on the day of the resident's discharge on (MONTH) 16, (YEAR), revealed the resident was receiving an evaluation of the right heel blister and coccyx ulcer which were present on admission. However there was no documentation of the right heel wound in the resident's admission assessments. Although the resident was discharged from the facility on (MONTH) 16, (YEAR), a wound assessment signed (MONTH) 22, (YEAR), revealed the resident had an unstageable deep tissue injury on the right heel. The assessment described the wound as a small intact blister and a small area of purplish discoloration. The wound assessment did not include the presence of any slough tissue or necrotic tissue and/or eschar. The assessment included the wound was present on admission; however there was no documentation of the right heel wound in the resident's admission assessments. An interview was conducted on (MONTH) 4, 2019 at 8:20 a.m., with a Licensed Practical Nurse (LPN/wound nurse/staff #107). She stated that the admission nurse was responsible for completing a full skin assessment when a resident was admitted to the facility. The LPN stated that if the admission nurse identifies a wound, the nurse would leave a note for her to complete a wound assessment. She said a second full skin assessment would also be conducted within 24 hours of admission by herself, the ADON, or the DON. She stated that the wound on the resident's right heel was present on admission because it was not the type of wound that could have developed in 3 days. The LPN said the resident's right heel had significant eschar, and that this amount of eschar would indicate the wound was chronic. She stated the wound documentation, including the provider's initial assessment, measurements, and documentation of the eschar was located in the paper records, not the electronic record. An interview was conducted on (MONTH) 4, 2019 at 8:57 a.m., with the Medical Records Director (staff #56). She stated there were no additional skin assessments, wound assessments, or provider progress notes in the paper records that had not already been provided. Review of the clinical record revealed no evidence of any other wound assessments for the resident's right heel wound. An interview was conducted on (MONTH) 4, 2019 at 12:34 p.m., with the DON (staff #32 ). She stated the expectation was that the admitting nurse would complete a skin assessment and notify the wound nurse of any areas of concern. She said the wound nurse would follow up and obtain any needed orders for pressure ulcer treatment. The DON stated the expectation is that pressure ulcer treatments be documented on the TAR, and if the documentation was missing it would not be possible to know if the treatment had been provided. She said the the wound provider would assess wounds, make recommendations, and document progress notes. The DON stated that the wound nurse would also complete weekly wound measurements and document along with the provider progress notes. -Resident #308 was admitted on (MONTH) 2, (YEAR), with [DIAGNOSES REDACTED]. Review of the pressure ulcer status records dated (MONTH) 2, (YEAR), revealed the resident was admitted with a sacral deep tissue injury measuring 18.5 centimeters (cm) x 7.0 cm, a right heel deep tissue injury measuring 7 cm x 4 cm, and a left heel deep tissue injury measuring 2 cm x 1.5 cm. Review of care plans dated (MONTH) 2, (YEAR), revealed a care plan for active infection of the wound as evidenced by abnormal culture with a goal that the wound infection will be resolved. Interventions included administering medications as ordered. The admission Minimum Data Set (MDS) assessment dated (MONTH) 9, (YEAR), revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. The MDS assessment included the resident had 3 unstageable pressure ulcers Review of a physician progress notes [REDACTED]. A physician order [REDACTED]. However, review of the Medication Administration Record [REDACTED]. Review of the nurse progress note dated (MONTH) 18, 2019, revealed the pharmacist was contacted regarding the [MEDICATION NAME] trough level. The note included that according to the pharmacist the resident should have been on [MEDICATION NAME] 1 gram every 12 hours. The note also included the patient was given [MEDICATION NAME] 1 gram once a day beginning on 2/14/18. An interview was conducted with a RN (staff #74) on (MONTH) 3, 2019 at 12:37 p.m. The RN stated that if the pharmacist is recommending IV [MEDICATION NAME] 1 gram twice a day, a physician's orders [REDACTED]. During an interview conducted on (MONTH) 4, 2019 at 2:23 p.m. with the DON (staff #32), Administrator (staff #132), and the clinical resource nurse, staff #32 stated that if a physician's orders [REDACTED]. Review of the facility's policy regarding Pressure Ulcer/Injury Prevention and Management revealed a comprehensive skin assessment on admission and re-admission may identify pre-existing signs of possible deep tissue damage already present. The policy revealed measures to maintain and improve the resident's tissue tolerance to pressure are implemented in the plan of care and included minimizing skin exposure to incontinence using skin barriers and proper positioning and turning at least every 2-4 hours. The policy included that when skin breakdown occurs, it requires attention and a change in the plan of care to appropriately treat the resident. Review of the facility's policy titled General Dose Preparation and Medication Administration revealed that prior to administration of a medication, staff should take all measures required by facility policy and applicable law including but not limited to confirming that the MAR indicated [REDACTED]",2020-09-01
455,DESERT COVE NURSING CENTER,35095,1750 WEST FRYE ROAD,CHANDLER,AZ,85224,2019-04-04,688,E,0,1,M6IO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure 2 out of 2 sampled residents (#25 and #26) received the recommended Restorative Nursing Assistant (RNA) services. The deficient practice could result in a reduction in range of motion. Findings include: Resident #26 was admitted to the facility on (MONTH) 31, (YEAR) with a [DIAGNOSES REDACTED]. Review of the clinical record revealed a Rehabilitation/Restorative Care Referral Form from Physical Therapy dated (MONTH) 12, (YEAR), for a restorative program 3 x weekly for 12 weeks. Review of the Restorative Care Flow Sheets (MONTH) 13, (YEAR) through (MONTH) 29, 2019 revealed the resident received one 15 minute session on (MONTH) 21, (YEAR). The quarterly Minimum Data Set (MDS) assessment dated (MONTH) 2, 2019 revealed the resident required extensive assistance for Activities of Daily Living (ADLS). The assessment also included the resident received no Restorative Nursing Assistance (RNA) during the look-back period. Review of the Restorative Care Flow Sheet for (MONTH) 2019 revealed no documentation except for one entry on (MONTH) 26 that the resident had refused due to a headache. The Restorative Care Flow Sheet for (MONTH) 2019 revealed the resident received one 15 minute session on (MONTH) 8. The sheet included two refusals, one on (MONTH) 5 and one on (MONTH) 21. The sheet also included the resident was out of the facility on (MONTH) 7. An interview was conducted with a RNA (staff #66) on (MONTH) 2, 2019 at 3:18 PM. The RNA stated that she has a caseload of 15 on the maintenance program. She stated that because of the case load of 15, she is unable to provide RNA services to them all in one day but that she tries to get to as many residents as she can. The RNA stated that she has a flow sheet in a book for each resident on the maintenance program. She stated that she uses the flow sheets to keep track of each session. She stated that they have a meeting with skilled therapy once a month where it is determined which residents will remain on the maintenance program and who will not. The RNA stated resident #26 is still on her caseload for maintenance. -Resident #25 was admitted on (MONTH) 24, (YEAR), with [DIAGNOSES REDACTED]. The admission MDS assessment dated (MONTH) 31, (YEAR) revealed the resident required extensive assistance with transfers and walking in the room. Review of the clinical record revealed a therapy referral dated (MONTH) 6, (YEAR) for RNA services 3 times a week for 4 week for transfers, active ROM and ambulation. Review of the Restorative Care Flow Sheet for (MONTH) (YEAR) revealed the resident only received 15 minutes of RNA services on (MONTH) 20, (YEAR). Review of the Restorative Care Flow Sheet for (MONTH) 2019 only revealed the resident's refusal of RNA services on (MONTH) 3, 2019 due to leg pain. An interview was conducted with the Director of Rehabilitation services (staff #29) on (MONTH) 3, 2019 at 11:31 a.m. She stated that before a resident is discharged from therapy, they will review and recommend RNA services if it is appropriate for that resident. Staff #29 stated they did write a maintenance RNA program for resident #25 when the resident was discharged from therapy. During an interview conducted with RNA (staff #66) on (MONTH) 3, 2019 at 11:48 a.m., the RNA stated that when therapy discharges a resident from their services, therapy will write a recommendation for RNA services if appropriate for the resident. She stated that the recommendation will include what services to provide and the frequency and duration of the RNA services. Staff #66 said she has a book that contains a flow sheet for each of the residents on the RNA maintenance program that she uses to keep track of each RNA session. She stated that they have a meeting with Therapy once a month and that during the meeting, it is determined which residents will remain on the RNA maintenance program and who will not. The RNA stated that resident #25 received RNA services once in (MONTH) and once in January. She stated that the resident was supposed to receive RNA services 3 times a week, but that the services were not provided to the resident 3 times a week. An interview was conducted with the Director of Nursing (DON/staff #32) on (MONTH) 3, 2019 at 2:02 p.m. The DON stated the expectation is that RNA provides the recommended RNA services. She stated that if Therapy recommends RNA services 3 times week, she expects RNA to provide RNA services 3 times a week. The DON also stated that the expectation is that the RNA document any resident refusals. Review of the facility's policy on Restorative Nursing revealed the facility is responsible for providing restorative programs that will maintain and/or improve each resident abilities in reaching the highest practicable level of physical, mental and psychosocial functioning.",2020-09-01
456,DESERT COVE NURSING CENTER,35095,1750 WEST FRYE ROAD,CHANDLER,AZ,85224,2019-04-04,695,E,0,1,M6IO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, resident and staff interviews, and policy review, the facility failed to ensure 3 of 3 sampled residents (#s 317, 311, and 38) who needed oxygen therapy, were provided such care, consistent with professional standards of practice. There were 9 residents receiving oxygen therapy. The deficient practice could result in respiratory complications. Findings include: -Resident #317 was admitted (MONTH) 24, 2019, with [DIAGNOSES REDACTED]. During an initial observation conducted of the resident on (MONTH) 1, 2019 at 11:09 a.m., the resident was observed to have oxygen on at 2 liters per nasal cannula. Another observation was conducted of the resident on (MONTH) 4, 2019 at 8:41 a.m. The resident was observed sleeping in bed with oxygen on at 2 liters per nasal cannula. However, review of the clinical record did not reveal a physician's order for oxygen or that the resident's oxygen saturations were checked or that there was a care plan for oxygen therapy. During an interview conducted with the resident on (MONTH) 4, 2019 at 11:09 a.m., the resident stated that staff tried weaning her off oxygen but was unsuccessful. She stated that she was informed by staff that the physician said she has to receive oxygen continuously. The resident was observed receiving oxygen at 2 liters per nasal cannula. During an interview conducted with health information staff (#25) on (MONTH) 4, 2019 at 1:15 p.m., staff #25 stated that the clinical record did not have documentation of oxygen saturations. An interview was conducted with a Licensed Practical Nurse (LPN/staff #120) on (MONTH) 4, 2019 at 1:25 p.m. The LPN stated that a physician's order is needed for a resident to receive oxygen therapy. She also stated that oxygen therapy is care planned and the resident's oxygen saturations are checked once a shift. The LPN stated that resident #317 is receiving oxygen therapy. After reviewing the resident's clinical record, the LPN stated that it does not look like there is an order for [REDACTED]. -Resident #311 was admitted on (MONTH) 26, 2019, with a [DIAGNOSES REDACTED]. An observation was conducted of the resident on (MONTH) 1, 2019 at 9:32 a.m. The resident was observed sitting in the wheelchair receiving oxygen at 2 liters via nasal cannula. An observation was conducted of the resident on (MONTH) 4, 2019 at 9:58 a.m. The resident was observed sleeping in bed receiving 2 liters of oxygen via nasal cannula. Review of nursing skilled documentation dated (MONTH) 26, 2019, revealed the resident had no labored breathing with O2 saturation at 97% on 2 Liter via Nasal cannula. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 2, 2019, revealed the resident was not receiving oxygen therapy. Review of a nurse progress note dated (MONTH) 3, 2019, stated Patient given scheduled SVN with good relief, the patient had even non labored breaths with O2 sat at 97 on 2L via nasal cannula. The patient had no complained of pain or respiratory distress. However, review of the clinical record did not reveal a physician's order for oxygen or a care plan for oxygen. An interview was conducted with a LPN (staff #120) on (MONTH) 4, 2019 at 1:37 p.m. The LPN stated the resident is receiving oxygen. After reviewing the clinical record, the LPN stated that there was no physician's order for oxygen or oxygen saturations and that there was no care plan for oxygen. She stated that there should be orders for oxygen therapy and a care plan for oxygen. During an interview conducted with the Director of Nursing (DON/staff # 32) and the Administrator (staff #132) with the clinical resource nurse present on (MONTH) 4, 2019 at 2:23 p.m., the DON stated that if a resident was admitted on oxygen therapy, there has to be a physician's order for the oxygen and it has to be care planned. -Resident #38 was admitted to the facility on (MONTH) 6, (YEAR), with [DIAGNOSES REDACTED]. Review if the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 21, 2019 revealed the resident scored a 9 on the Brief Interview for Mental Status BIMS, indicating the resident had moderate cognitive impairment. The assessment included the resident was receiving oxygen therapy. Review of the care plan revised on (MONTH) 6, (YEAR) revealed the resident had oxygen therapy related to [MEDICAL CONDITION] with a goal to have no signs or symptoms of poor oxygen absorption. Interventions included to observe for signs and symptoms of respiratory distress, oxygen settings at 2- 3 liters via nasal cannula, and to given medications as ordered. Review of the physician's orders revealed an order dated (MONTH) 25, 2019 for oxygen at 2 liters per minute via nasal cannula as needed to keep oxygen saturation at 90 percent or above. During an initial observation conducted of the resident on (MONTH) 1, 2019 at 11:02 a.m., the resident was observed to have oxygen on at 3 liters per nasal cannula. An interview was conducted on (MONTH) 4, 2019 at 9:56 a.m. with a LPN (staff #128). The LPN stated that a physician's order is needed for a resident receiving oxygen therapy and that the oxygen is to be administered as ordered. After observing resident #38, the LPN stated that the resident is receiving oxygen at 3 liters via nasal cannual and the physician's order is for 2 liters via nasal cannula. The LPN further stated that the oxygen is not being administered according to the order. During an interview conducted with the DON (staff #32) on (MONTH) 4, 2019 at 12:34 P.M., the DON stated that the oxygen therapy should be administered according to the physician's order. Review of the facility's policy regarding physician orders revealed that medications, therapy, and any treatments may not be administered to the resident without a written order from the attending physician.",2020-09-01
457,DESERT COVE NURSING CENTER,35095,1750 WEST FRYE ROAD,CHANDLER,AZ,85224,2019-04-04,725,F,0,1,M6IO11,"Based on resident and staff interviews, facility documentation, and policy review, the facility failed to ensure there was sufficient nursing staff to meet the needs of residents. This deficient practice resulted in residents' needs not being met. The census was 64. Findings include: During the initial phase of the survey, 7 out of 19 residents identified concerns of not having enough staff. Residents reported that they waited up to 2 hours for call lights to be answered, they did not receive scheduled restorative treatments, and they had family members stay all day to help provide needed care. Residents also stated that they were left in soiled briefs or on bedpans anywhere from 40 minutes to 2 hours after requesting assistance. They stated that staffing was worse on the weekends and when staff members called off work. Review of the Resident Council minutes for January, February, and (MONTH) 2019, revealed the residents had expressed concerns about sufficient staffing at each meeting. Residents expressed concerns about call light wait times up to 1 hour, long call light wait times at meal times and bed time, not enough staffing on nights and weekends, and other residents calling out for help at night. A Resident Council interview was conducted on (MONTH) 4, 2019 at 10:00 a.m. The residents stated that there was not enough staff, and that the staff appeared exhausted. The residents said call light wait times could be as long as two hours. They stated that when they asked staff for assistance, the staff replied I don't have time or I am too busy. Regarding staff treatment, the residents stated we are an entity to check off a box. They also stated that during the survey period, the facility was putting on a show. Review of the facility assessment dated (MONTH) 26, 2019, revealed the facility's general approach to ensure sufficient staff to meet the needs of the residents at any given time included 2.16 nurse aides per patient day. The nursing staff information postings for (MONTH) 1-31, 2019, revealed the facility had an average census of 66 residents, with the census ranging from 60 to 76 residents. The average number of hours worked by Certified Nursing Assistants (CNA) who provided direct care to residents was 117.4 hours per day. The average number of CNA hours per patient day was 1.77, which was lower than 2.16 stated in the facility's assessment. There were 27 days for the month of (MONTH) 2019 that the number of direct care CNA hours worked per patient day was less than 2.16. Review of the staff sign-in sheets and staff payroll records revealed the following for both wings: -On (MONTH) 10, 2019, 4 CNAs signed in for the 2:30 p.m. through 10:30 p.m. shift. However, review of the staff payroll records for (MONTH) 10, 2019, revealed that 3 CNAs worked in the facility during the 2:30 p.m. through 10:30 p.m. shift. -On (MONTH) 17, 2019, 5 CNAs signed in for the 2:30 p.m. through 10:30 p.m. shift. However, review of the staff payroll records for (MONTH) 17, 2019, revealed 3 CNAs worked in the facility during the 2:30 p.m. through 10:30 p.m. shift. -On (MONTH) 31, 2019, only 2 CNAs signed in and worked in the facility for the 2:30 p.m. through 10:30 p.m. shift, according to staff sign-in sheets and payroll records. An interview was conducted on (MONTH) 2, 2019 at 08:54 a.m. with a resident's representative. The representative stated that the resident was not receiving regular toileting care. The representative also said the resident required assistance with feeding, and that staff would leave the meal tray in front of the resident without uncovering and setting up the tray and without providing assistance with feeding. During an interview conducted with a staff member on (MONTH) 4, 2019 at 8:44 a.m., the staff member stated that the reason treatments including restorative services were not provided was because of insufficient staffing. An interview was conducted on (MONTH) 4, 2019 at 10:18 a.m., with another staff member. The staff member was aware that residents were complaining about long call light wait times. The staff member stated that there is not enough staff to answer call lights timely. The staff member stated that if staff is asked to work over a 16 hour shift and they say no, there would be a negative response. The staff member stated that residents' showers have been omitted in order to complete other assigned resident care. The staff member also said that sometimes management would help deliver meal trays, but that they would leave the tray on the bedside table without setting up the meal and making sure the resident was able to eat. An interview was conducted on (MONTH) 4, 2019 at 10:56 a.m., with the Staffing Coordinator/Central Supply Director (staff #53). She stated that staffing was based primarily on the facility census. She also stated that the facility did not use registry staff. She stated the basic staffing strategy for CNAs was to have 2 CNAs on the west wing and 4 to 5 CNAs on the east wing, for a total of 6 to 7 CNAs in the facility at any time to provide direct care. Review of the facility's Staffing policy revealed the facility would maintain adequate staff on each shift to meet residents' need. The policy further stated the facility utilized the Facility Assessment as the foundation to determine staffing levels necessary to ensure that residents' needs were met.",2020-09-01
458,DESERT COVE NURSING CENTER,35095,1750 WEST FRYE ROAD,CHANDLER,AZ,85224,2019-04-04,726,E,0,1,M6IO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, personnel record review, facility assessment review, and policy, the facility failed to ensure 2 out of 6 sampled nursing staff (staff #94 and #127) possessed the competencies and skills needed to care for residents' needs. The deficient practice could result in delayed care and inadequate care for residents. The facility census was 64. Findings include: Review of the Facility assessment dated (MONTH) 26, 2019, revealed that over the past year or during a typical month, 18.52% of the facility's residents required clinically complex care, and 23.7% of the facility's residents had reduced physical function. The Facility Assessment stated that the staff competencies needed to care for residents would include medication administration, labs, diabetes management, IV therapy, ostomy care, infection control, tube feeding, respiratory care, wound care, lifts/transfers, vital sign collection, resident assessment, identification of changes in condition, perineal care, behavioral management, resident rights, abuse and neglect, quality of life, resident dignity, dementia management, and activities of daily living. The Assessment included that staff competencies would be determined through staff education in the form of return demonstration, quizzes, or Health Care Academy (online training). -Review of the personnel record for a Registered Nurse (RN/staff #94), revealed a hire date of (MONTH) 12, 2014, for full time employment. The staff member attended in-service training on (MONTH) 17, (YEAR) for the topic [DIAGNOSES REDACTED] Protocol and Procedure, and on (MONTH) 31, (YEAR) for the topic Implementation of Acute Care Plan for Antibiotics/Infection. The duration of these in-service trainings was not listed. Staff #94 also completed 0.5 hours of online training for Safer Sharps Training on (MONTH) 24, (YEAR). Review of the personnel record for staff #94 revealed no other evidence of training or in-services. The personnel record contained no evidence of a comprehensive evaluation for nursing skills and competencies upon hire or annually thereafter. -Review of the personnel record for a Certified Nursing Assistant (CNA/staff #127) revealed a hire date of (MONTH) 15, (YEAR). The staff member attended in-service training on (MONTH) 6, (YEAR) for the topic Clinical, on (MONTH) 24, (YEAR) for the topic PCC Training, and on (MONTH) 21, 2019 for the topics Abuse, and Providing Care. The duration of these in-service trainings were not listed. Staff #127 also completed 1 hour of online training for Code of Conduct Refresher on (MONTH) 22, 2019. Review of the personnel record for staff #127 revealed no other evidence of training or in-service. The personnel record contained no evidence of a comprehensive evaluation for skills and competencies upon hire or annually thereafter. An interview was conducted on (MONTH) 4, 2019 at 10:18 a.m., with an anonymous staff member. The staff member stated that the facility did not provide in-services or staff education for over a year. The staff member said that during that time, the only training staff received was through annual online modules. An interview was conducted on (MONTH) 4, 2019 at 11:23 a.m., with the Director of Nursing (DON/staff #32) and the Executive Director (ED/staff #132). Staff #32 stated that both nurses and CNAs were checked for skills and competencies upon hire. She stated that one-on-one education would be provided if concerns were identified. Staff #132 stated that she could not locate skills checklists for staff #94 and staff #127 to confirm that these staff had the required skills. She also stated that she could not locate any other documentation on skills or training for staff other than what was already provided. Review of the facility's policy regarding In-service Education revealed that all facility staff should be educated upon hire, annually , or as indicated thereafter on the following topics to include but not limited to: communication, residents rights, abuse, neglect, exploitation, procedures for reporting allegations, dementia management, abuse prevention, Elder Justice Act, compliance and ethics, quality assurance and performance improvement, infection control, behavioral health, care of the cognitively impaired, privacy, dignity, and confidentiality. The policy further stated that staff in-service education topics would be determined in part by annual skills evaluations. The policy included that the Staff Development Coordinator/designee will be responsible for maintaining training records in the learning management system or records for live in-service trainings.",2020-09-01
459,DESERT COVE NURSING CENTER,35095,1750 WEST FRYE ROAD,CHANDLER,AZ,85224,2019-04-04,732,D,0,1,M6IO11,"Based on staff interview, review of facility documentation, and policy review, the facility failed to ensure current nurse staffing information was posted on a daily basis. Findings include: An observation conducted on (MONTH) 1, 2019 at 7:55 a.m. of the posted nurse staffing information located inside the front entrance of the facility revealed the posted nurse staffing information was dated (MONTH) 30, 2019. An observation was conducted on (MONTH) 2, 2019 at 9:11 a.m. of the posted nurse staffing information. The posted nurse staffing information was dated (MONTH) 1, 2019. An interview was conducted with the receptionist (staff #126) on (MONTH) 3, (YEAR) at 12:44 p.m. She stated that she was responsible for posting the nurse staffing information during the weekdays, and the weekend receptionist was responsible for posting the nurse staffing information on the weekends. She stated that the staffing coordinator would place the staffing sheets for the weekends in her mailbox on Friday, and the weekend receptionist would post the weekend nurse staffing information based on those sheets. She stated that a staffing sheet for (MONTH) 31, 2019 was not created and placed in her mailbox on Friday, so it was not updated and posted on (MONTH) 31, 2019. Review of the facility's policy on staffing revealed the facility must post the nurse staffing information on a daily basis at the beginning of each shift.",2020-09-01
460,DESERT COVE NURSING CENTER,35095,1750 WEST FRYE ROAD,CHANDLER,AZ,85224,2019-04-04,741,E,0,1,M6IO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, personnel record review, facility assessment review, and policy review, the facility failed to ensure 6 out of 6 sampled nursing staff (staff #2, #20, #59, #94, #102, and #127) had the competencies to provide behavioral health and dementia care to residents. The deficient practice could result in inadequate care for 15 residents in the facility who had [DIAGNOSES REDACTED]. The census was 64. Findings include: Review of the Facility assessment dated (MONTH) 26, 2019, revealed that common [DIAGNOSES REDACTED]. Types of care that the facility's resident population required and that the facility provided included: mental health and behavioral care, psycho/social/spiritual support, and assistance with activities of daily living. The Facility Assessment stated that the staff training and/or education competencies necessary to provide the level and types of support and care needed for the resident population included: staff education in the form of return demonstration, quizzes, or Health Care Academy (online training) for behavioral management, quality of life, resident dignity, dementia management, and activities of daily living. -Review of the personnel record for a Certified Nursing Assistant (CNA/staff #2) revealed a hire date of (MONTH) 1, 2008. The personnel record contained a form titled Competency/Skills Checklist dated (MONTH) 28, (YEAR). The checklist included a performance level of 4 out of 4 for the following categories: Skills: answers call lights promptly and leaves within reach, routinely makes rounds, assists with feeding, assists patients with bathing, assists with personal hygiene, documents activities of daily living appropriately Reports to Nurse: any unusual behavior. Further review of the personnel record did not reveal any other evidence of training for dementia care or behavioral health management. -Review of the facility's staff list revealed a Licensed Practical Nurse (LPN/staff#20) had a hire date of (MONTH) 1, 2006. Review of the facility's employee files revealed there was no personnel record for staff #20. -Review of the personnel record for a LPN (staff#59) revealed a re-hire date of (MONTH) 13, 2012. Review of the personnel record revealed no evidence of training for dementia care or behavioral management. -Review of the personnel record for a Registered Nurse (RN/staff#94) revealed a hire date of (MONTH) 12, 2014. Review of the personnel record revealed no evidence of training for dementia care or behavioral management. -Review of the personnel record for a RN (staff#102) revealed a hire date of (MONTH) 2, (YEAR). Review of the personnel record revealed no evidence of training for dementia care or behavioral management. -Review of the personnel record for a CNA (staff#127) revealed a hire date of (MONTH) 15, (YEAR). Review of the personnel record revealed no evidence of training for dementia care or behavioral management. An interview was conducted on (MONTH) 2, 2019 at 8:54 a.m., with an anonymous resident representative. The representative stated that they felt they were not able to leave the resident because the resident was confused and unable to push the call light. The representative stated that when they did leave the resident, they would return to find the resident in a wet brief. The representative stated the resident required assistance with feeding, and that they would stay to assist the resident with feeding because, no one else does. An interview was conducted on (MONTH) 3, 2019 at 1:36 p.m., with the Executive Director (ED/staff # 132). She stated that nursing staff received orientation upon hire, and annual training requirements thereafter. She said some training was live, on-site at the facility, and some training was online for a variety of topics. She said she would provide documentation of online training for the selected staff members. She stated the Director of Nursing and Human Resources were responsible for ongoing staff training. A follow-up interview was conducted on (MONTH) 4, 2019 at 9:56 a.m., with the ED (staff #132). She stated that upon hire, all staff were given written training materials on Code of Conduct, which would cover the topics of integrity, resident rights, privacy, fraud, financial abuse, and doing the right thing. Additionally, all staff were required to complete an annual online refresher course for Code of Conduct. She stated that she was not able to access any other documentation of online training for staff other than for Code of Conduct, and she was not able to provide any other documentation of staff training other than what had already been provided. An interview was conducted on (MONTH) 4, 2019 at 10:18 a.m., with an anonymous staff member. The staff member stated that the facility did not provide in-services or staff education for over a year. The staff member said that during that time, the only training staff received was through annual online modules. Review of the facility's policy regarding In-service Education revealed that the Executive Director is responsible for ensuring all facility staff are educated upon hire, annually, or as indicated thereafter on the following topics to include: dementia management, behavioral health, and care of the cognitively impaired. The policy further stated that in-service education topics related to specific needs of the facility, its residents and associates will be determined by a needs assessment based on annual skills evaluation, associate requests, and outcomes measures of performance improvement activities. The staff development coordinator/designee will be responsible for maintaining training records in the learning management system or records for live in-service trainings. If training is conducted in a live session, the records shall include the following: -Name and title of presenter -Date of presentation -Title of subject presented -Description of content -Signatures of those attending -Any state specific required documentation",2020-09-01
461,DESERT COVE NURSING CENTER,35095,1750 WEST FRYE ROAD,CHANDLER,AZ,85224,2019-04-04,812,D,0,1,M6IO11,"Based on observation, staff interviews, and policy and procedures, the facility failed to ensure food items in the freezer were sealed and/or dated. The deficient practice could result in a potential for food borne illness. Findings include: -An observation of the kitchen freezer was conducted with the Dietary Manger (staff #14) on 04/01/19 at 07:56 AM. A plastic bag containing hash browns was observed open to air and a plastic bag of raw hamburger patties was observed without a label or an opened date. An interview was conducted with staff #14 on 04/03/19 at 11:02 AM. Staff #14 stated that hamburgers were served the day before and that staff must have left a package unlabeled. He also stated that the hash browns were made that morning and that the open bag in the freezer should have been resealed after being used. Staff #14 stated that it is his expectation that all food be properly labeled and stored at all times. An interview was conducted with the Administrator (staff #132) on 04/04/19 at 09:24 AM. The Administrator stated that the raw hamburger patties should be labeled and the hash browns should not be left open to air in the freezer. She added that she finds this to be unsatisfactory practice. A review of the facility's policy for Freezer Food Storage, revised in (MONTH) of (YEAR), revealed that frozen food storage stock items are to be properly sealed and labeled.",2020-09-01
462,DESERT COVE NURSING CENTER,35095,1750 WEST FRYE ROAD,CHANDLER,AZ,85224,2019-04-04,849,D,0,1,M6IO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility documents, the facility failed to ensure a written agreement with hospice was signed by an authorized representative of the facility before hospice care was furnished to any resident including one sampled resident (#17). There were five residents receiving hospice services. Findings include: Resident #17 was admitted (MONTH) 11, (YEAR) with [DIAGNOSES REDACTED]. The admission Minimum Data Set assessment dated (MONTH) 18, (YEAR) revealed the resident was receiving hospice care. Review of the facility's written Hospice Inpatient Services Agreement effective (MONTH) 11, (YEAR), revealed the agreement was signed by the hospice representative, however, the agreement was not signed by the facility's authorized representative. During an interview conducted with a Licensed Practical Nurse (staff #59) on 04/03/19 at 9:37 AM, the LPN stated that the hospice staff visits resident #17 at least weekly and that they document their visits in the hospice book. An interview was conducted with the Business Office Manager (staff #61) on 04/03/19 at 2:15 PM. Staff #61 stated that the facility agreement with hospice was signed by the hospice's representative, but was never signed by the facility's representative. She stated that it must have been overlooked. She added that the agreement should have been signed by both representatives in order to be valid. An interview with the Administrator (staff #132) was conducted on 04/04/19 at 9:24 AM. The Administrator stated that the agreement was in place before she took over the position and she assumed it was signed and valid. She stated that it was overlooked.",2020-09-01
463,DESERT COVE NURSING CENTER,35095,1750 WEST FRYE ROAD,CHANDLER,AZ,85224,2019-04-04,880,E,0,1,M6IO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on personnel record reviews, staff interviews and policy and procedures, the facility failed to ensure that 4 out of 10 sampled staff members (#2, #20, #59 and #115) had current evidence of freedom from [MEDICAL CONDITION] (TB). The deficient practice could result in the potential exposure of infectious TB. Findings include: -Review of the personnel record for staff #2 (Certified Nursing Assistant) revealed a hire date of (MONTH) 1, 2008, for full time employment. A chest x-ray report dated (MONTH) 1, (YEAR), revealed staff #2 was free of TB. Further review of the personnel record for staff #2 revealed no additional evidence that staff #2 was free of TB, after (MONTH) 1, (YEAR). -Review of the facility's staff list revealed that staff #20 (Licensed Practical Nurse) was hired on (MONTH) 1, 2006, for full time employment. Review of the facility's employee files revealed there was no personnel record for staff #20. -Review of the personnel record for staff #59 (Licensed Practical Nurse) revealed a hire date of (MONTH) 13, 2012, for full time employment. A chest x-ray report dated (MONTH) 19, (YEAR), included no evidence of active TB. A form titled [MEDICAL CONDITION] Assessment completed on (MONTH) 7, (YEAR), revealed the employee did not have symptoms of TB. The form was signed by the employee, however it was not signed by a medical provider -Review of the personnel record for staff #115 (dietary aide) revealed a hire date of (MONTH) 8, (YEAR), for full time employment. A chest x-ray report dated (MONTH) 26, (YEAR), included no evidence of active TB. A form titled [MEDICAL CONDITION] Assessment completed on (MONTH) 8, (YEAR), revealed the employee did not have symptoms of TB. The form was signed by the employee, however it was not signed by a medical provider. An interview was conducted on (MONTH) 2, 2019 at 3:24 p.m., with the Human Resources Director (staff #123). She stated she believed that when a staff member had a chest X-ray that was negative for TB, they did not need to provide any additional documentation for 5 years. She stated that she did not realize that all employees were required to be screened for TB annually. An interview was conducted on (MONTH) 3, 2019 at 1:36 p.m., with the Interim Executive Director (staff #132). She stated that every staff member needed TB screening upon hire and annually thereafter. She stated that she expect staff members will provide current TB screening immediately or they would be removed from the schedule and not be able to return to work until they were able to provide current TB screening. An interview was conducted on (MONTH) 4, 2019 at 9:33 a.m., with the Human Resources Director (staff #123). She stated that she had not been able to find a personnel record for staff #20 since (MONTH) (YEAR), when she had conducted a full audit of the personnel files. She stated that she informed the Executive Director of the missing personnel file at that time. She stated that she asked members of the facility management team for current documentation of a nursing license, CPR certification, and [MEDICAL CONDITION] testing for staff #20, and she was told by the Assistant Director of Nursing, the Director of Nursing, and other members of management that they were sure these items existed, and they would get her the documents. She stated that she used online verification to confirm the nursing license for staff #20, but she was not able to verify CPR certification or [MEDICAL CONDITION] testing. She stated she was currently in the process of creating a new personnel file for staff #20, and the staff member would not be allowed to return to work until the personnel file was current and complete. Review of the facility's policy for [MEDICAL CONDITION] Screening for Associates revealed that all staff are screened for TB at the time of hire, annually, and when exposed to infected individuals. Staff with a history of a positive reaction to TB skin testing would be required to bring documentation from their private physician or the local health department of their work-up following conversion, or the facility will follow state-specific guidelines.",2020-09-01
464,DESERT COVE NURSING CENTER,35095,1750 WEST FRYE ROAD,CHANDLER,AZ,85224,2019-04-04,947,D,0,1,M6IO11,"Based on personnel record reviews, staff interviews, and policy and procedures, the facility failed to ensure that 2 out of 2 sampled Certified Nursing Assistants (CNA/staff #2 and staff #127) received in-services and training for at least 12 hours per year. The deficient practice failed to ensure the continuing competence of the CNAs. Findings include: -Review of the personnel record for staff #2 revealed a hire date of (MONTH) 1, 2008. Review of the training for staff #2 from (MONTH) (YEAR) through (MONTH) (YEAR), revealed 1 hour of online training completed on (MONTH) 22, (YEAR), for Code of Conduct Refresher. Review of the training for staff #2 from (MONTH) (YEAR) through (MONTH) (YEAR), revealed 1 hour of online training completed on (MONTH) 22, (YEAR), for Code of Conduct Refresher. The staff in-service sign-in sheets for (MONTH) 24, (YEAR) PCC Training, and (MONTH) 6, (YEAR) Clinical revealed the CNA attended but did not include the duration of each in-service. Review of the personnel record for staff #2 revealed no other evidence of training for (MONTH) (YEAR) through (MONTH) (YEAR), or for (MONTH) (YEAR) through (MONTH) (YEAR). -Review of the personnel record for staff #127 revealed a hire date of (MONTH) 15, (YEAR). Review of the training for staff #127 from (MONTH) (YEAR) through (MONTH) 2019, revealed staff #127 attended staff in-service on (MONTH) 24, (YEAR) PCC Training, and on (MONTH) 6, (YEAR) Clinical. The duration of each in-service was not documented. The record included staff #127 received 1 hour of online training on (MONTH) 22, 2019 for Code of Conduct Refresher. The record also included staff #127 attended a staff in-service on Abuse on (MONTH) 21, 2019. The duration of the in-service was not documented. Review of the training for staff #127 from (MONTH) (YEAR) through (MONTH) (YEAR), revealed staff #127 attended staff in-service on (MONTH) 24, (YEAR) and (MONTH) 6, (YEAR). The topic of the (MONTH) in-service was called PCC Training and the (MONTH) in-service was called Clinical. The duration of each in-service was not documented. Review of the personnel record for staff #127 revealed no other evidence of in-service or training from (MONTH) (YEAR) through (MONTH) 2019, or from (MONTH) (YEAR) through (MONTH) (YEAR). An interview was conducted on (MONTH) 4, 2019 at 10:18 a.m., with an anonymous staff member. The staff member stated that staff did not have in-services or meetings for more than a year. The staff member stated that competency check lists had not been done yearly, and that no education had been given to CNAs regarding resident perineal care, infection control, and hand washing for more than a year. The staff member stated that during this time the only training was through online modules. An interview was conducted on (MONTH) 4, 2019 at 11:23 a.m. with the DON (staff #32) and the Interim Executive Director (staff #132). Staff #32 stated that CNAs received orientation and training for skills upon hire. She also stated that staff in-services had been conducted monthly so far in 2019. Staff #132 stated she could not locate any other documentation on training in (YEAR) for the CNAs other than what was provided. She stated that she believed the required training had been done, but she did not have the documentation. Review of the facility's In-service Education policy revealed that all facility staff should be educated upon hire, annually , or as indicated thereafter on the following topics to include but not limited to: communication, residents rights, abuse, neglect, exploitation, procedures for reporting allegations, dementia management, abuse prevention, Elder Justice Act, compliance and ethics, quality assurance and performance improvement, infection control, behavioral health, care of the cognitively impaired, privacy, dignity, and confidentiality. The policy further stated CNA training must be sufficient to ensure continuing competence and be no less than 12 hours per year. In-service hours would be calculated from (MONTH) through December. If training was conducted in a live session, the records should include the following: -Name and title of presenter -Date of presentation -Title of subject presented -Description of content -Signatures of those attending -Any state specified required documentation",2020-09-01
465,"HAVEN OF SANDPOINTE, LLC",35096,2222 SOUTH AVENUE A,YUMA,AZ,85364,2016-09-01,279,D,0,1,OW6I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy review, the facility failed to ensure that a comprehensive care plan included specific interventions related to end stage [MEDICAL CONDITION] and [MEDICAL TREATMENT] for one resident (#256). Findings include: Resident #256 was admitted on (MONTH) 29, (YEAR) and was readmitted on (MONTH) 10, (YEAR), with [DIAGNOSES REDACTED]. The admission physician orders [REDACTED]. A physician visit note dated (MONTH) 11, (YEAR) included the resident had history of [MEDICAL CONDITION] and was on [MEDICAL TREATMENT] three times a week, after a failed kidney transplant. The documentation also included that the resident receives [MEDICATION NAME] (anti-anemic drug) and antibiotics at [MEDICAL TREATMENT]. A physician's orders [REDACTED]. The order also included for [MEDICATION NAME] to be given at [MEDICAL TREATMENT] on [MEDICAL TREATMENT] days. Review of a nutritional care plan dated (MONTH) 11, (YEAR) included that the resident had altered nutritional status, as evidenced by [MEDICAL CONDITION] and [MEDICAL TREATMENT]. However, there were no goals or interventions to address the resident's nutritional needs. Review of the Minimum data Set (MDS) admission assessment dated (MONTH) 17, (YEAR) revealed the resident had an active [DIAGNOSES REDACTED]. A nursing care plan dated (MONTH) 30, (YEAR), identified that the resident was at risk for fluid overload/deficit and electrolyte imbalance related to [MEDICAL TREATMENT]. The goal included that the resident would not have any complications from [MEDICAL TREATMENT] and for immediate interventions should any complications occur from [MEDICAL TREATMENT]. However, the care plan did not include any specific interventions. In an interview with a licensed practical nurse (LPN/staff #35) conducted on (MONTH) 31, (YEAR) at 12:08 p.m., she stated that residents on [MEDICAL TREATMENT] are care planned to include specific interventions regarding [MEDICAL TREATMENT] status and treatment. An interview with the assistant director of nursing (ADON/staff #6) was conducted on (MONTH) 1, (YEAR) at 3:21 p.m. She stated that the comprehensive care plan will be created to include specific interventions related to the resident's [MEDICAL TREATMENT] condition. Staff #6 stated that the comprehensive care plan will include goals and interventions such as; frequency of [MEDICAL TREATMENT], monitoring of bruit and thrill, monitoring of vital signs and other specific physician orders [REDACTED]. Review of a policy on care plans included that the facility's care plan committee/team will develop a comprehensive care plan for each resident. It also stated that This system is directed toward achieving and maintaining optimal resident status, optimal functional outcome as well as quality of life for all residents. The policy also included that The Care Planning Team shall meet as necessary to assure that each resident's care plan includes measurable objectives, goals and time tables to meet the resident's medical, nursing, and psychosocial needs as defined on the resident's assessments. The team will ensure that each problem in the care plan is dated, goals have time frames, and a plan of approach is written.",2020-09-01
466,"HAVEN OF SANDPOINTE, LLC",35096,2222 SOUTH AVENUE A,YUMA,AZ,85364,2016-09-01,281,E,0,1,OW6I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, review of the Arizona State Board of Nursing Rules and policy and procedures, the facility failed to ensure that physician's orders [REDACTED].#256). Findings include: Resident #256 was admitted on (MONTH) 29, (YEAR) and was readmitted on (MONTH) 10, (YEAR), with [DIAGNOSES REDACTED]. Regarding accuchecks: A physician's orders [REDACTED]. Review of the treatment administration records (TAR) and the medication administration records (MAR) for (MONTH) (YEAR) revealed that the above order for accuchecks to be done four times a day was not included. As a result, there was no documentation that the resident's accuchecks were done from (MONTH) 4 through (MONTH) 6. Review of the nurses notes from (MONTH) 4 through (MONTH) 6, (YEAR) revealed no documentation that the accuchecks were done as ordered by the physician. Per the clinical record documentation, the resident was admitted to the hospital on (MONTH) 7, and was readmitted back to the facility on (MONTH) 10. admission orders [REDACTED]. Review of the (MONTH) (YEAR) MAR/TAR revealed that the accucheck order was transcribed onto these records. Further review of the MAR/TAR from (MONTH) 10 through (MONTH) 31, (YEAR) revealed there were multiple times, with no documentation that the resident's blood sugar checks were done. Regarding fluid restriction and daily weights: A physician's admission order dated (MONTH) 10, (YEAR) included for daily weights and to monitor the resident's input and output amounts every shift. A physician's orders [REDACTED]. The per day fluid amounts were ordered as follows: 300 milliliter (ml) total for nursing with 150 ml for day shift, 150 ml for evening shift and 0 ml for night shift; and 1200 ml total for dietary needs with 720 ml for breakfast, 240 ml for lunch and 240 ml for dinner. The above orders were transcribed onto the MAR/TAR, with spaces to document the following treatments: monitoring input and output amounts every shift, daily weights and fluid restriction amounts as ordered above. However, further review of the MAR/TAR from (MONTH) 10 through 31, (YEAR) revealed there were multiple times, with no documentation of the resident's input/output amounts, daily weights and fluid amounts consumed. Review of the nurse's notes from (MONTH) 10 through 31, (YEAR) revealed no documentation of the resident's input/output amounts, daily weights or fluid amounts consumed during the corresponding time frame. Review of the certified nursing assistant (CNA) notes and ADL (Activities of Daily Living) sheets from (MONTH) 10 through 31, (YEAR) revealed that the resident's fluid intake with meals was recorded, however, it did not include the fluid intake between meals. In an interview with a licensed practical nurse (LPN/staff #35) conducted on (MONTH) 31, (YEAR) at 12:08 p.m., she stated that treatments are transcribed into the MAR/TAR. She said weights are taken by restorative nursing (RNA) and they report the weight to the nurse, who will record it in the TAR. She stated that blood glucose checks should be followed as ordered by the physician and documented in the MAR. Further, she stated that if there are boxes in the MAR/TAR that are blank and not initialed by the nurse and there is no documentation in the nurse's notes, then this indicates that the task was not done. At this time, staff #35 reviewed the MAR/TAR from (MONTH) 10 through (MONTH) 31, (YEAR) and confirmed that the input/output amounts, fluid amounts and weights were not consistently documented. Staff #35 stated that the boxes with no entries or initials indicate that it was not done. An interview with a RNA (staff #110) was conducted on (MONTH) 1, (YEAR) at 10:27 a.m. She stated that residents are weighed on admission, weekly for four weeks, and then monthly. During this interview, RNA (staff #143) was also present and stated that when there are orders for daily weights, the floor nurse will inform her, and resident's weight will be taken daily as ordered. Staff #143 stated that the daily weights will be recorded on her weight sheet and she will report it to the nurse, who will then document it in the MAR/TAR. She stated that daily weights sheets are not maintained and are disposed of after the weight has been reported to the nurse. An interview with the assistant director of nursing (ADON/staff #6) was conducted on (MONTH) 1, (YEAR) at 11:11 a.m. She stated that daily weights are taken by the CNAs and the monthly weights are taken by RNA, and then recorded in the MAR indicated [REDACTED]. She stated that this can also be documented on the CNA and ADL sheets. She stated that blood glucose monitoring is done by the floor nurses depending on the time of the glucose check. She stated that when nothing is written on the MAR/TAR, the order was not done by staff. After reviewing the clinical record with staff #6 on (MONTH) 1, (YEAR) at 1:05 p.m., she confirmed that there is no documentation that the order for the accuchecks was ever transcribed onto the MAR/TAR, or that the accuchecks were consistently done as ordered. She further stated that there is no documentation to show that daily weights and input/output amounts were done as ordered by the physician. A policy on General Dose Preparation and Medication Administration included that staff should document necessary medication and treatment information. According to the Rules of the Arizona State Board of Nursing included that a registered nurse and/or LPN administers prescribed aspects of care including treatment, therapies and medications.",2020-09-01
467,"HAVEN OF SANDPOINTE, LLC",35096,2222 SOUTH AVENUE A,YUMA,AZ,85364,2016-09-01,282,D,0,1,OW6I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, and policy review, the facility failed to ensure that a fall care plan intervention was implemented for one resident (#240). Findings include: Resident #240 was admitted to the facility on (MONTH) 30, (YEAR), with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 5, (YEAR), revealed the resident had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had severe cognitive impairment. Review of the functional status section revealed the resident was either independent or required limited assistance with activities of daily living (ADL). Section [NAME] of the MDS included the resident did not have a fall within 30 days or within 2-6 months of admission and that the resident had not had any falls since admission. Review of the Care Area Assessment (CAA) revealed falls triggered for inclusion on the care plan, due to unsteadiness with various movements and transfers and due to receiving antianxiety medications. A fall risk care plan included the resident had a history of [REDACTED]. The care plan also indicated the resident lost his balance and fell on (MONTH) 13, (YEAR), while self transferring. Interventions included to have the call bell pinned to his gown when in bed and to have commonly used articles, within easy reach. A progress note dated (MONTH) 18, (YEAR) indicated the resident was found on floor at approximately 8 p.m. in the bathroom. The note indicated the resident stated he was transferring to his wheelchair from the toilet and fell . Nursing progress notes dated (MONTH) 19, 20, 21, and 27, all indicated the resident's call light was within reach. A progress note dated (MONTH) 30, (YEAR) included the resident was found on floor by the nurse at 7 a.m. The note further indicated the resident told the RN that his call light was on the ground and that he leaned over while sitting on the edge of the bed to pick it up and fell forward. Further review of the fall risk care plan revealed the intervention to have the call bell pinned to the resident's gown was crossed off, and another intervention was hand written in. The new intervention was to have the call bell within reach. This intervention was not dated, as to indicate when it was first implemented. During an observation on (MONTH) 30, (YEAR) at 1:10 p.m., the resident was observed to be sitting on the side of his bed eating lunch, and his call light was draped over the bed side table, with the push button end hanging on the side farthest away from the resident and it was not within reach. In an interview conducted with a Certified Nursing Assistant (CNA/staff #84) on (MONTH) 31, (YEAR) at 1:14 p.m., the CNA stated the resident should have the call light within reach at all times. An observation was conducted on (MONTH) 31, (YEAR) at 2:20 p.m., of the resident asleep in bed and the call light was hanging over the bed approximately 4 inches from the floor. In an interview conducted on (MONTH) 31, (YEAR) at 2:37 p.m., a RN (registered nurse/staff #109) stated that she walked into the room of resident #240 yesterday, and his call light was on the floor. Another observation was conducted during the environmental tour on (MONTH) 1, (YEAR) at 8:30 a.m., with the Director of Maintenance (staff #61) and the Housekeeping Manager (staff #29) of the resident's call light. At this time, the resident's call light did not have a clip in place to attach the call light cord to the bed. The Director stated that all call lights are suppose to have a clip and that this issue had not been reported to him. Review of the policy titled, Answering the Call light revealed the purpose is to provide a sense of security to the resident. The policy further indicated to ensure that the resident's call light is within easy reach of the resident. In addition, the policy included that the call light is a safety device and a means for the resident to summon assistance. Staff should report all defective call lights to the staff/charge nurse promptly. Review of a policy on care plans included that the facility's care plan committee/team will develop a comprehensive care plan for each resident. It also stated that This system is directed toward achieving and maintaining optimal resident status, optimal functional outcome as well as quality of life for all residents.",2020-09-01
468,"HAVEN OF SANDPOINTE, LLC",35096,2222 SOUTH AVENUE A,YUMA,AZ,85364,2016-09-01,315,D,0,1,OW6I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, staff interviews and policy review, the facility failed to ensure that catheter care was provided for two residents (#266 and #96). Findings include: -Resident #266 was admitted on (MONTH) 30, (YEAR), with a [DIAGNOSES REDACTED]. Review of the admission nursing notes dated (MONTH) 30, (YEAR) revealed the resident had an indwelling urinary catheter. A nursing note dated (MONTH) 3, (YEAR) also included that the resident had a catheter in place. A physician's orders [REDACTED]. The Minimum Data Set (MDS) admission assessment dated (MONTH) 5, (YEAR) included a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. It also included that the resident had an indwelling catheter. Nursing progress notes dated (MONTH) 12 and (MONTH) 14, (YEAR) continued to document that the resident had a catheter in place. Review of a care plan dated (MONTH) 22, (YEAR) revealed the resident was at risk for infection and/or trauma related to the use of urinary catheter, due to retention. One of the interventions was to provide catheter care every shift. During an observation conducted on (MONTH) 30, (YEAR) at 1:39 p.m., the resident was observed with a urinary catheter in place. Review of the treatment administration record (TAR) from (MONTH) 5, (YEAR) through (MONTH) 31, (YEAR), revealed the order to provide catheter care every shift. However, the documentation showed that on multiple shifts, catheter care was not consistently done as ordered by the physician. An interview with the Assistant Director of Nursing (ADON/staff #6) was conducted on (MONTH) 1, (YEAR) at 1:05 p.m. After reviewing the TAR, staff #6 acknowledged that catheter care every shift was not consistently done as ordered, as staff initials were missing. -Resident #96 was admitted on (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. A nursing note dated (MONTH) 27, (YEAR) included that the resident had a catheter in place. Review of the physician's admission orders [REDACTED]. However, the admission orders [REDACTED]. During an observation conducted on (MONTH) 1, (YEAR) at 1:58 p.m., resident #96 was in her room lying in bed. The resident was observed with an indwelling urinary catheter in place. Review of the clinical record including the TARs revealed there was no documentation that catheter care was provided to the resident since admission. In an interview with a registered nurse (RN/staff #106) conducted on (MONTH) 1, (YEAR) at 10:08 a.m., she stated that catheter care every shift is a standing order for any resident with a catheter, and that catheter care is to be documented on the TAR. An interview with staff #6 was conducted on (MONTH) 1, (YEAR) at 11:11 a.m. She stated that nurses are expected to follow the order for catheter care every shift and document it in the TAR. She stated that when there are no entries in the TAR, it indicates that catheter care was not done. She also stated that if care was not done especially for consecutive days, the oncoming nurse should catch this and report the incident to her or to the Director of Nursing. During a later interview at 1:05 p.m. after reviewing the TAR, staff #6 acknowledged that catheter care every shift was not consistently done, per their protocol. According to a facility policy on Catheter Care, the primary purpose for giving daily urinary catheter care is to prevent infection. The policy stated that catheter care will be given every shift and that upon completion of catheter care, the caregiver should record that catheter care was done, including the time/shift and to record it on the TAR.",2020-09-01
469,"HAVEN OF SANDPOINTE, LLC",35096,2222 SOUTH AVENUE A,YUMA,AZ,85364,2016-09-01,318,D,0,1,OW6I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to ensure that one resident (#26) with contractures received the physician ordered therapy evaluations. Findings include: Resident #26 was admitted to the facility on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. Review of a physician's history and physical evaluation dated (MONTH) 18, (YEAR) revealed the resident had contractures. A physical therapy evaluation dated (MONTH) 27, (YEAR), identified that the resident had impaired range of motion on the right and left lower extremities, due to bilateral hamstring and gastroc/soleus contractures. Further, the evaluation included that the resident was not a candidate for skilled therapy, secondary to no change in functional condition. A care plan included the resident had mobility deficits related to weakness, impaired balance, and decreased strength. An intervention was to reassess quarterly and as needed. A social services progress note dated (MONTH) 1, (YEAR) included that the resident's family requested a therapy evaluation and that a RN (registered nurse) faxed a request to the doctor. A physician's orders [REDACTED]. However, review of the clinical record revealed there was no documentation that the PT/OT evaluations were completed. An interview was conducted on (MONTH) 30, (YEAR) at 11:59 a.m., with a Licensed Practical Nurse (LPN/staff #35). She stated that the resident does have lower extremity contractures and does not receive range of motion services or therapy. In an interview with the therapy department director (staff #121) on (MONTH) 31, (YEAR) at 1:51 p.m., she stated that the therapy department was unaware of the order from (MONTH) and did not perform any therapy evaluations at that time. She stated if nursing receives an order for [REDACTED]. In an interview with a Licensed Practical Nurse (LPN/staff #35) on (MONTH) 1, 1016 at 11:25 a.m., she stated that if an order for [REDACTED]. In an interview with the Director of Nursing (DON/staff #81) on (MONTH) 1, (YEAR) at 11:59 a.m., she stated that orders are reviewed each morning during the morning meeting, which is attended by administrative staff and department heads, including therapy. She stated that the order for therapy must have been missed.",2020-09-01
470,"HAVEN OF SANDPOINTE, LLC",35096,2222 SOUTH AVENUE A,YUMA,AZ,85364,2016-09-01,356,E,0,1,OW6I11,"Based on observations, staff interviews, and review of facility documents, the facility failed to post the daily nurse staffing data information for three days and failed to retain the nurse staffing data records for at least 18 months. Findings include: During an observation on (MONTH) 29, (YEAR) at 11:15 a.m., the posting of the daily nurse staffing data information was unable to be located. Additional observations were conducted throughout the facility on (MONTH) 30 and 31, (YEAR). Again, the posting of the daily nurse staffing data information was unable to be located. In an interview with the Administrator (staff #90) on (MONTH) 31, (YEAR) at 8:15 a.m., the Administrator stated the nurse staffing data is posted at the central station, however it was not posted previously. On (MONTH) 31, (YEAR) at 9:25 a.m., an interview was conducted with the scheduler (staff #52). Staff #52 stated that she took over the job of completing the postings approximately 1 year ago and was told to completed the sheets and post it daily, but was not trained to retain the records. She stated that each day when she posts the new sheet, she shreds the record from the previous day. She also stated the weekend hours are calculated on Friday, but no one has ever been assigned to post the sheets on the weekends. A copy of their policy regarding posting the daily nurse staffing data was requested, however, the Director of Nursing reported that they did not have one.",2020-09-01
471,"HAVEN OF SANDPOINTE, LLC",35096,2222 SOUTH AVENUE A,YUMA,AZ,85364,2016-09-01,371,D,0,1,OW6I11,"Based on observation, staff interviews, facility documentation and policy review, the facility failed to ensure that an outdated food item was not available for use. Findings include: During the initial kitchen tour conducted with the dietary manager (staff #8) on (MONTH) 29, (YEAR) at 11:00 a.m., there was one 13 ounce bottle of nutmeg which was located in the dry storage area, with an open date of (MONTH) 19, (YEAR) and a use by date of (MONTH) 19, (YEAR). This bottle was among multiple other bottles of spices and condiments. An interview with staff #8 was conducted immediately following the observation and she stated that the bottle of nutmeg should have been discarded, because it was past the 6 months storage time from the open date. In an interview with the Dietary Consultant conducted on (MONTH) 1, (YEAR) at 11:35 a.m., she stated that the facility follows a reference guide to determine the storage time for food and/or food products. A review of the Refrigerated Storage Quick Reference Guide was conducted with the Dietary consultant and she stated that the bottle of nutmeg falls under the category of ground spices, which has a storage time of 6 months for an opened or an unopened bottle. A policy on Food Storage included that any expired or outdated food products should be discarded.",2020-09-01
472,"HAVEN OF SANDPOINTE, LLC",35096,2222 SOUTH AVENUE A,YUMA,AZ,85364,2016-09-01,431,D,0,1,OW6I11,"Based on observation and staff interview, the facility failed to ensure that outdated laboratory tubes were not available for resident use. Findings include: During a medication storage room observation conducted with the assistant director of nursing (ADON/staff #6) on (MONTH) 29, (YEAR) at 12:15 p.m., there were seven green top laboratory specimen tubes, with expiration date of (MONTH) (YEAR). An interview was conducted with staff #6 immediately following the observation. Staff #6 stated that the laboratory technicians are doing their blood draws, however, in emergencies, the nurses on the floor do the blood draws and this is why the medication storage room has laboratory specimen tubes. She stated that the laboratory technicians are responsible for providing the laboratory tubes and for the disposal of expired laboratory specimen tubes. She stated that the seven green top laboratory tubes were expired and should have been disposed of by the laboratory technician who was just recently in the facility and that these tubes were missed.",2020-09-01
473,"HAVEN OF SANDPOINTE, LLC",35096,2222 SOUTH AVENUE A,YUMA,AZ,85364,2016-09-01,441,E,0,1,OW6I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and policy and procedures, the facility failed to ensure that contact precautions were implemented for one resident (#35) and failed to ensure that staff followed proper infection control procedures. Findings include: -Resident #35 was admitted on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. The physician admission orders [REDACTED]. Review of a care plan dated (MONTH) 10, (YEAR) revealed the resident was receiving IV therapy due to a UTI. Interventions included IV medications as ordered. A review of the nursing admission notes dated (MONTH) 10, (YEAR) included that the resident had ESBL infection and was on IV antibiotics and contact precautions. A physician's order dated (MONTH) 22, (YEAR) included for a urinalysis and culture. Review of the urine culture report dated (MONTH) 25, (YEAR) revealed it was positive for [MEDICATION NAME] Resistant [MEDICATION NAME] (VRE). According to the isolation skilled charting from (MONTH) 17 through (MONTH) 26, (YEAR), the resident had an active infection in the urine and required contact isolation. A physician's order dated (MONTH) 28, (YEAR) included for linezolid (antibiotic) 600 mg by mouth every 12 hours for 10 days for VRE/UTI. Review of the isolation skilled charting from (MONTH) 28, and (MONTH) 29, revealed the resident had an active infection in the urine with VRE and required contact isolation. During an observation conducted on (MONTH) 29, (YEAR) at 12:50 p.m., there was an isolation cart outside of resident #35's. This cart contained gloves, gowns and masks. Prior to entering the room, a certified nursing assistant (CNA/staff #77) was observed to apply a gown and gloves and then entered the room carrying a meal tray. Staff #77 was then observed to serve the tray to the resident, removed the gown and gloves and disposed of them in the bin located inside the resident's room. She then went into the bathroom which was inside of the resident's room and washed her hands. Before she exited the room, resident #35 asked for a cup of coffee. Staff #77 left the room and went to the kitchen. Staff #77 came back at 12:55 p.m. with a cup of coffee. She was observed to don gloves, but she did not apply a gown, before entering the room. She then entered the room and went behind the resident's privacy curtain and gave the resident the cup of coffee. Staff #77 then removed the gloves, washed her hands and exited the room. An interview with staff #77 was conducted at 1:00 p.m. immediately after the observation. She stated that anyone who enters this room must wear a gown and gloves. She stated the resident has ESBL in the urine, and this is the reason for the precautions. She said that she did not wear a gown the second time she entered the resident's room, because she did not have any contact with the resident's fluids, such as urine or saliva. She stated that she kept a good distance from the resident and did not touch the resident while she was inside the room. However, she further stated that anyone who enters the resident's room must wear a gown and gloves, even if it is only for an interview because of the potential for contact with the resident's fluids. In an interview with the assistant director of nursing (ADON/staff #6) conducted on (MONTH) 29, (YEAR) at 1:05 p.m., she stated that all persons entering the resident's room must wear a gown and gloves at all times. She stated that staff #77 should have worn a gown and gloves when she entered the room the second time. A review of the facility's policy on Isolation revealed that isolation precautions shall remain in effect until discontinued by the physician. It also included that contact precautions are considered for VRE and the use of gowns and gloves are recommended for anyone in direct contact with any resident that has an infection that requires contact precautions. Another facility policy regarding VRE included that Isolation precautions (e.g. contact precautions) should be implemented according to the type of VRE infection or colonization. Gloves should be worn when providing cares that involved personal contact or contact with items that may be contaminated by VRE. Gowns should be worn if the caregiver's clothing is likely to have substantial contact with a VRE-positive resident. -On (MONTH) 29, (YEAR) at 11:10 a.m., a CNA (staff #95) was observed in a resident room, who was on contact precautions for scabies. Staff #95 had on a gown and gloves. Staff #95 was observed to remove his gloves and gown, then partially exit the room to obtain another glove from the isolation cart outside the room, and then re-entered the room. Staff #95 used the glove like a hot pad and picked up the resident's coffee cup by the handle. He then exited the room, went down two halls and used a keypad to enter the kitchen area. He then handed the coffee cup to a dietary worker (staff #33). Staff #33 took the coffee cup, continuing to use the glove like a hot pad on the cups handle. Staff #33 refilled the coffee cup, placed a lid on it and returned the cup to staff #95. Staff #95 then walked back to the resident's room and set the cup on the isolation cart outside the room, while he donned a gown and gloves. He then picked up the cup and entered the resident's room and placed the coffee cup on the resident's bedside table. He then removed his gown and gloves and exited the room. After staff #95 exited the room, he stopped at the isolation cart to return a box of gloves to a drawer in the isolation cart and then entered the resident's room next door. At no time did staff #95 wash or sanitize his hands during this observation. An interview was conducted with staff #6 (ADON) on (MONTH) 30, (YEAR) at 11:56 a.m. The ADON stated if a resident is in isolation for scabies, then the resident is on contact precautions. She stated that a gown and gloves are required for anyone going in or out of the room. She further stated that staff must wash their hands before exiting the room. Another observation was conducted on (MONTH) 30, (YEAR) at 12:18 p.m. A CNA (staff #114) was observed in this same resident's room who was in isolation for scabies. Staff #114 had a gown and gloves on. Staff #114 was observed removing the gown and gloves and then left the room to retrieve a single glove from the box which was on top of the isolation cart, outside of the room. Staff #114 then re-entered the isolation room without donning a gown or gloves and used the glove like a hot pad to pick up the resident's large water mug. She then exited the isolation room, went through two hallways to the key pad door outside of the kitchen area. She then went into an ante area, which has a small bathroom and an ice machine. Staff #114 went into the bathroom and emptied the contents of the resident's water mug into the sink, then went to the ice machine and opened the machine. She then picked up a large ice scoop and placed several scoops of ice in the mug. During this process, the ice scoop was observed to touch the mouth of the mug several times and then she replaced the ice scoop to its container. Staff #114 then took a wall mounted water dispensing hose and filled the mug with water. The dispenser end was observed to touch the mug, as she tapped off the water drops. Staff #114 returned to the resident's room, set the water mug down on the isolation cart outside the room, while she donned a gown and gloves, entered the room and returned the mug to the resident. She then removed the gown and gloves but just prior to exiting, she was called back by the resident. Staff #114 put on a fresh glove and pushed backed the curtain at the request of the resident and then exited the room. Upon exiting, she then entered the resident's room next door, opened the bathroom door and washed her hands in that bathroom. Staff #114 was not observed to wash her hands, prior to exiting the resident's room who had scabies. In an interview conducted with staff #114 on (MONTH) 30, (YEAR) at 12:23 p.m., she stated that she was supposed to wash her hands before exiting the room. She also said that she had not been taught any specific way to refill the resident's mug with ice and water, so she thought this was the best way to get it filled without touching it. An interview was conducted with the Director of Nursing (DON/staff #81) on (MONTH) 30, (YEAR) at 1:05 p.m. The DON stated that if staff are going into a contact isolation room they should wear a gown and gloves. She further stated that prior to leaving the room, hands should be sanitized immediately upon exiting. She stated that what occurred today and yesterday, is not the expectation and that the staff have been trained in infection control practices. In an interview conducted with dietary staff (staff #33) on (MONTH) 31, (YEAR) at 8:20 a.m., staff #33 stated that the CNAs bring cups to the kitchen to be refilled often. He stated that we are not supposed to refill them, but instead they are to be placed in with the dirty dishes, per the policy. He also stated that he had refilled the cup on Monday (August 29) and knew he shouldn't have done that. During an interview conducted with staff #95 on (MONTH) 31, (YEAR) at 9:59 a.m., he stated that he should not have taken the cup to the kitchen with the glove and then brought it back. He said that should not have been done because of cross contamination. He further stated the process should be to remove the gown and gloves and sanitize or wash hands immediately when finished and exit the room. Review of the facility policy regarding Isolation revealed that contact precautions were to be used for scabies. The policy indicated that hands must be washed after touching the resident or potentially contaminated articles and before taking care of another patient. The policy also included that articles contaminated with infective materials should be discarded or bagged and labeled before being sent for decontamination. Review of the facility policy titled, Isolation Trays indicated that the Dietary Department is responsible for instituting dietary infection control precautions to prevent the transmission of infection. The policy included that water pitchers from rooms of residents in isolation should not be refilled in the kitchen, but a separate container should be brought to the patient's bedside. According to the Dish and Utensil Procedure, the resident's reusable water pitcher must be washed and sanitized per community policy and air dried before refilling with water. Review of the policy for Scabies revealed that the purpose is to prevent the transmission of infections to others. The policy further indicated hand washing is the best technique for protection of oneself and others.",2020-09-01
474,"HAVEN OF SANDPOINTE, LLC",35096,2222 SOUTH AVENUE A,YUMA,AZ,85364,2016-09-01,520,E,0,1,OW6I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the QA (Quality Assurance) documentation and staff interview, the facility failed to ensure that the QA committee identified issues and developed appropriate plans of action to correct identified quality concerns. Findings include: During the survey concerns were identified related to a lack of documentation on the MAR/TAR (Medication and Treatment Records) regarding the implementation of physician ordered treatments, a lack of implementing proper infection control practices regarding isolation rooms, the daily posting of the nurse staffing data information, and expired lab tubes. Review of the QA documentation revealed that the facility had identified concerns on (MONTH) 28, (YEAR), regarding medications not being signed off as given on the MAR. Their plan of correction included the DON or designee to review 10 resident's MARs weekly to ensure medications were administered as ordered and documented on the MAR as given. However, their QA documentation did not address any concerns related to the lack of documentation on the MAR/TAR regarding physician ordered treatments, such as accuchecks, intake and output amounts and daily weights. Further review of their QA documentation revealed that the facility had identified a concern regarding expired lab tubes. The facility completed medication room audits for expired medications and supplies for May, June, (MONTH) and (MONTH) (YEAR). The documentation included that lab tubes were removed from stock in the month they expired. Despite this, during the survey multiple lab tubes were found to be expired. An interview was conducted on (MONTH) 1, (YEAR) at 5:06 p.m., with the Director of Nursing (DON/staff #81), the Administrator (staff #90), and CEO (staff #156). They stated that they had not identified issues regarding infection control with isolation rooms or concerns regarding the daily posting of the nurse staffing data information. They stated that they had identified following physician's orders [REDACTED]. The CEO further stated that expired medications which included lab tubes had been in QA since the last survey and that monthly audits of the medication rooms were being conducted.",2020-09-01
475,"HAVEN OF SANDPOINTE, LLC",35096,2222 SOUTH AVENUE A,YUMA,AZ,85364,2017-09-14,157,D,1,1,ZEOT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interview, and policy review, the facility failed to ensure that one resident's (#197) responsible party was notified of the resident's falls. Findings include: Resident #197 was admitted (MONTH) 7, (YEAR) with [DIAGNOSES REDACTED]. Review of the admission MDS (Minimum Data Set) assessment dated (MONTH) 21, (YEAR), revealed the resident had a BIMS (brief interview for mental status) score of 9 out of 15, which indicated the resident had moderate cognitive impairment. The resident was further assessed to require extensive assistance of 1-2 staff for all activities of daily living (ADLs). The MDS also included that the resident had no falls since admission. Review of the nursing notes dated (MONTH) 5, (YEAR), revealed the resident had an unwitnessed fall in his room. The nurse's note also included the resident was found sitting on the floor, with his body leaning on the side of the bed with no apparent injuries. According to the fall investigation report dated (MONTH) 5, (YEAR), the resident had a fall with no injuries. The investigation did not include documentation that the resident's responsible party/Medical Power of Attorney (MPOA) was notified of the fall. Review of the clinical record revealed no documentation of any attempts to notify the resident's responsible party/MPOA of the fall. Review of another fall investigation report dated (MONTH) 21, (YEAR), revealed the resident was found on the floor in his room by a staff member with no apparent injuries. Further review of the investigation report revealed no documentation that the resident's responsible party/MPOA was notified of the fall. An interview was conducted with the Director of Nursing (DON/staff #17) (MONTH) 14, (YEAR) at 8:33 a.m. The DON stated that the nursing staff was expected to notify the responsible party/MPOA whenever a resident experienced a fall. The DON stated that nursing staff should have notified the responsible party/MPOA when resident #197 fell , and that it should have been documented in the medical record. The policy Change in a Resident's Condition included to promptly notify the resident/representative of changes in the resident's medical/mental condition and or status (e.g., a change in the level of care). The policy further included that except in a medical emergency, notification should be made within 24 hours of a change occurring in the resident's medical/mental condition or status.",2020-09-01
476,"HAVEN OF SANDPOINTE, LLC",35096,2222 SOUTH AVENUE A,YUMA,AZ,85364,2017-09-14,164,E,0,1,ZEOT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of policy, the facility failed to ensure confidential medical information and photographs for multiple residents were not communicated to a physician via staff's personal cell phone. Findings include: During an interview with a Registered Nurse (RN/staff #92) conducted on (MONTH) 11, (YEAR) at 12:45 p.m., staff #92 stated she had communicated the information and photographs of a resident's possible scabies bites to the physician over her personal cell phone. Staff #92 further stated that she always communicates information and photos to the physician as needed over her personal cell phone. This staff member stated she was not aware of what the policy was regarding the use of personal cell phones for this type of communication. Observation of the text message section of the personal cell phone belonging to staff #92 revealed text message with the first initial and last name of a current resident with a new [DIAGNOSES REDACTED]. In addition, at least 8 other text messages remained on the personal cell phone of staff #92 that dated back to (MONTH) 19, (YEAR). The text messages each included the first initial and last name of multiple residents, one text message included the date of birth, and another included a photograph that contained a resident's full name, date of birth, and all completed lab results. During an interview with the Corporate Chief Nursing Officer (CNO/staff #161) conducted (MONTH) 14, (YEAR) at 12:44 p.m., the CNO stated that no personal cell phones are to be used during work hours. The CNO further stated that personal cell phones are not to be used to transmit any resident information. The CNO stated the facility had the ability to do secured conversations with the physicians in the electronic health record program. The Confidentiality Policy included that all sensitive information must be regarded confidential. The policy further included that each resident is assured confidential treatment of [REDACTED]. The policy also included that confidential information included information regulated by HIPAA, resident information, resident's financial information, doctor's orders, and nursing care.",2020-09-01
477,"HAVEN OF SANDPOINTE, LLC",35096,2222 SOUTH AVENUE A,YUMA,AZ,85364,2017-09-14,309,E,0,1,ZEOT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#25) was assessed pre and post [MEDICAL TREATMENT]. Findings include: Resident #25 was readmitted (MONTH) 18, (YEAR) with a [DIAGNOSES REDACTED]. A physician's orders [REDACTED].>A MDS (Minimum Data Set) Quarterly assessment dated (MONTH) 1, (YEAR) revealed the resident was coded for [MEDICAL TREATMENT]. Review of the care plan dated (MONTH) 5, (YEAR) revealed the resident was at risk for fluid overload/deficit, electrolyte imbalance, weight gain, and mental confusion related to End Stage [MEDICAL CONDITION] and [MEDICAL TREATMENT]. A review of the clinical record revealed both pre and post [MEDICAL TREATMENT] assessments were inconsistently documented in the clinical record for the months of July, August, and (MONTH) (YEAR). There was no documentation of pre [MEDICAL TREATMENT] assessments for (MONTH) 25 & 27, August, 8,10,15,17, 24, 29, and 31, and (MONTH) 2, 7, and 9. There was no documentation of post [MEDICAL TREATMENT] assessments for (MONTH) 29, (MONTH) 5, 8, and 19, and (MONTH) 2, 7, and 9. An interview was conducted on (MONTH) 14, (YEAR) at 11:00 a.m. with an LPN (License Practical Nurse/staff #130). She stated the pre [MEDICAL TREATMENT] assessment consisted of taking a set of vital signs and documenting them in a vital signs record but they would not be documented in the resident's clinical record unless they were abnormal. She further stated that no other information is communicated to the [MEDICAL TREATMENT] center unless there were abnormal findings. Staff #130 stated that staff communicates with the [MEDICAL TREATMENT] center via faxed medical reports and the reports are documented in a [MEDICAL TREATMENT] folder. She further stated that the [MEDICAL TREATMENT] book went missing (MONTH) (YEAR) and that the assessments were not always being documented. An interview was conducted with the DON (Director of Nursing/staff #17) on (MONTH) 14, (YEAR) at 11:29 a.m. He stated that the pre [MEDICAL TREATMENT] assessment consists of obtaining a current set of vital signs and that no additional assessment was required. An interview was conducted with the ADON (Assistant Director of Nursing/staff #93) on (MONTH) 14, (YEAR) at 2:49 p.m. She stated the reason the pre and post [MEDICAL TREATMENT] assessments could not be located is because they had not been completed. She further stated the nurses are required to document their pre and post [MEDICAL TREATMENT] assessments. A review of the [MEDICAL TREATMENT] policy included that residents would be assessed pre and post [MEDICAL TREATMENT]. The policy further included assessments should include status of vascular access including signs of infection and patency. It also included that nursing staff shall maintain communication with the [MEDICAL TREATMENT] center pre and post [MEDICAL TREATMENT] and should include vital signs, weight, medications, lab results, changes noted pre and post [MEDICAL TREATMENT], and meal intakes.",2020-09-01
478,"HAVEN OF SANDPOINTE, LLC",35096,2222 SOUTH AVENUE A,YUMA,AZ,85364,2017-09-14,312,E,0,1,ZEOT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, resident, family, and staff interviews, and facility documentation, the facility failed to ensure one resident (#190) received showers consistently. Findings include: Resident #190 was admitted (MONTH) 3, (YEAR), with [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set) assessment dated (MONTH) 10, (YEAR), revealed the resident's BIMS (brief interview for mental status) score was 12 which indicated the resident had moderate cognitive impairment. The MDS also included the resident required assistance with bathing. Review of the shower schedule for resident #190 revealed the resident was to receive a shower every Monday, Wednesday, and Friday during the evening shift. Review of the shower documentation revealed there was no documentation that the resident received a shower from (MONTH) 3-12, (YEAR). Also, there was no documentation that the resident refused any showers. An interview with resident #190 was conducted on (MONTH) 12, (YEAR) at 10:59 a.m. The resident stated he is not able to choose how many times each week he takes a shower. The resident stated that he has not refused any showers. He further stated there is a shower schedule, but they are not giving him showers and he has not had one since he arrived. In an interview conducted on (MONTH) 12, (YEAR) at 10:59 a.m. with the resident's family member, the family member stated the resident has been here for 10 days and has not had a shower, but has one scheduled for (MONTH) 13. The family member stated he was told by staff that the resident could not have a shower, because he didn't have clean clothes to put on, but that there are clothes in the closet with his name on them. Further review of the shower documentation revealed the resident did receive a shower on (MONTH) 13, (YEAR) at 8:23 p.m. During an interview conducted with a Certified Nursing Assistant (CNA/staff #75) (MONTH) 14, (YEAR) at 8:45 a.m., staff #75 stated that residents are showered according to the schedule posted. Staff #75 stated when a resident has a shower it is documented in the computer. Staff #75 further stated that if a resident refuses a shower or if there are any problems, it is written on the shower sheet and given to the nurse to review and sign before giving it to the Assistant Director of Nursing (ADON). In an interview with the ADON (staff #156) on (MONTH) 14, (YEAR) at 1:13 p.m., the ADON stated she did not have any documentation that resident #190 had a shower (except for (MONTH) 13) or had refused a shower since admission.",2020-09-01
479,"HAVEN OF SANDPOINTE, LLC",35096,2222 SOUTH AVENUE A,YUMA,AZ,85364,2017-09-14,323,E,1,1,ZEOT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, facility investigative documentation, observations, resident and staff interviews, and policy and procedure, the facility failed to ensure the drop from the sidewalk to the ground was sufficient to prevent one resident's (#7) wheelchair from tipping and causing a fall with injury, failed to provide 1:1 monitoring for a high risk fall resident (#169), and failed to ensure that proper wheelchair positioning was implemented for one resident (#52). Findings include: Resident #7 was admitted (MONTH) 24, 2013, with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set assessment dated (MONTH) 24, (YEAR), revealed the resident's Brief Interview for Mental Status (BIMS) score was 7, indicating a severely impaired cognitive status. Review of the nurses notes dated (MONTH) 4, (YEAR), revealed the resident fell while wheeling herself in the wheelchair outside. The note also revealed the resident fell out of the wheelchair onto the grass and hit her head. The note further revealed the fall was witnessed by a certified nursing assistant, who reported it to the nurse. A review of the nurses notes dated (MONTH) 5, (YEAR), revealed the resident was hospitalized for [REDACTED]. Review of the facility's Reportable Event Record/Report dated (MONTH) 6, (YEAR), revealed a narrative that included Resident wheeling herself out front door as is her custom every day. W/C (wheelchair) apparently has a wheel go off sidewalk into grass. W/C tipped over. Resident was assessed with [REDACTED]. Next day, (MONTH) 5, (YEAR), she complained of pain. Sent to hospital for x-ray. Conclusion of fracture to L (left) arm . A review of the quarterly MDS assessment dated (MONTH) 14, (YEAR), revealed a BIMS score of 6, indicating a severely impaired cognitive status. During an observation conducted at 12:10 p.m. (MONTH) 11, (YEAR), the sidewalk was observed to the right when exiting the front lobby area, the sidewalk borders the driveway. The non-parking lot/driveway side of the sidewalk includes an area covered in rocks, approximately two feet by three feet in size, between the sidewalk and the front of the facility with a drop of approximately one to two inches to the area covered in rocks. To the right beyond the rock covered area, the space between the front of the facility and the sidewalk was covered in grass, with two benches sitting under areas shaded by two trees, approximately 6 to 8 feet from the sidewalk. The area of the sidewalk closest to the bench but farthest from the front door, was observed to have approximately a three inch drop from the sidewalk to the grass/ground. Multiple residents were observed sitting outside in front of the facility. During an interview conducted at 11:02 a.m. on (MONTH) 13, (YEAR), the receptionist (staff #11) stated the resident goes outside and sits outside the front door most days in the afternoon. She also stated that from the front desk residents cannot be seen if they move onto the sidewalk to the right side of the front door, or over to the grass by the benches under the trees. During an observations conducted at 11:30 a.m. on (MONTH) 13, (YEAR) with the Maintenance Director (staff #4), the sidewalk to the right of the front entrance, when exiting the facility, was observed to have the same drop from the sidewalk to the ground, as described above. One resident in a wheelchair was observed sitting in the wheelchair in the grass, off the sidewalk in the area to the right of the front door. The Maintenance Director stated that staff regularly checks on the residents who commonly sit in front of the facility. He stated that occasionally he had to help residents who were sitting in their wheelchairs in the grass to push their wheelchairs back up onto the sidewalk. He also stated that he was not informed that in (MONTH) of last year (prior to his employment in the facility) that a resident whose wheelchair had a wheel go off the sidewalk into the grass, had tipped over and fell resulted in the resident sustaining a broken arm. He further stated that after reviewing the Maintenance Work Orders for (MONTH) and (MONTH) (YEAR), he found no evidence of any requests for an assessment of the area for safety concerns. During an interview conducted at 1:15 p.m. on (MONTH) 13, (YEAR), the administrator stated he was unable to find any further facility documentation identifying any investigation completed by the former administrator identifying the role the drop from the sidewalk to the grass may have contributed to the resident's fall on (MONTH) 4, (YEAR). During an interview conducted at 1:22 p.m. on (MONTH) 13, (YEAR), the resident stated she had no recollection of having fallen outside or breaking her arm last year (2016). -Resident #169 was admitted on (MONTH) 7, (YEAR) with [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment dated (MONTH) 14, (YEAR) included the resident had a Brief Interview of Mental Status (BIMS) score of 0 which indicated the resident had severe cognitive impairment. The MDS assessment also included the resident had not had any falls within 6 months prior to admission, but did have two or more falls, both with and without injury since admission. The MDS assessment further included the resident required extensive assistance of one person for most activities, was not steady, and was only able to stabilize with a person for standing, moving to toilet, and walking. The MDS assessment additional included the resident used a walker and a wheelchair. A Care Plan Conference Summary note dated (MONTH) 20, (YEAR) revealed the resident had confusion, memory issues, and did not retain directions. The note also included the resident required maximum assistance with activities of daily living (ADL) and was not able to walk or stand and needed 24/7 supervision. A fall risk assessment dated (MONTH) 25, (YEAR) revealed the resident had a score of 21, which indicated the resident was a high risk for falls. Review of a Fall Investigation dated (MONTH) 28, (YEAR) revealed a CNA started to push the wheelchair when the resident fell forward onto the floor and re-opened a cut above the right eyebrow from a previous fall. One of the fall interventions in place at the time of the fall included 1:1 staff supervision. A fall risk assessment dated (MONTH) 28, (YEAR) revealed the resident had a score of 15, which indicated the resident was a moderate to high risk for falls. A fall risk care plan initiated (MONTH) 28, (YEAR) interventions included to analyze the previous falls to determine if a pattern/trend can be addressed and to relocate the resident close to the nurses' station while awake. Review of a nursing progress note dated (MONTH) 3, (YEAR) revealed the resident was being monitored 1:1 when he fell asleep in his wheelchair in the dining room. The note also included the CNA that was monitoring the resident got up and went into the nurses' station to return the vital machine. While the CNA was away from the resident, the resident woke up, stood up, walked unassisted, and fell . The note further included the resident sustained [REDACTED].#169 unclip something from his shoulder prior to getting up. A fall risk assessment dated (MONTH) 4, (YEAR) revealed the resident had a score of 23, which indicated the resident was a high risk for falls. During an interview conducted with the RN/Interim Director of Nursing (staff #17) on (MONTH) 14, (YEAR) at 2:11 p.m., staff #17 stated that when a resident is on 1:1 observation for falls or behavior, the staff member monitoring the resident has to stay right with the resident within arm's length and that someone should relieve them if they have to leave the resident's side. An interview was conducted with a Licensed Practical Nurse (LPN/staff #81) on (MONTH) 14, (YEAR) at 2:19 p.m. Staff #81 stated she was in the nurses' station on (MONTH) 3, (YEAR) and could see the dining room when the fall occurred. Staff #81 stated the resident was asleep in his wheelchair when the CNA left to return the vital sign machine and the resident was in her eyesight. Staff #81 stated she was working and typing when she looked up at the resident, the resident was already up and had fell and that she would not have been able to get to the resident before the resident fell . Staff #81 further stated that when a resident is on 1:1 supervision, the CNA is not to leave them. Staff #81 stated the staff supervising a resident 1:1 should be within arm's length of the resident and if the supervising staff had to leave the resident, another staff member would have to relieve them. A review of the Fall Prevention Program revealed the policy of the facility was to be proactive in reducing the number of resident falls and injuries. The program included the definition of Contributing Factors to Falls: (not all inclusive,) included Extrinsic: Environmental factor such as wet floor, poor lighting, furniture, clothing, slippers, medical or assistive devices (examples: IV Pole, walkers, etc.). -Resident #52 was readmitted (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. Review of Physical Therapy (PT) initial evaluation notes dated (MONTH) 3, (YEAR), revealed the resident used a wheelchair (WC) for mobility and the method of propelling was the use of his bilateral lower extremities. Review of the physician orders [REDACTED]. The fall risk assessment care plan included the resident had a history of [REDACTED]. On (MONTH) 12, (YEAR), at 9:51 a.m., the resident was observed propelling his WC through the hallway with about half of the lower bottom of each of his thighs hanging off the wheelchair seat. On (MONTH) 13, (YEAR), the resident was observed at the following times: 9:00 a.m., 12:00 p.m., and 2:00 p.m., in his wheelchair with the bottom of the lower portion of each thigh hanging off the WC seat. On (MONTH) 14, (YEAR) at 9:00 a.m., the resident was observed sitting in his WC, with the lower part of his bilateral thighs hanging off the WC seat. During an interview conducted with the Director of Rehabilitation Services (staff #152) (MONTH) 14, (YEAR), at 10:25 a.m., staff #152 stated that resident #52's WC seat was too short for proper accommodation of the resident's legs. Staff #152 further stated that the resident's thighs were not properly supported by the WC seat, which put the resident at risk for sliding out of his WC. Staff #152 stated that the depth of the WC seat was too short to support the 90 degree angle of the knee joints, which placed the resident at risk for sliding out of his WC. Staff #152 also stated that the resident was currently receiving PT/OT services. She further stated that WC positioning was not identified by PT/OT and it should have been identified and assessed as resident #52's WC was too small and he needed a bigger WC. On (MONTH) 14, (YEAR), at 10:25 a.m., the Director of Rehabilitation Services (staff #152) stated that there was no specific facility policy for positioning.",2020-09-01
480,"HAVEN OF SANDPOINTE, LLC",35096,2222 SOUTH AVENUE A,YUMA,AZ,85364,2017-09-14,431,E,0,1,ZEOT11,"Based on review of facility documentation, staff interviews, and policy, the facility failed to ensure that glucometer quality checks were consistently implemented and failed to provide documentation that narcotic reconciliation was consistently performed. Findings include: -Review of the daily glucometer quality control log for testing glucometers for (MONTH) (YEAR) revealed missing documentation for the 300 hall on the following dates: (MONTH) 2, 4, 5, and 6. Review of the daily glucometer quality control log for (MONTH) revealed missing documentation for the 500 hall on (MONTH) 2, 5, and 6. During an interview conducted (MONTH) 11, (YEAR) at 11:45 a.m., an LPN (Licensed Practical Nurse/staff #130) stated the night shift nurses are responsible to record the glucometer test results daily. An interview was conducted with the DON (Director of Nursing/staff #17) on (MONTH) 13, (YEAR) at 9:31 a.m. He stated the glucometer test results are performed by the night nurses and they are responsible for recording their results in the glucometer quality control logs. Staff #17 further stated the monthly logs are reviewed by the management team for completion. The policy Glucometer Check Record included a quality check is performed to ensure the blood glucose meter is functioning properly and the night shift nurse is responsible for performing the procedure every night. -A review of the daily narcotic shift count reconciliation sheet for (MONTH) (YEAR) on the 300 hall revealed there were no signatures for all shifts on the nurses' narcotic check list dated (MONTH) 1, (YEAR). Further review of the 300 hall narcotic record revealed that the morning shift on (MONTH) 7 and the afternoon and evening shifts for (MONTH) 5 and (MONTH) 9 were blank. Review of the nurses' narcotic check list for the 600 hall for the a.m. shift on (MONTH) 7, (YEAR) revealed no signatures. An interview was conducted (MONTH) 11, (YEAR) at 11:45 a.m. with a LPN (Licensed Practical Nurse/staff #130) who stated the off going nurses are responsible to reconcile the narcotic counts and sign the logs at the beginning and end of their shifts with the oncoming nurses. An interview was conducted with the DON (Director of Nursing/staff #17) on (MONTH) 13, (YEAR) at 9:31 a.m. He stated he was unable to produce a current written policy regarding shift change narcotic count reconciliation.",2020-09-01
481,"HAVEN OF SANDPOINTE, LLC",35096,2222 SOUTH AVENUE A,YUMA,AZ,85364,2017-09-14,441,E,0,1,ZEOT11,"Based on staff interviews and a telephone summary, the facility failed to ensure a water safety program was established to identify risks and prevent the spread of water-borne communicable diseases. Findings include: During an interview with the Infection Control Nurse/Assistant Director of Nursing (ICN/staff #93) (MONTH) 14, (YEAR) at 10:30 a.m., staff #93 stated she was not aware of any program regarding an assessment of the water system or testing for any communicable diseases in the water. During an interview conducted with the Corporate Chief Nursing Office (CNO/staff #161) conducted (MONTH) 14, (YEAR) at 11:45 a.m., the CNO stated the corporation is just beginning to look at what needs to be done for assessment and testing regarding Legionella. During an interview conducted with the Administrator (staff #3) (MONTH) 14, (YEAR) at 11:45 a.m., the Administrator stated he spoke with a company that he will be working with and a brief assessment was completed over the phone, but no testing or action have been started. Review of the telephone summary did not reveal an assessment. The Administrator stated the facility does not have a policy for the prevention of water-borne communicable diseases management.",2020-09-01
482,"HAVEN OF SANDPOINTE, LLC",35096,2222 SOUTH AVENUE A,YUMA,AZ,85364,2018-12-20,602,D,1,1,TKKY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interview, facility documentation and policy review, the facility failed to ensure one resident (#173) was free from misappropriation of property. Findings include: Resident #173 was admitted to the facility on (MONTH) 12, (YEAR), with [DIAGNOSES REDACTED]. The resident was discharged on (MONTH) 8, (YEAR). Review of a facility's investigative report revealed that the nursing home administrator (staff #131) received a call on (MONTH) 30, (YEAR) from prison officials, who reported that one of their employees (Licensed Practical Nurse/LPN/staff #156) who also works part time at the nursing home facility, was involved in a prison drug diversion investigation. Per the report, one of the prescription medication bottles in the possession of staff #156 had a resident's name on it (resident #173), along with other information. The report included that resident #173 had previously been a resident at the nursing home facility. The report further included that on the evening of (MONTH) 29, (YEAR), staff #131, the Chief Nursing Officer and the police, met with staff #156. A search of staff #156's vehicle was conducted at this time and revealed additional medications belonging to resident #173. Staff #156's explanation was that he did not realize there were medications in the bottle. The report included that staff #156 was suspended pending the investigation and that staff #156 resigned on 12/1/18. On (MONTH) 19, (YEAR), former staff #156 was contacted by phone for an interview. He stated that he would return the call within two hours, however, no returned calls were received. An interview was conducted with a Corporate Registered Nurse (staff #152) on (MONTH) 19, (YEAR) at 1:05 p.m. She stated they were notified by prison officials on (MONTH) 30, (YEAR) of a prescription bottle which was full of medications that had been located in the vehicle of staff #156. Staff #152 said that the bottle of medications listed the name of resident #173, who the police had identified as being a prior resident in the facility back in (MONTH) (YEAR). Staff #152 stated that staff #156 was immediately suspended and an investigation was initiated. She stated that when a resident is admitted , all medications brought with the resident are sent home. She said that for whatever reason, the medication for resident #173 remained in the facility in the secured medication room. She confirmed that staff #156 had worked in the facility on (MONTH) 22, (YEAR), when the resident resided at the facility. Review of the policy regarding Misappropriation of Personal Property revealed the facility recognizes and respects that each resident has the right to be free from misappropriation of resident's property. The facility is committed to developing and operationalizing policies and procedures for screening and training employees regarding misappropriation of resident personal property. Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful use of a resident's belongings without the resident's consent.",2020-09-01
483,"HAVEN OF SANDPOINTE, LLC",35096,2222 SOUTH AVENUE A,YUMA,AZ,85364,2018-12-20,610,D,1,1,TKKY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interview, facility documentation and policy and procedures, the facility failed to prevent the potential for further abuse while an investigation was in progress for one resident (#373). Findings include: Resident #373 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of an admission MDS (Minimum Data Set) assessment dated [DATE], revealed a BIMS (Brief Interview for Mental Status) score of 4, which indicated the resident had severe cognitive impairment. Review of the facility's abuse investigation revealed that the resident reported to a registered nurse (RN) on 8/9/18 during the night shift that a CNA had hit her and dragged her out of bed that same night. The report included a statement from the accused CNA who stated that a second CNA was helping her provide care for the resident that night. Per the statement from the accused CNA, the nurse told them that the resident had accused both of them of hitting her. A statement from the second CNA also included the nurse had told them that the resident had alleged that both of them had hit her. Further review of the investigative report revealed that the nurse advised the accused CNA to not care for the resident and to keep a distance from the resident and have the second CNA take care of anything that the resident needed for the remainder of the shift. The facility was unable to provide any documentation that at the time of the allegation, both CNA's were removed from providing care to the resident's in the facility, while the investigation was in progress. An interview was conducted with the Chief Nursing Officer (staff #152) on 12/19/18 at 12:58 p.m. Staff #152 stated that when there is an allegation of abuse or neglect, the person who receives the report calls either the Director of Nursing or her immediately. She stated that if it happens at night, they are to call and keep calling until they reach her or the DON to receive further direction. She stated that if the person accused is an employee, it is her expectation and the facility's policy to immediately suspend the employee and begin a full investigation. She said that both CNA's should have been suspended and sent home after the allegation was made. Review of the facility's Abuse policy revealed that In the event of an allegation of abuse, the facility will immediately assess the resident, notify the physician and resident representative, and protect the resident and other residents from further harm. The policy also included When a specific staff is identified as being allegedly involved in the abuse allegation, the staff may be re-assigned or suspended during the investigation.",2020-09-01
484,"HAVEN OF SANDPOINTE, LLC",35096,2222 SOUTH AVENUE A,YUMA,AZ,85364,2018-12-20,641,D,0,1,TKKY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, review of the Resident Assessment Instrument (RAI) manual and policy and procedures, the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected one resident's (#58) status. Findings include: Resident #58 was admitted on (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of a care plan dated (MONTH) 15, (YEAR) revealed the resident had a history of [REDACTED]. Review of the Behavior Monitoring record for (MONTH) 16, 18, and 19, (YEAR) revealed the resident displayed behaviors of striking out. Review of the nurse progress notes from (MONTH) 15 through (MONTH) 21, (YEAR) revealed the resident exhibited the following behaviors: -November 15: the resident was aggressive, agitated and hitting the Certified Nursing Assistant (CNA). -November 16: the resident was resisting care, was verbally and physically abusive, was cursing in Spanish and called staff bad words, was trying to hit staff and was combative with care. -November 17: the resident cursed at staff on several occasions and made dirty sign language using her finger at another resident this p.m. -November 18: the resident became aggressive and combative with the RN and CN[NAME] She scratched the arm of the RN and hit the CNA in the chest and was combative with care. -November 19: the resident is very combative during Activities of Daily Living (ADL) and medication pass and strikes out at other residents. -November 20: Attempted to slap the Licensed Practical Nurse (LPN) and a CNA on the arms. According to the admission MDS assessment dated (MONTH) 21, (YEAR), the resident was assessed to have short and long term memory problems and was severely impaired with decision making. However, the MDS did not include that the resident had any physical or verbal behaviors directed toward others. An interview was conducted with a MDS nurse (LPN/staff #150) on (MONTH) 20, (YEAR) at 1:05 p.m. She stated that they use the RAI manual for directions on completing the MDS and that they have an imbedded link within the program to the section of the RAI manual that coincides with the section they are working on. She stated that it is important that the MDS be accurate, as it documents the overall status of the resident and how we take care of the resident. She stated that the Care Area Assessments (CAA) section triggers areas which prompts for a deeper investigation and leads to the development of care plans. Staff #150 said that the care plan is important to show others how to take care of the resident. She stated that an inaccurate MDS could result in an incomplete care plan. At this time, the clinical record and MDS were reviewed with staff #150, who stated that the assessment was not accurate for this resident. She stated that she did not follow the RAI manual or their policy for accuracy of the MDS, which could put the resident at risk of not receiving the appropriate care. An interview was conducted with the MDS corporate nurse (RN/staff #155) on (MONTH) 20, (YEAR) at 1:20 p.m. She stated that they use the RAI manual for the MDS/RAI process. She stated that the MDS is expected to be accurate, per the RAI manual instructions. She stated that if the MDS is inaccurate it could lead to not identifying the appropriate risks, problems, or preferences of a resident. At this time, staff #155 reviewed the clinical record documentation and the MDS and stated that staff did not fulfill her expectations for accuracy of the MDS. Review of the facility's policy regarding the MDS revealed that the MDS is completed by following the Centers for Medicare and Medicaid (CMS) RAI manual. The MDS coordinator is to follow the RAI manual instructions when completing all MDS assessments. Review of the RAI manual revealed that the items in section [NAME] identify behavioral symptoms in the last seven days which may cause distress to the resident, or may be distressing or disruptive to facility residents, staff members or the care environment. These behaviors may place the resident at risk for injury, isolation, and inactivity and may also indicate unrecognized needs, preferences, or illness. Direction for coding of physical behavioral symptoms directed toward others, verbal behavioral symptoms directed toward others and other behavioral symptoms not directed toward others includes to code based on whether the symptoms occurred.",2020-09-01
485,"HAVEN OF SANDPOINTE, LLC",35096,2222 SOUTH AVENUE A,YUMA,AZ,85364,2018-12-20,758,D,0,1,TKKY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy review, the facility failed to ensure that a that a physician's order for a PRN (as needed) antianxiety medication included an end date or that there was documentation of the rationale for its continued use for one resident (#10). Findings Include: Resident #10 was admitted on (MONTH) 15, (YEAR), with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set assessment dated (MONTH) 21, (YEAR) revealed the resident had short and long term memory problems and was severely impaired with daily decision making. A physician's order dated (MONTH) 9, (YEAR) included for [MEDICATION NAME] (antianxiety) 1 mg tablet by mouth every 4 hours PRN for anxiety. The order did not include an end date, but listed the medication as indefinite. A care plan identified that the resident was at risk for adverse effects related to [MEDICAL CONDITION] medication. The goal was that the resident would have no adverse effects related to [MEDICAL CONDITION] medications. Interventions included for medical doctor review for appropriateness and pharmacy review for medical necessity. According to the (MONTH) and (MONTH) (YEAR) Medication Administration Records, the resident received the PRN [MEDICATION NAME] daily from (MONTH) 26-30, from (MONTH) 3-12, on (MONTH) 14 and from (MONTH) 17-19. Further review of the clinical record revealed there was no documentation from the provider regarding the rationale for the continued use of the medication. An interview was conducted with a Licensed Practical Nurse (LPN/staff #117) on (MONTH) 20, (YEAR) at 9:58 a.m. She stated that an as needed (PRN) antianxiety medication can be given for 14 days and then the resident has to have a face to face with the provider to decide whether to discontinue or extend the medication. Staff #117 said that if the provider decides to continue the medication, it can be ordered in 14 day increments. At this time, staff #117 reviewed the clinical record and stated that they did not follow their policy, as there was no documentation of a face to face with the provider within 14 days and there was no documentation of a decision to extend or discontinue the medication. An interview was conducted with the Corporate Director of MDS (RN/staff #155) on (MONTH) 20, (YEAR) at 11:30 a.m. She stated that PRN [MEDICAL CONDITION] medications cannot be given more than 14 days, without an in person visit by the provider to renew the order. She stated the PRN [MEDICATION NAME] should not have been given to this resident for more than 14 days, without documentation from the provider. Review of the policy regarding Psychopharmacological Medication Use revealed the facility should comply with the State Operations Manual and all other applicable laws relating to the use of psychopharmacological medications. When a physician/prescriber orders a psychopharmacologic medication for a resident, the facility should ensure that the physician/prescriber has conducted a comprehensive assessment of the resident and has documented in the clinical record that the psychopharmacologic medication is necessary.",2020-09-01
486,"HAVEN OF SANDPOINTE, LLC",35096,2222 SOUTH AVENUE A,YUMA,AZ,85364,2018-12-20,761,D,0,1,TKKY11,"Based on observation, staff interviews and policy review, the facility failed to store narcotic drugs in a permanently affixed compartment and securely locked. Findings include: An observation of the facility's medication room was conducted on (MONTH) 20, (YEAR) at 3:35 p.m. In the medication room, there was an unsecured pharmacy emergency narcotic medication box, which was in an unlocked partially opened cabinet. The narcotic box was approximately 8 inches by 16 inches by 3 inches and was held closed by numbered breakaway plastic locks. The narcotic box was not permanently affixed and could be easily removed from the cabinet. The narcotic box was also not being stored using a double lock system. An interview was conducted with a Registered Nurse (Interim Director of Nursing (DON/staff #13) on (MONTH) 20, (YEAR) at 3:37 p.m. He stated that narcotic medications require two locks. He stated that their policy and the regulatory requirements were not followed, as there is only one lock on the box and the box is not secured. An interview was conducted with the Corporate RN (staff #152) on (MONTH) 20, (YEAR) at 3:40 p.m. She stated that the narcotic box was not under lock and key and it should be, therefore; the facility did not follow the regulations. Review of the policy on the Storage of Medications revealed that after receiving controlled substances and adding to inventory, the facility should ensure that schedule II-V controlled substances are immediately placed into a secured storage area (i.e. safe, self-locked cabinet or locked room, in accordance with applicable law).",2020-09-01
487,"HAVEN OF SANDPOINTE, LLC",35096,2222 SOUTH AVENUE A,YUMA,AZ,85364,2018-12-20,842,D,0,1,TKKY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy review, the facility failed to ensure medical records were complete for one resident (#10). Findings include: Resident #10 was admitted on (MONTH) 15, (YEAR), with [DIAGNOSES REDACTED]. Review of a care plan revealed the resident was at risk for adverse effects related to [MEDICAL CONDITION] medications. The approaches included to monitor behaviors related to [MEDICAL CONDITION] medication and to observe for adverse effects. Review of the (MONTH) (YEAR) Behavioral Monitoring Record revealed the following: -To monitor and document behaviors related to psychoactive medications for [MEDICATION NAME] and [MEDICATION NAME] every shift. However, there was no documentation that the resident was monitored for behaviors on (MONTH) 1, (MONTH) 4-15, (MONTH) 17, (MONTH) 19-21, and on (MONTH) 31 during the day shift, and on (MONTH) 6, 12, 17 and 22 on the night shift. -Has the resident been free from any side effects related to antipsychotic medication each shift? There was no documentation that the resident was monitored for any side effects on (MONTH) 4-15, (MONTH) 17, (MONTH) 19-21, and on (MONTH) 31 on day shift, and on (MONTH) 6, 12, 17 and 22 on the night shift. -Has the resident been free from any side effects related to antidepressant medication each shift? There was no documentation that the resident was monitored for side effects related to antidepressant medication on (MONTH) 4-15, (MONTH) 17, (MONTH) 19-21, and on (MONTH) 31 on the day shift, and on (MONTH) 6, 12, 17 and 22 on the night shift. -Has the resident been free from any side effects related to antianxiety medication each shift? There was no documentation that the resident was monitored for side effects on (MONTH) 4-15, (MONTH) 17, (MONTH) 19-21 and on (MONTH) 31 on the day shift, and on (MONTH) 6, 12, 17 and on (MONTH) 22 on the night shift. Review of the Treatment Administration Record (TAR) for (MONTH) (YEAR) revealed to monitor for the following care and treatment: -Leg abductor cushion for wheelchair every day shift for weakness. There was no documentation on (MONTH) 5 or 8. -Monitor left front hand bruise every shift. There was no documentation on the day shift for (MONTH) 5 and 8 or on the night shift on (MONTH) 7. -Monitor wound sites every shift. There was no documentation on (MONTH) 5 and 8 or on the night shift on (MONTH) 7. -Pain assessment every shift. There was no documentation on the day shift on (MONTH) 5 and 8. Review of the (MONTH) (YEAR) Behavioral Monitoring Record revealed the following: -To monitor and document behaviors related to psychoactive medication for [MEDICATION NAME], and [MEDICATION NAME] every shift. However, there was no documentation the resident was monitored on (MONTH) 1, 5, and 15 on the day and night shift. -Has the resident been free from side effects related to antipsychotic medication each shift? There was no documentation on (MONTH) 1 and 5 on the day shift. -Has the resident been free from any side effects related to antidepressant medication each shift? There was no documentation on (MONTH) 1 and 5 on the day shift. -Has the resident been free from any side effects from antianxiety medication each shift? There was no documentation on (MONTH) 1, 5 and 15 on the day shift. Review of the TAR for (MONTH) (YEAR) revealed to monitor for the following care and treatment: -Leg abductor cushion for wheelchair every day shift for weakness. There was no documentation on (MONTH) 5. -Pain assessment every shift. There was no documentation on the day shift on (MONTH) 5. Review of the (MONTH) (YEAR) Behavioral Monitoring Record revealed the following: -To monitor and document behaviors related to the psychoactive medication for [MEDICATION NAME], and [MEDICATION NAME] every shift. There was no documentation on (MONTH) 3 and 13 on the day shift. -Has the resident been free from any side effects related to antianxiety medication each shift? There was no documentation on (MONTH) 3 on the day shift. An interview was conducted with a Licensed Practical Nurse (LPN/staff #117) on (MONTH) 20, (YEAR) at 1:56 p.m. She stated that she is expected to document on the behavior monitoring record and document any treatments which are done by her during her shift. She stated that there should not be any blanks on the behavior monitoring records or on the medication and treatment records, because if there are blanks, then there is no documentation that the work was done. In reviewing the medication and treatment records and the behavior monitoring records, staff #117 stated that the blank boxes should have initials in them and that their policy was not being followed in regards to documentation. An interview was conducted with the interim Director of Nursing (DON/staff #13) on (MONTH) 20, (YEAR) at 2:12 p.m. He stated that he expects staff to document medications given and side effects, treatments done and monitoring of behaviors. He stated that holes in the medication and treatment records and on the behavioral monitoring records would mean there is no documentation that the item was assessed, or that the medication was given, or the treatment was done. He stated that incomplete documentation does not follow facility policy or his expectations. Review of the facility's policy on Charting and Documentation revealed the purpose is to provide a complete account of the resident's care, treatment and response to care, as well as the progress of the resident's care, and to provide guidance to the physician in prescribing appropriate medications and treatments and to provide a tool for measuring the quality of care provided to the resident. The policy included to document daily treatments and medications on the medication and treatment records.",2020-09-01
488,THE LEGACY REHAB & CARE CENTER,35097,2812 SILVER CREEK ROAD,BULLHEAD CITY,AZ,86442,2017-03-21,242,D,0,1,ULT111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interview and clinical record review, the facility failed to ensure one resident (#13) was able to make choices regarding the preference for no male care givers. Findings include: Resident #13 was admitted to the facility on (MONTH) 9, (YEAR) with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set assessment dated (MONTH) 15, (YEAR) revealed the resident had a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. Review of the resident's functional capacity revealed the resident was identified as total dependence or extensive assistance and required one to two persons to assist her with the activities of daily living except for eating which required only supervision. Review of the Resident Mood Interview indicated the resident had a score of 15, which indicated she was depressed but according to the behavior section the resident did not exhibit any behaviors during this review period. Review of the nursing progress notes for (MONTH) and (MONTH) (YEAR) revealed the resident frequently refused medications, care, and would yell at staff to get out of her room. Review of the nursing progress notes for the month of (MONTH) (YEAR) revealed only a few days where the resident had documented episodes of yelling at staff, yelling out into the halls, and refusing medications. During an interview with the resident on (MONTH) 14, (YEAR) at 10:44 a.m., the resident stated that she did not want a man caregiver providing her incontinent care. Review of the resident's care plan revealed a problem titled, At times I say racial remarks to staff, but did not include any concerns regarding male caregivers. In an interview conducted with a Certified Nursing Assistant (CNA/staff #61) on (MONTH) 16, (YEAR) at 10:47 a.m., the CNA stated she performs all types of daily care for the resident which includes showers, providing continent care, getting the resident ready for meals, and dressing the resident. She further stated to reduce the resident's anxiety; they work with her to keep things to her preference. The CNA further stated the resident stated she did not want males providing her care including showering her and she does not want more than 3 people in her room at a time. Staff #61 stated if a male CNA attempts to assist the resident, the resident tells the male CNA to get out. The CNA stated she has known about the resident preference regarding no male care givers for about a month. In an interview conducted with a Licensed practical Nurse, (LPN/staff #136) on (MONTH) 16, (YEAR) at 11:13 a.m., the LPN stated she never heard the resident did not want male CNAs providing her care. The LPN stated it should be on the care plan so everyone is aware of the resident's preference. In an interview conducted with the Director of Nursing (DON/staff #92), on (MONTH) 16, (YEAR) at 11:14 a.m., the DON stated there is a regular schedule for review of the care plans to ensure they are all updated for the resident. The DON stated that if a resident has a preference no male care giver, then it should be cared planned so all staff are aware.",2020-09-01
489,THE LEGACY REHAB & CARE CENTER,35097,2812 SILVER CREEK ROAD,BULLHEAD CITY,AZ,86442,2018-05-29,600,D,1,1,T32211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, resident and staff interviews, facility documentation, and policy, the facility failed to ensure four residents (#339 & #25 and #28 & #58) were free from resident to resident abuse. Findings include: -Resident #339 was admitted on (MONTH) 22, (YEAR), with [DIAGNOSES REDACTED]. An admission care plan dated (MONTH) 22, (YEAR), revealed the resident exhibited unsafe wandering related to a decline in cognitive status and poor decisions that put the resident at risk for upsetting other residents. Interventions included to monitor for any needed safety checks, anticipate needs, monitor for increased restlessness, and redirect to safe areas. The goal was for the resident to be able to wander safely on the unit, free from injury to himself or others. The admission Minimum Data Set (MDS) assessment dated (MONTH) 29, (YEAR), revealed the resident was assessed to have severe cognitive impairment with short and long term memory loss. In addition, the resident was assessed to exhibit wandering behavior that intruded on the privacy of other residents. Revisions to the care plan dated (MONTH) 21, (YEAR), revealed the resident had a problem of swearing and insulting other residents and exhibiting negative physical behavior that included hitting, kicking, spitting, pinching, or biting other residents and staff. Interventions included removing him from the situation if he was showing signs of agitation and to remind him calmly about the necessity to refrain from physically acting out. The goal was for him to respond to calming interventions at the earliest signs of aggressive tendencies, to be free of physical altercations with injury involving other residents, and to accept necessary help from staff without causing injury to self and others. Review of the nursing notes from (MONTH) 30 through (MONTH) 21, (YEAR), revealed documentation that the resident had been observed on multiple occasions (over 8 occasions) to exhibit wandering behaviors into other residents' rooms. A nursing note dated (MONTH) 21, (YEAR), revealed the resident was wandering aimlessly down the halls and would curse at staff when attempts were made to redirect him away from entering residents' rooms. Review of a nursing note dated (MONTH) 23, (YEAR), revealed the resident threatened the staff with raised fists and entered a resident's room and urinated on the floor despite staff attempting to intervene. A nursing note dated (MONTH) 26, (YEAR), revealed the resident was not cooperating with staff as evidenced by repeatedly going into other residents' rooms, spitting on the floor, and kicking at a window in the dining room. The note also included that the resident did not take redirection well, would not go to bed, and that other residents did not want him in their rooms. -Resident #25 was admitted to the facility on (MONTH) 22, (YEAR), with [DIAGNOSES REDACTED]. An admission care plan dated (MONTH) 22, (YEAR), revealed the resident had a problem of unsafe wandering related to a decline in cognitive status and poor decisions that put the resident at risk for upsetting other residents. Interventions included to monitor for any needed safety checks, anticipate needs, monitor for increased restlessness, and redirect to safe areas. The goal was for the resident to be able to wander safely on the unit, free from injury to himself or others. The care plan included the resident exhibit negative physical behavior that included hitting, kicking, spitting, pinching, or biting towards other residents and staff. Interventions included removing him from the situation if he was showing signs of agitation and to remind him calmly about the necessity to refrain from physically acting out. The goal was for him to respond to calming interventions at the earliest signs of aggressive tendencies, to be free of physical altercations with injury involving other residents, and to accept necessary help from staff without causing injury to self and others. An admission MDS assessment dated (MONTH) 29, (YEAR), revealed the resident was assessed to have severe cognitive impairment with short and long term loss. In addition, the resident was assessed to display behavioral symptoms that significantly intruded on the privacy of others and significantly disrupted the living environment. A review of the nursing notes from (MONTH) 1 through 26, (YEAR), revealed no evidence the resident had increased behaviors of wandering or exhibiting aggressive behaviors towards other residents. Review of the facility's documentation revealed an altercation between resident #339 and resident #25 captured on the facility's camera system that occurred on (MONTH) 26, (YEAR). The documentation included that at approximately 8:09 p.m., resident #339 stopped his wheelchair in front of the doorway of resident #25's room. Resident #25 walked out of his room and immediately grabbed a hold of resident #339 with both hands. Resident #339 then grabbed the left arm of resident #25 to block him. Resident #339 then raised his fist and struck resident #25 in the nose. The two residents then grabbed each other. Resident #339 stood up from the wheelchair. Eventually both residents fell to the floor. An outside agency nurse saw the altercation and located a facility nurse for intervention. Resident #25 sustained a bloody nose that required first aid treatment. The documentation further included that there were no obvious injuries noted for resident #339. During an interview conducted with the administrator/staff #103 on (MONTH) 23, (YEAR) at 9:29 a.m., she stated that there had been no prior altercations between the two residents. An interview was conducted with the outside agency nurse/staff #153 on (MONTH) 23, (YEAR) at 9:43 a.m. She stated that she could not recall any specific details about the physical altercation between the two residents on the secured unit. An interview was conducted with a Registered Nurse/staff #75 on (MONTH) 23, (YEAR) at 10:03 a.m. She stated that resident #339 had some behaviors that had escalated in the past month and that he was not open to redirection. She stated that resident #339 would enter other residents' rooms and had a tendency to become loud, angry, and verbally aggressive. Staff #75 stated that resident #25 tended to be pleasant, liked his room, and only wanted himself and his roommate to enter his room. During an interview conducted with a Certified Nursing Assistant/staff #78 on (MONTH) 23, (YEAR) at 10:18 a.m., she stated that she had provided care for both residents. She stated that resident #339 could be aggressive with staff and would sometimes try to hit her or swing out at her. Staff #78 stated that resident #25 liked his room and did not want other residents to come into his room. An attempt to interview resident #25 on (MONTH) 24, (YEAR) at approximately 1:00 p.m., was unsuccessful. Another interview was conducted with the administrator/staff #103 on (MONTH) 25, (YEAR) at 8:51 a.m. She identified the altercation as abuse and stated that all residents have the right to be free from abuse. -Resident #58 was admitted to the facility on (MONTH) 10, (YEAR), with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated (MONTH) 17, (YEAR), revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact. The assessment also included the resident displayed verbal behavioral symptoms directed toward others and other behavioral symptoms that was not directed toward others. Review of the care plan initiated (MONTH) 26, (YEAR), revealed the resident had verbal behaviors of screaming disruptive sounds and screaming/cursing at others and behaviors of making inappropriate sexual comments to the female staff and other residents. Interventions included redirecting behaviors as able, utilizing different staff members, offering food, fluids, activities, 1:1 conversation, psychiatrist consults as needed, and to document all behaviors. The quarterly MDS assessment dated (MONTH) 15, (YEAR), revealed resident a BIMS score of 15 which indicated the resident was cognitively intact. The assessment also included the resident had no behavioral symptoms. -Resident #28 was admitted to the facility on (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. A review of the admission MDS assessment dated (MONTH) 6, (YEAR), revealed a BIMS score of 8 which indicated the resident was moderately cognitively impaired. The assessment included the resident displayed physical behavioral symptoms directed toward others. Review of the care plan initiated on (MONTH) 7, (YEAR), revealed the resident exhibited behaviors of making sexual comments at staff and grabbing staff bottoms. Interventions included redirecting all behaviors as able, psychiatric consults as needed, reminding the resident that his behaviors are inappropriate, offering food, fluids, and activities, and documenting all behaviors. A review of the quarterly MDS assessment dated (MONTH) 4, (YEAR), revealed a BIMS score of 9 which indicated the resident was moderately cognitively impaired. The assessment included the resident had had no behavioral symptoms. During an interview conducted with resident #28 on (MONTH) 22, (YEAR) at 9:30 a.m., he stated that another resident (#58) threw coffee creamer all over him that morning. Resident #28 stated that the housekeeper saw it happen and helped him get cleaned up. He also stated that he had just reported the incident to his nurse. The incident was reported to the administrator (staff #109) on (MONTH) 22, (YEAR) at 9:40 a.m. During an interview conducted with resident #58 on (MONTH) 23, (YEAR) at 1:30 p.m., resident #58 stated that he threw coffee creamer at resident #28 because resident #28 would not stop moving the cart which caused him to spill his coffee. He stated that resident #28 had threatened to throw coffee at him first. Resident #58 stated that resident #28 is always playing games and hitting his arm with his wheelchair. He also stated that once resident #28 hit him in the chest with his fist. Resident #58 stated that he had never hit resident #28. He stated that he did not report these incidents to anyone. Review of the facility's documentation regarding the incident that occurred on (MONTH) 22, (YEAR), revealed an interview with resident #58 and resident #28. Resident #28 stated that he and resident #58 were attempting to get coffee of the coffee cart. He stated that he put two packs of sugar in his coffee but was unable to reach the trash bag, so he pulled the coffee cart toward him. He stated that is when resident #58 threw coffee creamer on him. Resident #58 stated he and resident #28 was getting coffee at the same time. He stated that resident #28 kept pulling the cart to made his coffee spill, so he threw the coffee creamer at him. The facility's documentation also included that during the interviews, the residents spoke of another incident that occurred. Resident #58 stated that resident #28 tried to block his way so he slapped resident #28 in the chest. He stated that resident #28 then slugged him in the chest. The facility's documentation also included that resident #28 stated that he hit resident #58 in the chest after being hit by resident #58 two days ago outside of the therapy room. He further stated that there were no witnesses and that he did not report the incident to anyone. An interview was conducted with the Director of Nursing (DON/staff #90) on (MONTH) 23, (YEAR) at 2:19 p.m. The DON stated that she had been reviewing their camera videos and did not see any altercations between the two resident. She stated that she interviewed the therapy department and that they could not confirm the two residents were in the therapy room at the same time. During an interview conducted with the administrator and the DON on (MONTH) 25, (YEAR) at 8:53 a.m., the administrator stated that resident #58 admitted that he had hit resident #28 in the chest. The facility's policy titled Abuse Prevention Program included the following: It is the policy of this facility for our residents to have the right to be free from abuse. Our facility is committed to protecting our residents from abuse by anyone including from other residents.",2020-09-01
490,THE LEGACY REHAB & CARE CENTER,35097,2812 SILVER CREEK ROAD,BULLHEAD CITY,AZ,86442,2018-05-29,638,D,0,1,T32211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, policy, and the RAI (Resident Assessment Instrument) manual, the facility failed to ensure one resident (#1) was assessed using the Standardized Quarterly Review assessment once every 3 months. Findings include: Resident #1 was admitted on (MONTH) 13, (YEAR), with [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment dated (MONTH) 11, (YEAR), revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15 which indicated the resident was cognitively intact. Review of the clinical record revealed the resident was discharged to the hospital on (MONTH) 14, (YEAR) with return anticipated and was readmitted to the facility on (MONTH) 6, (YEAR). Continued review of the clinical record revealed a 5 day MDS assessment was completed on (MONTH) 13, (YEAR), a 14 day MDS assessment was completed on (MONTH) 19, (YEAR), and a 30 day MDS assessment was completed on (MONTH) 5, (YEAR). However, there was no evidence that the (MONTH) quarterly MDS assessment had been completed. An interview was conducted on (MONTH) 22, (YEAR) at 1:40 p.m. with the MDS nurse (staff #139). The MDS nurse stated that the next quarterly MDS assessment for resident #1 should have been completed on (MONTH) 24, (YEAR). The MDS nurse also stated that the quarterly MDS assessment was not completed because when the MDS assessments were being scheduled for the month of April, the resident was still in the hospital. During an interview conducted on (MONTH) 22, (YEAR) at 1:52 p.m. with the administrator (staff #103), the administrator stated that the 5 day MDS assessment completed on (MONTH) 13, (YEAR) was not coded correctly. He stated that the assessment should have been coded as the quarterly MDS assessment. A facility's policy titled Resident Assessment (MDS) Accuracy and Timing revealed the MDS assessment timing is determined by the RAI manual. The RAI manual included that a quarterly MDS assessment for a resident must be completed at least every 92 days following the previous OBRA assessment of any type. The manual also included that the quarterly assessment is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored.",2020-09-01
491,THE LEGACY REHAB & CARE CENTER,35097,2812 SILVER CREEK ROAD,BULLHEAD CITY,AZ,86442,2018-05-29,842,D,0,1,T32211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy, the facility failed to ensure medical records were accurately documented and/or complete for two residents (#21 and #86) regarding advanced directives. Findings include: -Resident #21 was readmitted to the facility on (MONTH) 6, (YEAR), with [DIAGNOSES REDACTED]. A form titled, Resident Advanced Directives was signed by the resident on (MONTH) 6, (YEAR), which included the resident did not wish to be resuscitated in the event of an emergency where the heart and breathing stop. A form titled, State of Arizona, Prehospital Medical Care Directive (Do Not Resuscitate) was signed by the resident on (MONTH) 6, (YEAR). The form informs emergency medical technicians or hospital personnel to do not resuscitate the patient and is to be signed by the patient, the patient's witness, and their health care provider. Further review of the form revealed the form was signed by the resident and a Licensed Practical Nurse but was not signed by the health care provider. Review of the physician's recap orders dated (MONTH) (YEAR), revealed an order that the resident was a full code. The resident's face sheet also listed the resident as being full code status. During an interview conducted with the administrator (staff #103) on (MONTH) 24, (YEAR) at 2:01 p.m., she stated that the code status is reviewed with the resident or their representative upon each admission. She also stated that the code status for this resident should have been updated in the electronic record and the full code order should have been removed. The administrator stated that the nurses are trained to follow the forms in the medical record which indicate the code status. -Resident #86 was admitted to the facility on (MONTH) 25, (YEAR), with [DIAGNOSES REDACTED]. Review of the resident's advance directives form revealed no evidence the date had been completed on the form. During an interview conducted with a Licensed Practical Nurse/staff #95 on (MONTH) 23, (YEAR) at 11:23 a.m., she stated that it is necessary for all advanced directive forms to be completed with a date. An interview was conducted with the Director of Nursing/staff # 90 on (MONTH) 23, (YEAR) at 11:35 a.m. She stated that the admission nurse is responsible for the completion of the advanced directive form, including the date. The facility's policy regarding medical records included the following: It is the policy of this facility to maintain medical records in accordance with current applicable laws. Procedure: Medical records will be maintained for each resident that are complete.",2020-09-01
492,THE LEGACY REHAB & CARE CENTER,35097,2812 SILVER CREEK ROAD,BULLHEAD CITY,AZ,86442,2019-08-02,641,D,0,1,5EQ911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, interviews and policy review, the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected one resident's (#238) status. The deficient practice could result in inaccuracies within resident's clinical record. Findings include: Resident #238 was admitted to the facility on (MONTH) 9 2019, with [DIAGNOSES REDACTED]. Review of a care plan dated (MONTH) 10, 2019, revealed the resident had poor oxygenation and needed supplemental oxygen related to [MEDICAL CONDITION]. A nurse's note dated (MONTH) 10, 2019, revealed the resident was receiving oxygen via nasal cannula. Another nurse's note dated (MONTH) 21, 2019, revealed the resident was receiving oxygen at a rate of 2 liters per minute. However, the admission MDS assessment dated (MONTH) 22, 2019 included documentation that the resident had not received oxygen while at the facility. An observation of the resident was conducted on (MONTH) 29, 2019 at 2:27 p.m. The resident was observed to have oxygen on at a rate of 3.5 liters per minute, via nasal cannula. An interview was conducted with a Licensed Practical Nurse (LPN/staff #10) on (MONTH) 31, 2019 at 3:05 p.m. She stated the resident was admitted to the facility with oxygen. Staff #10 said the admitting nurse did not obtain an order from the physician to continue to administer oxygen at the facility. An interview was conducted on (MONTH) 1, 2019 at 1:13 p.m., with the MDS coordinator (staff #23). She stated that she reviews the physician's orders [REDACTED]. She said that based on the physician orders [REDACTED]. She said she did not remember if she had observed this resident to determine if he was receiving oxygen. She stated the MDS assessment should have shown that the resident was receiving oxygen, whether the administration was continuous or intermittent. An interview was conducted on (MONTH) 1, 2019 at 2:34 p.m., with the Director of Nursing (DON/staff #152). She stated her expectation is that the MDS assessment accurately reflects the resident's condition. Review of the Resident Assessment policy revealed that all sections of the MDS assessment should be completed accurately and completely.",2020-09-01
493,THE LEGACY REHAB & CARE CENTER,35097,2812 SILVER CREEK ROAD,BULLHEAD CITY,AZ,86442,2019-08-02,658,E,0,1,5EQ911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure that one out of five sampled residents (#24) was provided medications as ordered by the physician, in accordance with professional standards of practice. Findings include: Resident #24 was admitted on (MONTH) 9, 2014, with [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS) assessment dated (MONTH) 29, 2019 revealed the resident had moderate cognitive impairment. Section G of the MDS indicated the resident required extensive assistance with bed mobility, transfers, eating and toileting. A [MEDICAL CONDITION] medication care plan related to the use of [MEDICATION NAME] included an intervention to administer medication as ordered by the physician. A care plan related to [MEDICAL CONDITION] included an intervention to give medications as ordered. Review of the physician's orders [REDACTED]. -Memantine [MEDICATION NAME] (HCL/anti-Alzheimer's agent) 5 milligrams (mg) twice daily -[MEDICATION NAME] (anxiolytic) 0.5 mg twice daily for anxiety. -Entacapone (anti-Parkinson agent) 200 mg one tablet three times daily for [MEDICAL CONDITION] -[MEDICATION NAME] HCl ([MEDICATION NAME]) 25 mg four times daily for itching -[MEDICATION NAME] lotion topical application for dry skin every morning -[MEDICATION NAME] (anesthetic) 4% patch apply topically every morning, remove every evening -Donepezil HCl (anti-Alzheimer's agent) 10 mg daily for [MEDICAL CONDITION] -[MEDICATION NAME] (antihypertensive) 2.5 mg every evening for hypertension -Ropinirole HCl (anti-[MEDICAL CONDITION] agent)1 mg three times daily for [MEDICAL CONDITION] -[MEDICATION NAME]-[MEDICATION NAME] Extended Release (ER) 50 mg-200 mg three times daily for [MEDICAL CONDITION] -[MEDICATION NAME] HCl (antihypertensive) 0.2 mg twice daily for hypertension -[MEDICATION NAME] (urinary tract [MEDICATION NAME]) 5 mg twice daily -Vitamin D-3 1000U (vitamin supplement) every evening Review of the (MONTH) 2019 Medication Administration Record (MAR) revealed there was no documentation that the resident was administered the following medications: [REDACTED] -On (MONTH) 27 at 7 p.m. for Memantine HCl -On (MONTH) 14 and 25 for [MEDICATION NAME] -On (MONTH) 12 at 6 a.m. for Entacapone -On (MONTH) 25 at 6 p.m. and (MONTH) 26 at midnight for [MEDICATION NAME] There was also no documentation that the resident refused these medications or that the medications had been held. Review of the (MONTH) 2019 MAR revealed there was no documentation that the resident was administered the following medications: [REDACTED] -On (MONTH) 3, 9, 13, 17, 20, 24, 25, 26, 27 and 31 at 7 p.m. for Memantine HCl -On (MONTH) 5, 10, 12, 17 and 31 for [MEDICATION NAME] lotion -On (MONTH) 2 and 3 in a.m., (MONTH) 4 and 5 in p.m., (MONTH) 6 in a.m./p.m., (MONTH) 9 in a.m./p.m., On (MONTH) 12 and 13 in a.m., (MONTH) 14 in a.m./p.m., (MONTH) 15, 16, 17, 18, 19, 20, 21, 22, 23, 24 in a.m., (MONTH) 25 in a.m./p.m., (MONTH) 26, 27, 28 and 29 in a.m., (MONTH) 30 in a.m./p.m. and (MONTH) 31 in a.m. for the [MEDICATION NAME] 4% patch. -On (MONTH) 25 for Donepezil HCl There was also no documentation that the resident refused these medications or that the medications had been held. Review of the (MONTH) 2019 MAR revealed there was no documentation that the resident was administered the following medications: [REDACTED] -On (MONTH) 9 and 6 at 6 p.m. for [MEDICATION NAME] -On (MONTH) 9 and 15 at 6 p.m., (MONTH) 16 at midnight, (MONTH) 23 at midnight and (MONTH) 30 at midnight for [MEDICATION NAME] HCl -On (MONTH) 2, 7, 14, 15, 21, 22, 28 and 29 at 7 p.m. for Memantine HCl -On (MONTH) 7 for [MEDICATION NAME] lotion -On (MONTH) 1, 2, 3, 4, 5, 6, 7, 8 in a.m., (MONTH) 9 in a.m./p.m., (MONTH) 11, 12, 13, 14 and 15 in a.m., (MONTH) 16 in a.m./p.m., (MONTH) 17, 18, 19, 20, 21 in a.m., (MONTH) 22 in a.m./p.m., and (MONTH) 23, 25, 26, 27, 28, 29 and 30 in a.m. for [MEDICATION NAME] 4% patch -On (MONTH) 9, 16 and 22 for Donepezil HCl -On (MONTH) 26 for [MEDICATION NAME] There was also no documentation that the resident refused these medications or that the medications had been held. Review of the (MONTH) 2019 MAR revealed there was no documentation that the resident was administered the following medications: [REDACTED] -On (MONTH) 7 at midnight and (MONTH) 24 at 6 p.m. for [MEDICATION NAME] HCl -On (MONTH) 6 and 20 at 7 p.m. for Memantine HCl -On (MONTH) 19, 20, 24, 25 and 31 in p.m. for [MEDICATION NAME] 4% patch There was also no documentation that the resident refused these medications or that the medications had been held. Review of the (MONTH) 2019 MAR revealed there was no documentation that the resident was administered the following medications: [REDACTED] -On (MONTH) 4 at 2 p.m. for Ropinirole HCl -On (MONTH) 4 at 2 p.m. for [MEDICATION NAME]-[MEDICATION NAME] ER -On (MONTH) 4 at 6 p.m. for [MEDICATION NAME] -On (MONTH) 4 at 2 p.m. for Entacapone -On (MONTH) 4 at 12 p.m. for [MEDICATION NAME] HCl -On (MONTH) 4 at 6 p.m. for Memantine HCl -On (MONTH) 5, 6, 14, 19, 20, 21, 26, 27 and 28 in a.m. and (MONTH) 29 in p.m. for [MEDICATION NAME] 4% patch -On (MONTH) 4 for Donepezil HCl There was also no documentation that the resident refused these medications or that the medications had been held. Review of the (MONTH) 2019 MAR revealed there was no documentation that the resident was administered the following medications: [REDACTED] -On (MONTH) 19 at 8 p.m. for Ropinirole HCl -On (MONTH) 19 at 8 p.m. for [MEDICATION NAME]-[MEDICATION NAME] ER -On (MONTH) 19 at 10 p.m. for Entacapone -On (MONTH) 5 at midnight for [MEDICATION NAME] HCl -On (MONTH) 19 and 20 at 8 p.m. for [MEDICATION NAME] HCl -On (MONTH) 19 and 20 at 8 p.m. for [MEDICATION NAME] -On (MONTH) 3, 4, 5, 6, 19 and 20 in p.m. for [MEDICATION NAME] 4% patch -On (MONTH) 13, 19 and 20 for Vitamin D-3 -On (MONTH) 19 and 20 for [MEDICATION NAME] There was also no documentation that the resident refused these medications or that the medications had been held. An interview was conducted on (MONTH) 31, 2019 at 1:43 p.m., with the Director of Nursing (DON/staff #152 ). She stated that her expectation for nursing in regard to documentation is to sign the MAR to show that the medication was given, held or that the resident refused the medication. She said if the medication administration documentation is incomplete, they get the nurses in as soon as possible to complete it. She stated she wasn't sure why the medication administration record for resident #24 had so much missing documentation from nursing, and had no explanation for it. An interview was conducted on (MONTH) 2, 2019 at 9:04 a.m. with a Licensed Practical Nurse (LPN/staff #7) regarding the process for medication documentation. She stated that if she needs to hold a medication for any reason she documents it. She said if a resident refuses the medication she throws it away, then documents that they refused and why. In regards to resident #24, she acknowledged there was missing documentation on the MAR, but she said that her process is always to document it. According to a facility policy titled, Medication Administration the individual administering medications must initial the resident's medication administration record on the appropriate area, after giving each medication, and before administering the next. Documentation must include administration sites, as necessary. Any topical medications given must be documented on the treatment administration record. If a medication is withheld, refused, or given at a time other than the scheduled time, the individual administering must initial and circle the MAR space provided, document on the as needed sheet regarding the reason, and notify the physician.",2020-09-01
494,THE LEGACY REHAB & CARE CENTER,35097,2812 SILVER CREEK ROAD,BULLHEAD CITY,AZ,86442,2019-08-02,690,D,0,1,5EQ911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff and resident interviews and policy review, the facility failed to provide care and services for one resident (#25) who was admitted with an indwelling urinary catheter. The deficient practice poses an increased risk for catheter complications. Findings include: Resident #25 was admitted to the facility on (MONTH) 12, 2019 and readmitted on (MONTH) 25, 2019. [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated (MONTH) 19, 2019 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS also included the resident had an indwelling catheter. Review of a physician's order dated (MONTH) 26, 2019 revealed for a Foley (indwelling urinary catheter) 16 French, 10 cubic centimeter (cc) balloon per medical doctor protocol for a [DIAGNOSES REDACTED]. A care plan dated (MONTH) 26, 2019 included the resident had a Foley catheter in place, due to a stage 4 sacral wound. Review of the clinical record revealed a hospital progress note dated (MONTH) 23, 2019 which stated that the resident had been admitted to the hospital on (MONTH) 15, 2019. A nurse progress note included that the resident was readmitted from the hospital on (MONTH) 25, 2019. A physician's progress note dated (MONTH) 25, 2019 included the resident had a Foley catheter in place. However, review of the admission physician's orders dated (MONTH) 25, 2019 revealed there were no orders for the indwelling urinary catheter, which included the size of the catheter and the balloon size, how often the catheter should be changed, or for any catheter care. An observation of resident #25 was conducted on (MONTH) 29, 2019 at 2:02 p.m., and a urinary catheter was in place. At this time, an interview was conducted with resident #25 regarding catheter care. She stated that staff do not clean it each shift, but they try to clean it daily. Another observation of resident #25 was conducted on (MONTH) 1, 2019 at 11:04 a.m. and a urinary catheter was observed to be in place. The current physician orders were reviewed in the a.m. on (MONTH) 1, 2019, and there were no orders for the indwelling catheter, which included the size of the catheter and the balloon size, how often the catheter should be changed, or for any catheter care. The (MONTH) and (MONTH) 2019 Treatment Administration Records (TARs) were also reviewed in the a.m. on (MONTH) 1, 2019, and there was no documentation regarding the urinary catheter or any documentation that catheter care was provided. An interview was conducted with a Certified Nursing Assistant (CNA/staff #121) on (MONTH) 1, 2019 at 11:25 a.m. She stated that she knows that resident #25 had a Foley catheter in place when she most recently returned to the facility from the hospital. She stated that she does perineal care each morning at the end of the shift and with any incontinent episodes, for her residents that have a catheter. Staff #121 said that she does not have a place to document the care. An interview was conducted with a Licensed Practical Nurse (LPN/staff #7) on (MONTH) 1, 2019 at 12:00 p.m. She stated that a resident with a Foley catheter would have physician's orders for the catheter size and care. She stated the nurse does the catheter care two times a shift and documents the care in the electronic record on the TAR. After reviewing the physician orders for resident #25, the nurse stated that the resident did not have current orders for the indwelling catheter or for the care of the catheter. Upon reviewing the TAR, she stated there were no entries related to the indwelling catheter and no documentation that catheter care had been provided. She stated the resident had recently returned from the hospital and the catheter was present prior to the hospitalization and was in place when she returned from the hospital. The physician's orders were reviewed again in the p.m. on (MONTH) 1, 2019 and now included orders for a 16 French Foley catheter with a 10 cc balloon for a stage 4 coccyx pressure ulcer and for Foley care per protocol. Review of the (MONTH) 2019 TAR revealed entries dated (MONTH) 1, 2019, which included for indwelling Foley catheter care as follows: check tubing every shift to ensure it is secured to the thigh; monitor skin integrity every shift where tubing lays; allow Foley drainage by gravity; change Foley bag 1 time a month; and change indwelling Foley catheter 16 French 10 cc (balloon) one time a month and as needed; replace [MEDICATION NAME] securing Foley tubing to thigh as needed; irrigate bladder with 60 cc 0.9% normal saline as needed to maintain patency; and change Foley bag as needed. An interview was conducted with the Director of Nursing (DON/staff #152) on (MONTH) 2, 2019 at 8:07 a.m. She stated that if a resident has an indwelling urinary catheter in place, there should be physician's orders for its use, which include the tube size and balloon size. She stated there should also be orders that correspond with the facility's catheter protocol, which includes securing the tubing, tubing placement, skin assessment, catheter care, drain by gravity, catheter change orders, bag change orders and flushing orders. She stated the CNA's are responsible for catheter care at least one time per shift, and the nurse's are responsible to make sure the care was given and to document the care in the TAR each shift. She acknowledged that on return from the hospital there were no orders obtained for the catheter or for the catheter care for resident #25, and that there was no documentation that catheter care was being provided during the current stay. She stated the lack of orders and documentation of care for this resident did not meet her expectation or facility policy, and would increase the risk for urinary tract infections, pain and discomfort. Review of the facility policy regarding Urinary Catheters revealed that indwelling catheters will be cared for in a manner to prevent infections and cross contamination. The policy included that prevention of infection measures included providing catheter care on a regular basis.",2020-09-01
495,THE LEGACY REHAB & CARE CENTER,35097,2812 SILVER CREEK ROAD,BULLHEAD CITY,AZ,86442,2019-08-02,695,D,0,1,5EQ911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, interviews and policy review, the facility failed to ensure one resident (#238) who was receiving oxygen had physician orders [REDACTED].#67) was receiving oxygen as ordered by the physician. The deficient practice could result in respiratory complications. Findings include: -Resident #238 was admitted to the facility on (MONTH) 9 2019, with [DIAGNOSES REDACTED]. Review of a care plan dated (MONTH) 10, 2019, revealed the resident had poor oxygenation and needed supplemental oxygen related to [MEDICAL CONDITION]. A nurse's note dated (MONTH) 10, 2019, revealed the resident was receiving oxygen via nasal cannula. However, review of the admission physician orders [REDACTED]. A nurse's note dated (MONTH) 21, 2019 revealed the resident was receiving oxygen at a rate of 2 liters per minute. A nurse's note dated (MONTH) 25, 2019 revealed the resident was receiving oxygen at a rate of 3 liters per minute. An observation of the resident was conducted on (MONTH) 29, 2019 at 2:27 p.m. The resident was observed with oxygen in place via nasal cannula at a rate of 3.5 liters per minute. An interview was conducted with a Licensed Practical Nurse (LPN/staff #10) on (MONTH) 31, 2019 at 3:05 p.m. She said oxygen should not be administered without a physician's orders [REDACTED]. She said that is where the mistake was made. An interview was conducted on (MONTH) 1, 2019 at 2:34 p.m., with the Director of Nursing (DON/staff #152). She said that oxygen should be administered by following the physician orders. She stated her expectation is that the nurse would assess the resident on admission and review the physician's orders [REDACTED]. She said the facility also has standing orders to administer oxygen to a resident for shortness of breath at any time, which could be implemented. She said these standing orders could be used temporarily as a bridge until the physician could be contacted to obtain an order for [REDACTED].> -Resident #67 was admitted on (MONTH) 10, 2019, with a [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A care plan dated (MONTH) 10, 2019 included a problem of poor oxygenation and the need for supplemental oxygen related to [MEDICAL CONDITION] or other respiratory conditions. The interventions included to monitor for signs of shortness of breath, make sure the oxygen tank is turned on and that the nasal cannula is in place. Review of a nurses progress notes on (MONTH) 30, 2019, revealed the resident's oxygen saturation was 97% on 2 Liters of oxygen. A nurses note on (MONTH) 5, 2019 included the resident's oxygen saturation was 95% on 2 Liters of oxygen. Review of the medication administration records (MAR's) for May, (MONTH) and (MONTH) 2019, revealed the resident was receiving oxygen continuously at 2 liters per minute via nasal cannula. The quarterly Minimum Data Set (MDS) assessment dated (MONTH) 22, 2019, revealed a Brief Interview for Mental Status score of 14, which indicated the resident was cognitively intact. The MDS also included the resident had shortness of breath and received oxygen therapy. During an observation conducted on (MONTH) 29, 2019 at 11:55 p.m., the resident was observed resting in bed, without any oxygen on. The resident was in an isolation room. On (MONTH) 30, 2019 at 10:25 a.m., the resident was observed sitting in a wheelchair in her room, without any oxygen in place. The oxygen concentrator was in the corner of the room. Another observation was conducted on (MONTH) 31, 2019 at 3:18 p.m. of the resident in bed, without any oxygen on. An interview was conducted on (MONTH) 31, 2019 at 3:18 p.m., with a LPN (Licensed Practical Nurse/staff #170). The nurse stated that the resident is supposed to be on oxygen at 2 Liters continuous per nasal cannula. At this time, the nurse checked resident #67's oxygen saturation level and it was at 96%. The nurse then placed the oxygen on the resident via nasal cannula. Staff #170 stated that since the resident was 96% on room air, she will contact the physician to see if they can get an order for [REDACTED]. Staff #170 said if the resident is taking the oxygen off, then they need to assess the resident and notify the physician, because it is very important for the heart to get the oxygen it needs. Staff #170 stated that she was not aware the resident was without oxygen. An interview was conducted on (MONTH) 1, 2019 at 12:53 p.m., with a CNA (staff#110). Staff #110 stated that if a resident is on continuous oxygen they are supposed to be on it at all times. She stated if a resident refused oxygen, she would let the nurse know. An interview was conducted on (MONTH) 1, 2019 at 1:10 p.m., with a LPN (staff #163). Staff #163 stated that if a resident has orders for oxygen at 2 Liters continuously, then they should be on oxygen at all times. She stated that if the resident was refusing oxygen, they should educate the resident about the risks and notify the physician, and they would need to document it. She also stated that by the end of the shift, it would need to be care-planned that the resident is refusing and has been advised of the risks. An interview was conducted on (MONTH) 1, 2019 at 3:09 p.m., with the DON (Director of Nursing/staff #152). The DON stated if a resident already has orders for oxygen on the treatment administration record, she expects the nurses to verify the flow rate that the resident is receiving. She stated if a resident is on continuous oxygen, they should be on it continuously. She stated if a resident refused oxygen, she would expect the nurse to do an assessment, check the oxygen saturation level and then discuss it with the provider, so they can make a recommendation to continue or change the oxygen to as needed or discontinue it. Review of the facility's policy for Oxygen Administration revealed the purpose of oxygen therapy is to provide sufficient oxygenation to the blood stream and tissues. The policy included that oxygen therapy is administered as ordered by the physician, or as an emergency measure until the order can be obtained.",2020-09-01
496,THE LEGACY REHAB & CARE CENTER,35097,2812 SILVER CREEK ROAD,BULLHEAD CITY,AZ,86442,2019-08-02,732,E,0,1,5EQ911,"Based on review of facility documentation, staff interviews and policy and procedure, the facility failed to ensure the nurse staffing information was complete and accurate. Findings include: Review of the nurse staffing postings for (MONTH) 2019 revealed the following issues: -July 2: A Licensed Practical Nurse (LPN) was listed as a Registered Nurse (RN). -July 3, 5 and 6: There were no postings for these dates. -July 7: The posting did not include any information regarding the night shift staffing. -July 10: There was no nurse staffing posting information for this date. -July 15: The nurse staffing posting did not include any information regarding the night shift staffing. -July 19 and 22: The nurse staffing posting did not include the facility's census or the night shift staffing information. -July 23: The nurse staffing posting did not include the facility's census for the day shift or any night shift staffing information. -July 25: The nurse staffing posting did not include the census or the night shift staffing information. -July 26: A Medication Technician (MT) was listed as an RN and the night shift staffing was not included in the posting. -July 27: The nurse staffing posting did not include the day shift staffing information. -July 28: The nurse staffing posting did not include the night shift census. On (MONTH) 1, 2019 at 8:23 a.m., an interview was conducted with the Director of Nursing (DON/staff #152). In regard to the missing information on the nurse staffing postings, she stated that the receptionist must not have updated it. She said the receptionist is responsible to ensure the postings are complete and accurate. She stated that the medication technician is not a nurse and should not have been listed as one. She said technically, that individual is a Certified Nursing Assistant. On (MONTH) 2, 2019 at 8:52 a.m., the facility receptionist (staff #64) was interviewed. She stated it is her responsibility to fill out the nurse staffing posting information for the day shift, and that other staff are responsible for posting it on the weekends and on Mondays. She said the evening secretary completes it for the evenings. She stated that he is a new employee, and that she has been training him to do the postings. She said that she gets her information from the nursing sign-in sheets, after staff sign in for their shift. She said she uses that information to fill out the posting for that shift. She stated that she only posts the day shift information for Tuesday-Friday. She said that she has tried to check the evening secretary's work to ensure the form is filled out correctly. Review of a facility policy titled, Nurse Staffing Posting Information revealed to post information on a daily basis, which included the total number and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care. Further, the policy stated within two hours of the beginning of each shift, the number of licensed nurses (Registered Nurses and Licensed Practical Nurses) and the number of unlicensed personnel (Certified Nursing Assistants/CNA's) directly responsible for resident care will be posted in a prominent location and shall be accessible to residents and visitors, and that the data shall be in a clear and readable format. The policy further included that the information recorded on the form shall include the resident census at the beginning of the shift for which the information is posted, the type (RN, LPN, CNA) and category (licensed or non-licensed) of nursing staff working during that shift; the actual time worked during that shift for each category and type of nursing staff; and the total number of licensed and non-licensed nursing staff working for the posted shift.",2020-09-01
497,THE LEGACY REHAB & CARE CENTER,35097,2812 SILVER CREEK ROAD,BULLHEAD CITY,AZ,86442,2019-08-02,756,D,0,1,5EQ911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy review, the facility failed to ensure that pharmacy recommendations were implemented and that the physician/provider responded to pharmacy recommendations for one resident (#15). The deficient practice could result in unnecessary medication administration for residents. Findings include: Resident #15 was admitted to the facility on (MONTH) 23, 2019, with [DIAGNOSES REDACTED]. The admission physician's orders [REDACTED]. Review of the pharmacy review dated (MONTH) 25, 2019 revealed the following recommendation to the physician: [MEDICATION NAME] may reduce the metabolism of [MEDICATION NAME] which may result in increased EPS (extrapyramidal symptoms) as well as fall risk. Consider either reducing [MEDICATION NAME] by 50% or [MEDICATION NAME] by 50%. The pharmacy review contained a space for the physician to agree or disagree with the recommendation. In front of agree there was a slash, with written documentation by the physician to decrease [MEDICATION NAME] by 50%. The form was signed by the physician on (MONTH) 9, 2019. However, review of the physician's orders [REDACTED]. There were no orders to decrease the [MEDICATION NAME] by 50%. Review of the physician's orders [REDACTED]. Review of a pharmacy recommendation dated (MONTH) 30, 2019 revealed recommendations for a dose taper for [MEDICATION NAME] and [MEDICATION NAME]. The recommendation also requested a quarterly note for [MEDICATION NAME]. Review of the clinical record revealed no evidence that the physician/provider had responded to the (MONTH) 2019 pharmacy recommendations. An interview was conducted on (MONTH) 1, 2019 at 2:34 p.m., with the Director of Nursing (DON/staff #152). She stated the pharmacy reviewed medication regimens for each resident on admission, every 30 days and as needed. She stated her expectation is that pharmacy recommendations would be addressed as quickly as possible, and the nurse would be expected to transcribe new orders which were written on pharmacy recommendations. She said the order to reduce [MEDICATION NAME] by 50% on (MONTH) 6, 2019 had not been transcribed or implemented, but it should have been. She said the pharmacy recommendations for (MONTH) 30, 2019 had been placed in the psychiatric provider's notebook for review, but the recommendations were still in the notebook and had not been addressed yet. Review of the facility's Medication Regimen Review policy revealed the consultant pharmacist would review the medication regimen of each resident at least monthly. The physician would respond in writing on the report with the action being taken and sign and date the report. Reports would be reviewed and written/verbal orders would be received within 7 working days of receipt of the review. The facility's policy for Gradual Dose Reduction (GDR) for [MEDICAL CONDITION] Medications stated the pharmacist would evaluate the dose, duration and continued need for all medications during the monthly medication review. Within the first year that a resident was admitted on a [MEDICAL CONDITION] medication or after a new order for a [MEDICAL CONDITION] medication, the pharmacist would recommend a GDR in two separate quarters, unless clinically contraindicated. Upon receipt of a pharmacy recommendation, the provider would assess the resident and determine if a GDR was appropriate or clinically contraindicated, and the provider would document such on the recommendation form.",2020-09-01
498,THE LEGACY REHAB & CARE CENTER,35097,2812 SILVER CREEK ROAD,BULLHEAD CITY,AZ,86442,2019-08-02,758,E,0,1,5EQ911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy review, the facility failed to ensure there were clinical indications and adequate monitoring for the use of [MEDICAL CONDITION] medications for one resident (#15), and failed to ensure that gradual dose reductions (GDR) were implemented or that there was documentation that GDR's were contraindicated. The deficient practice could result in unnecessary medication administration for residents. Findings include: Resident #15 was admitted to the facility on (MONTH) 23, 2019, with [DIAGNOSES REDACTED]. Review of the admission physician's orders [REDACTED]. Care plans dated (MONTH) 23, 2019 identified that the resident was receiving [MEDICATION NAME] and [MEDICATION NAME]. Interventions included to administer the medication per physician's orders [REDACTED]. Review of the pharmacy review dated (MONTH) 25, 2019 revealed the following recommendation to the physician: [MEDICATION NAME] may reduce the metabolism of [MEDICATION NAME] which may result in increased EPS (extrapyramidal symptoms) as well as fall risk. Consider either reducing [MEDICATION NAME] by 50% or [MEDICATION NAME] by 50%. The pharmacy review contained a space for the physician to agree or disagree with the recommendation. In front of agree there was a slash, with written documentation by the physician to decrease [MEDICATION NAME] by 50%. The form was signed by the physician on (MONTH) 9, 2019. An admission Minimum Data Set (MDS) assessment dated (MONTH) 30, 2019, revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The assessment revealed the resident had received an antipsychotic and an antidepressant during the 7 day lookback period. Review of a history and physical dated (MONTH) 5, 2019, revealed [DIAGNOSES REDACTED]. The psychiatric review of systems included denies depression, anxiety, complaint of memory loss, mental disturbance, suicidal ideation, hallucinations, paranoia. The physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. According to the Weekly Psychiatric Medication Monitoring forms for (MONTH) 2019, there was also no evidence that the resident was monitored for any targeted behaviors related to depression or [MEDICAL CONDITION]. Review of the MAR for (MONTH) 2019 revealed the resident continued to receive [MEDICATION NAME] 25 mg and [MEDICATION NAME] 0.5 mg daily, and was monitored for adverse reactions related to [MEDICAL CONDITION] medication use. Review of the Weekly Psychiatric Medication Monitoring forms for (MONTH) 2019, revealed the resident was monitored for targeted behaviors of depression related to [MEDICATION NAME] use, and [MEDICAL CONDITION] related to the use of [MEDICATION NAME]. Per the documentation, the resident had no behaviors related to depression or [MEDICAL CONDITION]. The MAR for (MONTH) 2019 included the resident continued to receive [MEDICATION NAME] 25 mg and [MEDICATION NAME] 0.5 mg daily, and was monitored for adverse reactions related to [MEDICAL CONDITION] medication use. The Weekly Psychiatric Medication Monitoring forms for (MONTH) 2019, revealed no evidence that the resident was monitored for any targeted behaviors related to depression for [MEDICATION NAME]. The documentation also showed that the resident was not monitored for targeted behaviors related to [MEDICATION NAME] during the weeks of (MONTH) 4 and 12. During the weeks of (MONTH) 18 and 25, the resident had only one behavior related to [MEDICAL CONDITION]. Review of the MAR for (MONTH) 2019 revealed the resident continued to receive [MEDICATION NAME] 25 mg and [MEDICATION NAME] 0.5 mg daily, and was monitored for adverse reactions related to [MEDICAL CONDITION] medication use. Review of the Weekly Psychiatric Medication Monitoring forms for (MONTH) 2019, revealed the resident was monitored for targeted behaviors related to [MEDICATION NAME] and [MEDICATION NAME]. Per the documentation, the resident had demonstrated ten behaviors related to depression or [MEDICAL CONDITION]. According to a pharmacy review dated (MONTH) 30, 2019, the pharmacist recommended for a dose taper for [MEDICATION NAME] and [MEDICATION NAME]. The recommendation also requested a quarterly note for [MEDICATION NAME]. Review of the MAR for (MONTH) and (MONTH) 2019 revealed the resident continued to receive [MEDICATION NAME] 25 mg and [MEDICATION NAME] 0.5 mg daily, and was monitored for adverse reactions related to [MEDICAL CONDITION] medication use. Review of the Weekly Psychiatric Medication Monitoring forms for (MONTH) and (MONTH) 2019, revealed the resident was monitored for targeted behaviors of depression and [MEDICAL CONDITION]. Per the documentation, the resident had no behaviors of depression and [MEDICAL CONDITION]. Further review of the clinical record revealed no evidence that a gradual dose reduction was implemented for [MEDICATION NAME] or [MEDICATION NAME] or that a GDR was contraindicated. An interview was conducted on (MONTH) 1, 2019 at 2:34 p.m., with the Director of Nursing (DON/staff #152). She said for [MEDICAL CONDITION] medications, the physician would document the necessity of the medication in a psychiatric progress note. However, she said there were no psychiatric provider notes in this resident's chart. She stated her expectation is that residents who are on [MEDICAL CONDITION] medications should receive weekly monitoring for targeted behaviors. Staff #152 said if there were any changes or concerns, the physician should be notified. She said targeted behavior documentation for this resident was missing for (MONTH) 2019, and was partially missing for (MONTH) 2019. She also stated her expectation is that pharmacy recommendations would be addressed as quickly as possible and the nurse would be expected to transcribe new orders from the pharmacy recommendations. She said the order to reduce [MEDICATION NAME] by 50% on (MONTH) 6, had not been transcribed or implemented, but it should have been. She said the pharmacy recommendations for (MONTH) 30, had been placed in the psychiatric providers notebook for review, but the recommendations were still in the notebook and had not been addressed yet. Review of the facility's [MEDICAL CONDITION] Medication Use policy revealed that residents will only receive [MEDICAL CONDITION] medications when necessary to treat a specific condition for which they are indicated and effective. The prescriber and facility staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, symptoms and risks. Nursing staff will document an individual's target behavior(s). The provider will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications. Based on assessing the resident's symptoms and overall situation, the provider will determine whether to continue, adjust, or stop existing antipsychotic medication. The facility's policy for Gradual Dose Reduction (GDR) for [MEDICAL CONDITION] Medications stated the pharmacist would evaluate the dose, duration and continued need for all medications during the monthly medication review. Within the first year that a resident was admitted on a [MEDICAL CONDITION] medication or after a new order for a [MEDICAL CONDITION] medication, the pharmacist would recommend a GDR in two separate quarters, unless clinically contraindicated. Upon receipt of a pharmacy recommendation, the provider would assess the resident and determine if a GDR was appropriate or clinically contraindicated, and the provider would document such on the recommendation form.",2020-09-01
499,"SAPPHIRE OF TUCSON NURSING AND REHAB, LLC",35099,2900 EAST MILBER STREET,TUCSON,AZ,85714,2019-01-10,552,D,0,1,V3CM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record review, staff interviews and policies and procedures, the facility failed to ensure that one resident (#135) had been informed in advance of the risks and benefits of an antipsychotic medication. Findings include: Resident #135 was admitted on (MONTH) 7, (YEAR), with [DIAGNOSES REDACTED]. Review of the closed clinical record revealed a form titled Admission Record dated (MONTH) 7, (YEAR), which included the resident was self-responsible. A form titled, Consent to Admit and Treat dated (MONTH) 7, (YEAR) included a statement that the signer of the form was the responsible party for medical decision making. The form was signed by resident #135. A physician's orders [REDACTED]. A written care plan initiated on (MONTH) 10, (YEAR) for the use of [MEDICAL CONDITION] medications related to behavioral management included an intervention for staff to educate the resident/family/caregivers about the risks, benefits and side effects and toxic symptoms of the medication. Further review of the clinical record revealed no evidence that the resident was informed of the risks, benefits and side effects of Risperdone. An interview was conducted on (MONTH) 10, 2019 at 9:17 a.m., with the Director of Nursing (DON/staff #125). The DON stated that when an antipsychotic drug is prescribed, the use of the medication is explained to the resident, and they have a form which includes the risks and benefits of the medications. The DON stated that they are to obtain informed consent. The DON said that after the risks and benefits are explained, the resident signs the form. An interview was conducted on (MONTH) 10, 2019 at 9:35 a.m. with a RN (Registered Nurse/staff #165). During the interview, the nurse stated that there are consent forms for antipsychotic medications. Staff #165 said if the resident is unable to sign the consent form, consent is obtained from the resident's responsible party. Staff #165 stated they are required to obtain informed consent, prior to providing an antipsychotic medication to a resident. An interview was conducted on (MONTH) 10, 2019 at 10:04 a.m. with medical records staff (#183), who stated that there was no informed consent for the use of Risperdone for resident #135. A policy regarding resident rights included that Federal and State laws guarantee certain basic rights to all residents of the facility. These rights include the resident's right to choose a treatment and participate in decisions and care planning.",2020-09-01
500,"SAPPHIRE OF TUCSON NURSING AND REHAB, LLC",35099,2900 EAST MILBER STREET,TUCSON,AZ,85714,2019-01-10,578,E,0,1,V3CM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews and policy review, the facility failed to ensure that two residents (#164 and #121) were afforded the right to formulate advance directives. Findings include: -Resident #164 was admitted to the facility on (MONTH) 18, (YEAR), with [DIAGNOSES REDACTED]. Review of an Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident scored a 9 on the Brief Interview for Mental Status (BIMS), which indicated moderate cognitive impairment. Review of the resident's clinical record revealed no evidence of any advance directives for resident #164. There was also no documentation that the resident declined formulating advance directives. Further review of the clinical record revealed there was no code status listed on the resident's face sheet or in the available space specific for code status in the electronic record. According to the current physician's orders [REDACTED]. In an interview with a Licensed Practical Nurse (LPN/staff #153) on (MONTH) 10, 2019 at 9:30 a.m., she stated if she needed to find out a resident's code status, she would look in the electronic record, as there is a place where the code status is easily viewable. Further, she stated the resident's code status is listed on their report sheet. She stated the code status should be updated, as soon as the resident is admitted . An interview with medical record staff (staff #184) was conducted on (MONTH) 10, 2019 at 9:34 a.m. At this time, she reviewed resident #164's scanned documents and was unable to find any advance directives. She stated it could be in a stack of documents that are waiting to be scanned, however, no advanced directives were located. She also stated it could be in the physician's binder waiting to be signed by the physician, however, no advanced directives were found in the binder. In an interview with the Director of Nursing (DON/staff #125) on (MONTH) 10, 2019 at 1:31 p.m., she stated an audit had just been done in late December, ensuring that all residents had advanced directive forms filled out. -Resident #121 was admitted to the facility on (MONTH) 13, (YEAR), with [DIAGNOSES REDACTED]. Review of the admission MDS assessment dated (MONTH) 20, (YEAR), revealed the resident was cognitively intact. A physician's orders [REDACTED]. However, review of the clinical record revealed there were no advance directives which were signed by the resident. Also, the code status was not listed on the resident's face sheet or in the available space specific for code status in the resident's electronic record. An interview was conducted with a LPN (staff #150) on (MONTH) 8, 2019 at 1:25 PM. The LPN stated that upon admission all consent forms are signed including advance directives. She stated that a resident's code status could be found on the face sheet or in the document section of the electronic medical record. Staff #150 was unable to locate any advanced directives which were signed by the resident. An interview was conducted with Medical Records (staff #183) on (MONTH) 8, 2019 at 1:46 PM. She stated there was no record of advance directives on file for resident #121. She said the advance directives should be filled out upon admission or a few days later. An interview with the DON (staff #125) was conducted on (MONTH) 10, 2019 at 11:40 AM. She stated the floor nurse is responsible for obtaining signed consents, including advance directives when the resident is admitted to the facility. She said if there is a problem social services should be notified. The DON stated she could not answer for what happened in September, as she was not employed by the facility at that time. The facility policy for Interpretation and Implementation for Advance Directives indicated that upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive, if he or she chooses to do so. The policy stated that the information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. The Director of Nursing or designee will notify the attending physician of advance directives, so that appropriate orders can be documented in the resident's medical record and plan of care.",2020-09-01
501,"SAPPHIRE OF TUCSON NURSING AND REHAB, LLC",35099,2900 EAST MILBER STREET,TUCSON,AZ,85714,2019-01-10,584,E,0,1,V3CM11,"Based on observations, and family, resident and staff interviews, the facility failed to maintain an environment that was free of odors. Findings include: During a family interview conducted on (MONTH) 7, 2019 at 11:07 a.m., the family member of a resident stated that the hallways on the second floor always smell like urine. An interview with a resident who resided on the second floor was conducted on (MONTH) 7, 2019 at 11:49 a.m. The resident stated that he keeps his door to the bathroom shut, because of the sewage odor. During an interview conducted on (MONTH) 7, 2019 at 1:28 p.m. with another resident who resided on the second floor, a strong pervasive urine odor was detected in this resident's room and in the bathroom. During the survey from (MONTH) 7 through 10, 2019, pervasive urine odors were frequently smelled in the hallways on the second floor. An environmental tour was conducted on (MONTH) 10, 2019 at 12:30 p.m., with the maintenance director (staff #180) and the administrator (as of (MONTH) 12/staff #222). At this time, there was still a slight sewage odor in the first resident's bathroom on the second floor. An interview was conducted with the maintenance director (staff #180) on (MONTH) 10, 2019 at 12:40 p.m. Staff #180 stated that he would call a plumber to address the odor in the bathroom. An interview was conducted with staff #222 on (MONTH) 10, 2019 at 12:45 p.m. Staff #222 stated that she thought she smelled urine yesterday, when the resident was being changed. The facility did not have policy regarding the prevention of odors throughout the facility.",2020-09-01
502,"SAPPHIRE OF TUCSON NURSING AND REHAB, LLC",35099,2900 EAST MILBER STREET,TUCSON,AZ,85714,2019-01-10,600,E,1,1,V3CM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, clinical record reviews, staff and resident interviews, facility documents and policies and procedures, the facility failed to ensure that one resident (#225) with dementia and behaviors was free from neglect, failed to ensure that one resident (#61) was free from abuse by resident (#275), failed to ensure that one resident (#117) was free from abuse by resident (#61), and that one resident (#21) was free from abuse by resident (#62). Findings include: -Resident #225 was admitted on (MONTH) 22, (YEAR) and readmitted on (MONTH) 16, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed a written care plan initiated on (MONTH) 11, (YEAR), with a revision date of (MONTH) 16, (YEAR), which identified that the resident was an elopement risk/wanderer, related to escapist behavior and history of attempts to leave the facility unattended. A goal included the resident would not leave the facility unattended. Interventions included identifying a pattern of wandering and intervening as appropriate, monitoring the resident's location every 30 minutes and documenting wandering behavior. A quarterly MDS (Minimum Data Set) assessment dated (MONTH) 25, (YEAR) included a BIMS (Brief Interview for Mental Status) score of 9, which indicated the resident had moderate cognitive impairment. The MDS also included the resident was delusional, had physical and verbal behavioral symptoms directed at others, refused care, wandered daily and had dementia and [MEDICAL CONDITION]. A nurse practitioner assessment dated (MONTH) 2, (YEAR), revealed the resident had dementia, wandering, [MEDICAL CONDITION], anxiety, adjustment disorder and depression. The assessment included the resident was residing on the behavioral unit for safety and received psychiatric services. The assessment also included the resident desperately tries to escape if given the chance. She speaks Spanish mostly, but understands a lot of English. Under assessment and plan it included the following: wandering-provide a safe and nuturing environment. A nursing note dated (MONTH) 17, (YEAR) at 6:34 a.m. included the resident had been exit seeking from the unit through the main locked door to the unit and also by a (locked) back door to the unit. A nursing note dated (MONTH) 23, (YEAR) included the following: the resident had been exit seeking and had attempted to leave through the front door, and had struck a staff member when redirected back to the unit. A nursing note dated (MONTH) 5, (YEAR) at 10:05 a.m. revealed the resident was discovered missing at 8:15 a.m. The note included the resident was not discovered in her room and that a code yellow had been initiated. Continued review of the closed record for resident #225 revealed that the resident did not return to the facility after she eloped. Review of the facility's investigative report dated (MONTH) 5, (YEAR) revealed that on the morning of (MONTH) 5, (YEAR), the resident had not reported for breakfast and the missing person procedures were immediately implemented. The investigation included the resident was able to leave the facility, obtain transportation, cross the border into Mexico, and after entering Mexico obtained transportation to a family home in Mexico, arriving unharmed. The report also included that the resident had been residing on a behavioral health (secured) unit, and that exit seeking and wandering behaviors were being monitored. Continued review of the investigative report revealed a written staff statement obtained by a CNA (Certified Nursing Assistant/staff #222) dated (MONTH) 5, (YEAR) at 2:45 p.m. The statement included that the resident was last seen in the resident dining room on (MONTH) 4, (YEAR) between 8:30 p.m. and 9:00 p.m. The report further included that facility policies were not followed, as safety checks were missed. An interview was conducted with the Administrator (staff #20) on (MONTH) 7, 2019 at 10:15 a.m. The Administrator stated that it had been determined through the facility investigation that resident #225 had obtained an identification badge from a staff member (which the staff member thought had been misplaced) two weeks prior to her elopement from the facility, and had obtained money in small increments over time from her visitors, which enabled her to purchase bus fare. The Administrator also stated that the security camera footage, which had been examined during the investigation showed the resident had used a staff badge to open the exit door and then quickly exited the unit. An interview was conducted on (MONTH) 8, 2019 at 12:30 p.m. with a CNA (staff #97), who stated that she had been assigned to provide care to resident #225 on (MONTH) 5, (YEAR) on the night shift (11:00 p.m. until 7:00 a.m.). She stated that when she arrived at 11:00 p.m., the previous CNA reported to her that all of the residents in her section were in bed, including resident #225 and that she observed the door to the resident's room was closed. Staff #97 stated that there were other residents in her section who were very ill and she was unable to check on resident #225, because she was busy caring for the residents who were ill. Staff #97 said the facility protocol was to check the residents every 15-30 minutes but not less than hourly, and that she did not check the resident that night. She stated that she assumed her co-worker (CNA/staff #49) who was assigned to another section was checking on all of the residents and assumed that resident #225 was in her room, because the door to her room was closed. She stated that she never actually saw the resident on her shift. She further stated that at approximately 2:00 a.m., she observed staff #49 enter the resident's room as he was passing water, and then exit the resident's room, and assumed that the resident was in her room. The CNA stated she was aware that the resident had a history of [REDACTED].#49 told her that although he entered the resident's room to pass ice water during the night shift, he did not see the resident in her room and did not know where she was. During an interview conducted on (MONTH) 8, 2019 at 12:35 p.m. with a CNA (staff #49), the CNA stated that he did not remember resident #225 and did not remember anything about a resident eloping from the facility. An interview was conducted on (MONTH) 8, 2019 at 1:15 p.m. with a LPN (Licensed Practical Nurse/staff #201). Staff #201 stated that she worked on the secured behavioral unit on the night shift on (MONTH) 5, (YEAR). Staff #210 said that she did not see the resident on her shift and the door to the resident's room was closed all night. The nurse stated that she was aware that the resident had made frequent statements that she was going to leave the facility and go to Mexico where she owned a home. The facility was unable to provide a written policy regarding frequent resident safety checks on the behavioral unit. A policy and procedure titled, Recognizing Signs and Symptoms of Abuse/Neglect included the definition of neglect, as the failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. The policy also listed signs of actual physical neglect that included inadequate provision of care and leaving someone unattended who needs supervision. Review of the Reporting Abuse policy revealed that all suspected violations or substantiated incidents of abuse/neglect will be immediately reported to the State licensing/certification agency. -Resident #61 was admitted to the facility on (MONTH) 20, 2014, with [DIAGNOSES REDACTED]. Review of a Nursing Note dated (MONTH) 4, (YEAR) revealed .Resident has had a few outbursts when there is an excessive amount of noise. Resident had three episodes of yelling out (using profanity) and two episodes of attempting to go down to the room of the resident who was yelling out to shut him up. Staff was there to redirect resident immediately. A Nursing Note dated (MONTH) 3, (YEAR) revealed Resident had several verbal outbursts during shift. Resident primarily has these outbursts when other residents are having an increase in behaviors by making loud noises and yelling . A Nursing Note dated (MONTH) 21, (YEAR) revealed Resident has episodes of yelling out when he is startled with other loud noises like other residents yelling or doors slamming . A quarterly MDS assessment dated (MONTH) 6, (YEAR), revealed the resident had short-term and long-term memory problems and was severely impaired with daily decision making. The MDS also included the resident required extensive assistance with one staff assistance with activities of daily living. A Behavior care plan dated (MONTH) 20, (YEAR) revealed resident #61 has behavior problems (agitation, poor safety awareness, verbal aggression, repetitive statements, disruptive/intrusive, wandering, mood issues, pacing, exit seeking, refusal of care, disorganized thinking and physical aggression), related to [MEDICAL CONDITION], anxiety, mood disorder and status [REDACTED]. The goal included the resident will have fewer episodes of behaviors. Interventions were to administer medications as ordered; assist the resident to develop more appropriate methods of coping and interacting with other dementia residents; encourage the resident to express feelings appropriately and if reasonable, discuss the resident's behavior; explain/reinforce why behavior is inappropriate and/or unacceptable; intervene as necessary to protect the rights and safety of others; approach/speak in a calm manner; divert attention; remove from situation and take to alternate location as needed; monitor behavior episodes and attempt to determine underlying cause; and when resident is sitting next to other peers, ensure appropriate space to prevent physical aggression towards peers. Review of a Nursing Note dated (MONTH) 30, (YEAR) revealed .Resident began having a verbal altercation with another resident and he went up to the other resident and struck her in the face on the right cheek. The other resident retaliated and struck this resident on both arms. Both residents were immediately separated. No visible injuries noted to this resident . Review of the annual MDS assessment dated (MONTH) 1, (YEAR) revealed resident #61 had a BIMS (Brief Interview for Mental Status) score of 9, which indicated moderate impaired cognition. A Nursing Note dated (MONTH) 16, (YEAR) revealed a CNA reported to this writer that resident #61 and resident #275 were swinging their arms with closed fists. Both residents were separated. Resident #61 stated that resident #275 hit him in the face. Reddened area noted to resident face. -Resident #275 was admitted to the facility on (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. Review of a Nursing Note dated (MONTH) 17, (YEAR) revealed called into room by staff at 5:55 p.m., observed resident #275 laying in bed, and another resident was sitting on floor mat with blood on his face. The other resident was unable to explain what happened due to cognitive deficit. Resident #275 stated the resident woke him up and was messing with his bed and he hit peer in the face . A Nursing Note dated (MONTH) 11, (YEAR) revealed that resident #275 started hitting a resident from another room with a wire waste basket in the hallway. Resident #275 was upset that another resident was wearing his hoodie. Resident #275 has shown that he is very territorial and aggressive with male residents that might wander into his room, let's not forget that this is a unit where many of the residents suffer from dementia . A Behavior care plan dated (MONTH) 20, (YEAR) revealed that resident #275 has a history of initiating physical aggression. The goal was resident will not initiate aggression towards other residents. Resident should have a quiet area to stay in after dinner. He is sensitive to noise and busyness. Interventions to prevent the behaviors were to anticipate and prevent new incidents of violence towards another resident; provide snack, provide activities that promote non-aggressive interactions with other residents like one to one social activity; and provide activity so resident is not focused on busyness after meal times, as it is becoming evident he is not able to tolerate noise. Review of the quarterly MDS assessment dated (MONTH) 6, (YEAR), revealed a BIMS score of 1, which indicated the resident had severe cognitive impairment. A Nursing Note dated (MONTH) 16, (YEAR) revealed this writer was notified by a CNA that resident #275 and resident #61 were swinging their arms with closed fists. Residents were quickly separated by CN[NAME] Reddened area noted on resident #61's face. Further review of resident#275's clinical record revealed he had two more altercations with other residents on (MONTH) 14 and 19, (YEAR) in which he was the aggressor. Resident #275 was discharged from the facility on (MONTH) 19, (YEAR). An interview was conducted with a CNA who stated that the facility usually staffed three CNA's on this unit for 20-24 high acuity behavioral residents. The CNA stated that one CNA is supposed to monitor the hallway at all times to ensure that resident to resident altercations do not occur, but that doesn't always happen when staff call in. An interview was conducted with another CNA who stated that we are supposed to have someone monitor the hallway at all times, but that does not always happen. The CNA stated we do the best we can but if there is a call in we often do not have someone to monitor the hallway and that's when the residents get in to it. The CNA stated that resident #275 got into a lot of incidents with other residents and would laugh afterwards. The CNA stated that resident #61 does not like loud noises and doors slamming and that was usually when he got into altercations with other residents, because it upset him. The CNA stated that when resident #61 got upset he clapped his hands and said shhh and that irritated a lot of residents. The CNA further stated that a lot of the resident to resident altercations usually occurred when the facility did not have someone to monitor the hallway. An interview was conducted with a LPN who stated that resident #61 runs up and down the hall and resident #275 is paranoid. The LPN stated that staffing was recently cut on this high acuity behavioral unit and that they do the best they can. An interview was conducted with the administrator (staff #20) on (MONTH) 10, 2019 at 9:25 a.m. Staff #20 stated that there should be a monitor on the hallway at all times on that unit. -Resident #117 was admitted to the facility on (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. A care plan revised on (MONTH) 28, (YEAR), included the resident required a secured unit due to [DIAGNOSES REDACTED]. Interventions included redirecting the resident when having behaviors. A quarterly MDS assessment dated (MONTH) 17, (YEAR) revealed the resident had short-term and long-term memory problems and was moderately impaired with daily decision making. The assessment also included the resident required supervision with set up help only for most activities of daily living and utilized a walker. Review of the clinical record revealed multiple nursing notes for (MONTH) (YEAR) describing the resident as being verbally aggressive toward staff and laughing loudly at other residents. A nursing note dated (MONTH) 30, (YEAR) revealed that at approximately 9:53 a.m., resident #117 began having a verbal altercation with another resident (#61), and the other resident struck resident #117 in the face on the right cheek. Resident #117 then struck resident #61 back, hitting him on the arms. Both residents were immediately separated. No visible injuries noted. Both residents will not be in the same dining hall as each other. Review of the facility's investigative documentation dated (MONTH) 30, (YEAR), revealed that resident #117 was in the hallway by her room, which was across the hall from resident #61's room. Resident #117 began cursing in the hallway, as she has a history of this behavior. Resident #61 was sitting in his wheelchair in the doorway to his room and got up and confronted resident #117 in the hallway outside their rooms. They began yelling back and forth and before staff could intervene, resident #61 hit resident #117 and then resident #117 hit resident #61. The residents were separated and resident #117 was moved to another room. No injuries were noted. When resident #117 was asked about the incident, she stated He hit me! Per the report, a housekeeping staff (#135) witnessed the incident. She reported that resident #117 was cursing at her and resident #61 told resident #117 to be quiet. Resident #117 kept cursing, and then resident #61 got up, went to resident #117 and they both made contact with each other. A statement from a licensed practical nurse (LPN/staff #166) included that she did not witness the incident but was at the nurses' station and heard resident #117 yelling that resident #61 hit her. She immediately went to the hallway and found resident #61 standing in front of resident #117 with his fists up. The residents were separated immediately. In an interview with staff #135 on (MONTH) 9, 2019 at 9:32 a.m., she stated she had worked at the facility for over three years and is usually on the secured behavioral unit. She said that resident #117 is constantly being verbally aggressive and intimidates a lot of people. In an interview with a LPN (staff #148) on (MONTH) 9, 2019 at 9:41 a.m., she stated that resident #61 usually hangs out in the hallway and is not one to instigate things. Staff #148 said he has a behavior of yelling out, which sometimes sets other residents off inadvertently, and he is easily triggered by noises. She stated when resident #117 used to be on her hall, her loud laughing and yelling would irritate resident #61. She stated staff tried to redirect resident #117 by asking her to stop or taking her to an activity or to a different area. In an interview with a LPN (staff #156) on (MONTH) 9, 2019 at 9:49 a.m., he stated resident #117's behaviors include laughing out loud at random and yelling at others. He stated the other residents sometimes get agitated and they think resident #117 may be doing it on purpose. He stated sometimes she yells racial slurs and the other residents tell her to shut up. Additionally, he stated resident #117 is easily redirectable, but that does not work all the time. The LPN stated she is followed by the behavioral health team but for the most part, her behavior does not change. An observation was conducted on (MONTH) 9, (YEAR) at 10:35 a.m., during a resident smoke break. Resident #117 was observed to be laughing loudly and sticking her tongue out, which appeared to be directed at no one in particular. The staff present redirected the resident who then sat back down and continued to smoke her cigarette without further incident. In an interview with the administrator (staff #20) on (MONTH) 10, 2019 at 1:17 p.m., he stated when he receives an allegation of a resident to resident altercation, he will get more information about what happened, report to appropriate parties and begin an investigation. -Resident #21 was admitted to the facility on (MONTH) 18, (YEAR), with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] included the resident had a BIMS score of 15, indicating no cognitive impairment. The MDS assessment also included the resident had verbal behavioral symptoms directed toward others. Review of the care plan regarding antipsychotic medication related to [MEDICAL CONDITION] included the following interventions: when the resident becomes agitated intervene before agitation escalates; guide the resident away from the source of distress; engage calmly in conversation; and if the response is aggressive remove other residents from the area and approach later. A nursing note dated 11/29/2018 revealed that at approximately 10:50 a.m., resident #21 was witnessed sitting towards the end of the hall in front of another resident's (#62) room. Resident #21 began to yell and curse in Spanish. Resident #62 approached the doorway and told resident #21 to move. Both residents were yelling and swinging their arms at each other. The residents were immediately separated and redirected into opposite directions. No injuries noted at this time. -Resident #62 was admitted on (MONTH) 06, (YEAR), with [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] included a BIMS score of 15, which indicated the resident had no cognitive impairment. The MDS assessment also included the resident had verbal behavioral symptoms directed toward others. Review of the current behavior care plan revealed the resident had the potential to be physically aggressive and threatening toward other residents and staff. Interventions included for staff to escort the resident from room to destination and from destination to room, and keep him a safe distance from other residents. A nurse's note dated 11/29/2018 included that at approximately 10:50 a.m., resident #62 was witnessed standing in front of resident #21. Resident #21 was sitting in front of his doorway in a wheelchair and resident #62 told him to move. Resident #21 started to yell and curse at him in Spanish. Resident #62 then raised his left hand and with a closed fist, hit resident #21. Both residents were swinging their arms at each other. They were immediately separated and redirected into opposite directions. No injuries were noted. Review of the facility's investigative report revealed that on (MONTH) 29, (YEAR) at 10:50 a.m., resident #21 was sitting in his wheelchair in front of the door to resident #62's room. Resident #62 asked resident #21 to move, and angry words were exchanged. The residents struck out at each other and no injuries were noted. The report also included a witness statement from the housekeeper (staff #135) that she heard the residents arguing in front of resident #62's door who was telling resident #21 to move. The statement included that resident #21 hit resident #62 in the face and that both residents were hitting each other. The report revealed that resident #21 was unable to recall the incident and resident #62 reported that He kept cussing at me and I told him to stop. I told him if he didn't stop I would hit him, and he didn't stop, so I hit him. During an interview conducted with resident #62 on 1/8/19 at 2:29 p.m., the resident stated that resident #21 was sitting in front of his door and that he asked him to leave. Resident #62 stated that the resident called his mother names in Spanish and that he hit him. During an interview conducted with resident #21 on 1/8/2019 at 2:43 p.m., the resident stated that resident #62 yelled at him and he yelled back. Resident #21 stated that resident #62 hit him and that he hit him back and that they punched each other until they were separated. An interview was conducted with a LPN (staff #148) on 1/09/19 at 10:01 a.m. The LPN stated that she heard yelling and saw the housekeeper separating resident #21 and resident #62. She stated that she helped separate the residents and then assessed them for injuries. The LPN stated that both residents do occasionally yell and blow off steam, but that resident #62 is often more verbal and physically threatening. Review of the facility's policy regarding Abuse Prevention Program revealed Our residents have the right to be free from abuse, neglect . Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to staff and other residents . The facility's policy regarding Unmanageable Residents revealed that each resident will be provided with a safe place of residence. The policy included that should a resident's behavior become abusive in any way that would jeopardize his or her safety or the safety of others, the Nurse Supervisor/Charge Nurse must immediately provide for the safety of all concerned. The policy also included unmanageable residents may not be retained by the facility. Review of a facility policy titled, Resident-to-Resident Altercations included that staff will monitor residents for aggressive/inappropriate behavior towards other residents. The policy included that all altercations, including those that may represent resident-to-resident abuse, shall be investigated and reported to the Administrator/Director of Nursing.",2020-09-01
503,"SAPPHIRE OF TUCSON NURSING AND REHAB, LLC",35099,2900 EAST MILBER STREET,TUCSON,AZ,85714,2019-01-10,607,E,0,1,V3CM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, facility documents and policy review, the facility failed to include in their Abuse policy that all alleged violations of abuse and neglect, must be reported to the State Survey Agency within two hours after the allegation is made, as manifested by an allegation of neglect for one resident (#225). Findings include: Resident #225 was admitted on (MONTH) 22, (YEAR), with [DIAGNOSES REDACTED]. A nursing note dated (MONTH) 5, (YEAR) at 10:05 a.m. revealed the resident was discovered missing at 8:15 a.m. The note included the resident was not discovered in her room and that a code yellow had been initiated. Review of the facility's investigative report dated (MONTH) 5, (YEAR) revealed that on the morning of (MONTH) 5, (YEAR), it was determined that the resident had not reported for breakfast, so missing person procedures were immediately implemented. The report included the resident was able to leave the facility obtain transportation, cross the border into Mexico, and after entering Mexico obtained transportation to a family home, arriving unharmed. Continued review of the investigative report revealed that although the resident was discovered missing on (MONTH) 5, (YEAR) at 8:30 a.m., the facility did not notify the State Survey Agency until 3:30 p.m. on (MONTH) 5. An interview was conducted with the Administrator (staff #20) on (MONTH) 8, 2019 at 2:46 p.m. The Administrator stated that the facility had two hours to report all allegations of abuse, including neglect to the State Agency. The Administrator also stated that he was unable to explain why the elopement of resident #225 was reported late to the State Agency. Review of the facility's policy and procedure titled, Reporting Abuse to State Agencies and other Entities/Individuals revealed that all suspected violations and all substantiated incidents of abuse will be immediately reported to appropriate state agencies and other entities as may be required by law. The policy included that should a suspected violation or substantiated incident of mistreatment, neglect or abuse be reported, the facility Administrator or his/her designee, will promptly notify the State licensing/certification agency. The verbal/written notice to agencies will be made within twenty-four hours of the occurrence (not two hours as required).",2020-09-01
504,"SAPPHIRE OF TUCSON NURSING AND REHAB, LLC",35099,2900 EAST MILBER STREET,TUCSON,AZ,85714,2019-01-10,609,D,0,1,V3CM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, facility documents and policies and procedures, the facility failed to ensure that an allegation of neglect for one resident (#225) was reported to the State Survey Agency within two hours after the allegation. Findings include: Resident #225 was admitted on (MONTH) 22, (YEAR), with [DIAGNOSES REDACTED]. A nursing note dated (MONTH) 5, (YEAR) at 10:05 a.m. revealed the resident was discovered missing at 8:15 a.m. The note included the resident was not discovered in her room and that a code yellow had been initiated. Review of the facility's investigative report dated (MONTH) 5, (YEAR) revealed that on the morning of (MONTH) 5, (YEAR), it was determined that the resident had not reported for breakfast, so missing person procedures were immediately implemented. The report included the resident was able to leave the facility obtain transportation, cross the border into Mexico, and after entering Mexico obtained transportation to a family home, arriving unharmed. The report also included that the resident had been residing on a behavioral health (secured) unit, and that exit seeking and wandering behaviors were being monitored. Continued review of the facility investigative report revealed that although the resident was discovered missing on (MONTH) 5, (YEAR) at 8:30 a.m., the facility did not notify the State Survey Agency until 3:30 p.m. on (MONTH) 5. An interview was conducted with the Administrator (staff #20) on (MONTH) 8, 2019 at 2:46 p.m. The Administrator stated that the facility had two hours to report all allegations of abuse, including neglect to the State Agency. The Administrator also stated that he was unable to explain why the elopement of resident #225 was reported late to the State Agency. A facility's policy and procedure titled Recognizing Signs and Symptoms of Abuse/Neglect included a definition of neglect as the failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. The policy also listed signs of actual physical neglect that included inadequate provision of care and leaving someone unattended who needs supervision. Review of the facility's policy and procedure titled, Reporting Abuse to State Agencies and other Entities/Individuals revealed that all suspected violations and all substantiated incidents of abuse will be immediately reported to appropriate state agencies and other entities as may be required by law. The policy included that should a suspected violation or substantiated incident of mistreatment, neglect or abuse be reported, the facility Administrator or his/her designee, will promptly notify the State licensing/certification agency. The verbal/written notice to agencies will be made within twenty-four hours of the occurrence (not two hours as required).",2020-09-01
505,"SAPPHIRE OF TUCSON NURSING AND REHAB, LLC",35099,2900 EAST MILBER STREET,TUCSON,AZ,85714,2019-01-10,623,D,0,1,V3CM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews and review of policies and procedures, the facility failed to notify the State Long Term Care Ombudsman when one resident (#50) was transferred/discharged to the hospital on two separate occasions, and when one resident (#175) was discharged to home. Findings include: -Resident #50 was readmitted to the facility on (MONTH) 26, (YEAR), with [DIAGNOSES REDACTED]. A progress note dated (MONTH) 26, (YEAR) revealed the resident was sent to the emergency room , due to difficulty breathing. A progress note dated (MONTH) 29, (YEAR) revealed the resident was readmitted to the facility. Review of a quarterly MDS (Minimum Data Set) assessment dated (MONTH) 31, (YEAR), revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. A progress note dated (MONTH) 23, (YEAR) revealed that the resident was admitted to Banner South Hospital Intensive Care Unit. Another progress note dated (MONTH) 26, (YEAR) revealed that the resident was readmitted to the facility. However, there was no documentation that the State Long Term Care Ombudsman was sent a copy of the notice of discharges for each hospitalization . An interview was conducted with a licensed practical nurse (LPN/staff #150) on (MONTH) 8, 2019 at 1:08 p.m., who stated that when she gets a patient ready to be transferred, she does not notify the Ombudsman and said the case manager (#190) completes the paperwork when a patient is being discharged . An interview was conducted on (MONTH) 8, 2019 at 1:19 p.m. with case manager (staff #190), who stated that she completes the paperwork when a resident is being discharged and staff #193 notifies the Ombudsman about the discharge. Staff #193 was interviewed on (MONTH) 8, 2019 at 2:42 p.m. He stated that the facility had a meeting last fall to talk about a better way to make sure the Ombudsman is notified. He said that he called the Ombudsman and asked if he could notify her by email, when a resident is discharged . He said that she told him that she doesn't want to be notified, because they don't need the information and they are being inundated with notifications. He said that Social Services was handling the notifications at that time. An interview was conducted on (MONTH) 8, 2019 at 3:06 p.m. with the Director of Social Services (staff #204), who stated that there was a meeting with the Ombudsman on (MONTH) 6, (YEAR), because she wanted to verify the process for notifying the Ombudsman when a resident is discharged . She said the Ombudsman didn't want to be notified when a resident is discharged . She acknowledged that the facility has not been notifying the Ombudsman when a resident is discharged and stated that she will be notifying the Ombudsman in writing on a monthly basis from this point forward. -Resident #175 was admitted to the facility on (MONTH) 1, (YEAR), with a [DIAGNOSES REDACTED]. Review of the discharge care plan initiated on (MONTH) 4, (YEAR) revealed resident #175 was to discharge to her previous residence an assisted living facility, after skilled nursing services were completed. A physician's orders [REDACTED]. A review of the Minimum Data Set (MDS) assessment discharge/return not anticipated dated (MONTH) 13, (YEAR), revealed the resident was discharged to the community. Review of the clinical record revealed there was no documentation that the State long term care ombudsman had been sent a copy of the notice of discharge. An interview was conducted with the Director of Social Services (staff #204) on (MONTH) 9, 2019 at 9:21 AM. She stated the facility has not been notifying the ombudsman when a resident is discharged . She stated that she is aware that the facility is responsible for notifications, but the ombudsman did not want to be notified of discharges. An interview with the Director of Nursing (DON/staff #125) was conducted on (MONTH) 10, 2019 at 11:04 AM. The DON stated that she had been told the ombudsman did not want to be notified of discharges, but that the facility must notify her anyway. She stated the facility will be sending a list of discharges to the ombudsman at the end of every month. Review of a facility policy regarding Transfer or Discharge Notice revealed the resident an/or representative will be notified of an impending transfer or discharge from the facility as soon as it is practicable but before the transfer or discharge, when the transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility or when an immediate transfer or discharge is required by the resident's urgent medical needs. The policy also stated that a copy of the discharge notice will be sent to the Office of the State Long-Term Care Ombudsman.",2020-09-01
506,"SAPPHIRE OF TUCSON NURSING AND REHAB, LLC",35099,2900 EAST MILBER STREET,TUCSON,AZ,85714,2019-01-10,641,D,0,1,V3CM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurate regarding antibiotic use and refusal of care for one resident (#62). Findings include: Resident #62 was admitted on (MONTH) 06, (YEAR), with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. -Bactrim 400-80 milligrams (mg) by mouth once a day by mouth for [MEDICATION NAME] for chronic UTI dated (MONTH) 16, (YEAR) -[MEDICATION NAME] HFA aerosol solution 17 micrograms (mcg) one puff orally every 6 hours for [MEDICAL CONDITIONS] dated (MONTH) 24, (YEAR) -[MEDICATION NAME] 25 mg by mouth once a day for hypertension dated (MONTH) 25, (YEAR) -[MEDICATION NAME] 75 mcg by mouth once a day for [MEDICAL CONDITION] dated (MONTH) 25, (YEAR). A review of the MAR for (MONTH) (YEAR) revealed that the resident was administered Bactrim from (MONTH) 16-31. The MAR indicated [REDACTED]. However, review of the quarterly MDS assessment dated (MONTH) 1, (YEAR), revealed the resident did not receive an antibiotic and displayed no refusal of care during the 7 day look-back period. The MDS assessment also included a Brief Interview for Mental Status score of 15 which indicated the resident had no cognitive impairment and that the resident displayed verbal behaviors directed towards others. An interview was conducted with a MDS Coordinator (staff #182) on 01/09/19 at 11:31 AM. Staff #182 stated that information obtained from the nurses' notes and the medication records are used to code a MDS assessment. She also stated that information is obtained from speaking with the residents and the staff. She acknowledged that the quarterly MDS assessment dated (MONTH) 1, (YEAR) was an error in documentation regarding refusal of care. During an interview conducted with the Director of Nursing (DON/staff #125) on 01/09/19 at 11:44 AM., the DON stated that her expectation is that the MDS assessments are accurate, and that incorrect information on the MDS assessment is not acceptable. An interview was conducted with a MDS Coordinator (staff #181) on 01/10/19 at 01:18 PM. She stated that her hand written notes for (MONTH) included the resident was on antibiotics through the end of (MONTH) (YEAR). She agreed that the MDS assessment was marked incorrectly and stated that it was an oversight. The RAI manual for the MDS assessment states that the importance of accurately completing and submitting the MDS assessment cannot be over emphasized. The manual also included that the MDS assessment is the basis for the development of an individualized care plan. The RAI manual instructs to review the clinical record for documentation regarding any antibiotics that were received by the resident during the 7 day look-back period and record the number of days it was received. The RAI manual also instructs to review the clinical record and interview staff for any refusal of care (e.g. taking medications) during the 7 day look-back period and code the behavior if it occurred.",2020-09-01
507,"SAPPHIRE OF TUCSON NURSING AND REHAB, LLC",35099,2900 EAST MILBER STREET,TUCSON,AZ,85714,2019-01-10,645,E,0,1,V3CM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of facility policies and procedures, the facility failed to ensure one resident (#61) was referred to the appropriate state-designated authority for Level II PASARR (pre-admission screening and resident review) evaluation and determination. Findings include: Resident #61 was admitted to the facility on (MONTH) 20, 2014 with [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed a Level I PASARR dated (MONTH) 4, (YEAR) which revealed the resident had a primary [DIAGNOSES REDACTED]. Further review of the clinical record revealed no evidence that the facility referred the resident to the appropriate state-designated authority for a Level II PASARR. An interview was conducted with a social worker (staff #203) on (MONTH) 9, 2019 at 9:00 a.m. Staff #203 stated that if a resident had a primary [DIAGNOSES REDACTED]. Staff #203 stated that she was unsure if a referral for a Level II PASARR was completed for this resident. An interview was conducted with another social worker (staff #204) on (MONTH) 9, 2019 at 10:26 a.m. Staff #204 stated that the facility did an audit about a month ago and the resident qualified for a referral for a Level II PASARR. Staff #204 stated that the referral was not completed yet. Review of the facility's policy Admission Criteria revealed .Nursing and medical needs of individuals with mental disorders or intellectual disabilities will be determined by coordination with the Medicaid Pre-Admission Screening and Resident Review program (PASARR) to the extent possible .",2020-09-01
508,"SAPPHIRE OF TUCSON NURSING AND REHAB, LLC",35099,2900 EAST MILBER STREET,TUCSON,AZ,85714,2019-01-10,657,E,0,1,V3CM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and policy and procedure, the facility failed to ensure a care plan was revised for one resident (#74). Findings include: Resident #74 was admitted to the facility on (MONTH) 7, (YEAR) with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated (MONTH) 8, (YEAR) revealed the resident was cognitively intact and required extensive/total assist with activities of daily living (ADLS). Review of the care plan for mobility dated (MONTH) 24, (YEAR) revealed the resident had limited physical mobility related to current co-morbidities including [MEDICAL CONDITION] (MS). Interventions included applying splints to both arms at night and removing in the morning. Further review of the care plan revealed it was not revised to reflect the splints had been discontinued. An interview was conducted with the Assistant Director of Nursing (ADON/staff #21) on (MONTH) 9, 2019 at 3:46 PM. Staff #21 stated the resident's splints had been discontinued. She stated that she did not know why the care plan had not been updated. The ADON stated all departments are responsible for updating the care plan, including nursing. She said the nursing management meets every morning to discuss residents' care plans, change of condition, etc. An interview was conducted with the Director of Nursing (DON/staff #125) on (MONTH) 10, 2019 at 9:29 AM. The DON stated anything in the care plan related to nursing is updated daily. She said they have an interdisciplinary team (IDT) meeting every morning. She stated they are good at adding to the care plan but need to get better at discontinuing things. The DON said the splints should have been resolved in the care plan. Review of the facility's policy titled Care Plans - Comprehensive revealed assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change.",2020-09-01
509,"SAPPHIRE OF TUCSON NURSING AND REHAB, LLC",35099,2900 EAST MILBER STREET,TUCSON,AZ,85714,2019-01-10,689,D,0,1,V3CM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and review of policies and procedures, the facility failed to ensure that a public restroom accessible to residents was free from accident hazards. Findings include: During an observation conducted on (MONTH) 7, 2019 at 10:30 a.m., two unlocked restrooms were observed near the front entrance of the facility. When the door to restroom [ROOM NUMBER] was opened and released, the door rapidly slammed shut causing a potential accident hazard to residents who may use the restroom. Multiple residents passed by this area to go to the front lobby and to go outside of the facility. An interview was conducted with a receptionist (staff #191) on (MONTH) 8, 2019 at 9:25 a.m. Staff #191 stated that they asked the residents not to use the public restrooms but that some of them go in there anyway. Staff #191 stated that the residents probably use the public restrooms at night when no one is at the receptionist desk. Staff #191 further stated the public bathroom doors used to be locked. Additional observations conducted on (MONTH) 8, 9, and 10, 2019 revealed the area near the public restrooms and front lobby continued to be a high traffic area with residents going to the front lobby or out of the facility. An interview was conducted with another receptionist (staff #194) on (MONTH) 10, 2019 at 11:00 a.m. Staff #194 stated that the residents were asked to not use the public restrooms. Staff #194 further stated the doors used to be locked. An interview was conducted with the managing partner of the facility (staff #220) on (MONTH) 10, 2019 at 12:35 p.m. Staff #220 stated that the facility will be repairing the door today so that it does not slam shut. Review of the facility's policy Safety and Supervision of Residents revealed Our facility strives to make the environment as free from accident hazards as possible. The policy included resident safety and supervision and assistance to prevent accidents are facility-wide priorities.",2020-09-01
510,"SAPPHIRE OF TUCSON NURSING AND REHAB, LLC",35099,2900 EAST MILBER STREET,TUCSON,AZ,85714,2019-01-10,695,D,0,1,V3CM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy and procedures, the facility failed to ensure one resident (#50) was provided respiratory care consistent with the physician's order. Findings include: Resident #50 was readmitted to the facility on (MONTH) 26, (YEAR), with [DIAGNOSES REDACTED]. Review of the current summary of physician's orders revealed an order for [REDACTED]. Review of the quarterly MDS (Minimum Data Set) assessment dated (MONTH) 31, (YEAR) revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The assessment also included the resident was receiving oxygen therapy. The current care plan revealed the resident had altered respiratory status related to [MEDICAL CONDITION] with [MEDICAL CONDITION]. The interventions included administering medication/puffers as ordered and monitoring for effectiveness and side effects and monitoring/documenting/reporting abnormal breathing patterns to the physician. During an interview conducted with the resident on (MONTH) 7, 2019 at 3:23 p.m., the oxygen concentrator was observed to be set at 2.5 liters, however, the resident did not have on the nasal cannula, as it was lying on the resident's tray. Observation of the tubing revealed no date when the tubing had been changed. On (MONTH) 9, 2019 at 12:28 p.m., the resident was observed sleeping in his wheelchair with the oxygen tubing on and the concentrator was set at 2.5 liters. The tubing was not observed to have a date to reflect when the tubing had been last changed. An interview was conducted with a certified nursing assistant (CNA/staff #58) on (MONTH) 10, 2019 at 9:14 a.m., who stated that the CNA's on the overnight shift change the tubing on the oxygen concentrators every Sunday, and tape the date on the tubing to show when the tubing was changed. She stated that if there is no date on the tubing or if the date indicates that it is overdue, she changes the tubing. After observing the oxygen tubing, she confirmed that there was no date on the resident's tubing or anywhere on the oxygen machine. She also confirmed that the level of oxygen was set at 2.5 liters per minute. An interview was conducted on (MONTH) 10, 2019 at 9:22 a.m. with a licensed practical nurse (LPN/staff #159), who stated that the CNA's on the night shift change and date the oxygen tubing every Sunday and document the tubing was changed in the computer in the task section. She stated that if she did not see a date on the tubing, she would change the tubing. She also stated that it is the nurse's responsibility to monitor the amount of oxygen received per a minute. After reviewing the orders, she stated the order is for oxygen at 2 liters. Review of the resident's electronic record including in the task section, revealed there was no documentation that the tubing was changed in (MONTH) and (MONTH) (YEAR). During an interview conducted with the Director of Nursing (DON/staff #125) on (MONTH) 10, 2019 at 11:05 a.m., she stated the expectation is that the oxygen tubing is to be changed by the CNA's on the night shift every Sunday. The facility's policy regarding Oxygen Administration included the following: -The purpose of this procedure is to provide guidelines for safe oxygen administration. -Verify that there is a physician's order for this procedure. -Review the physician's order or facility protocol for oxygen administration. The policy did not address a process for monitoring when oxygen equipment is to be changed.",2020-09-01
511,"SAPPHIRE OF TUCSON NURSING AND REHAB, LLC",35099,2900 EAST MILBER STREET,TUCSON,AZ,85714,2019-01-10,698,E,0,1,V3CM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure physician orders [REDACTED].#151) regarding [MEDICAL TREATMENT]. Findings include: Resident #151 was admitted to the facility on (MONTH) 16, (YEAR) with [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment dated (MONTH) 23, (YEAR) included the resident had short-term and long-term memory problems and had severe impairment with daily decision making. The MDS assessment also included the resident was receiving [MEDICAL TREATMENT]. A nursing note dated (MONTH) 23, (YEAR) revealed the resident had a right sided vascular catheter. Review of the clinical record revealed the resident went out to [MEDICAL TREATMENT] appointments on several occasions in (MONTH) and (MONTH) (YEAR) and (MONTH) 2019. A care plan dated (MONTH) 21, (YEAR) included the resident needs [MEDICAL TREATMENT] related to end stage [MEDICAL CONDITION]. Interventions included checking and changing the dressing daily at access site and document. However, review of the clinical record revealed no evidence that there was a physician's orders [REDACTED]. In an interview with a licensed practical nurse (LPN/staff #165) on (MONTH) 10, 2019 at 10:31 a.m., he stated that for a resident receiving [MEDICAL TREATMENT], there should be an order for [REDACTED]. The nurse reviewed resident #151's electronic record and was unable to locate an order for [REDACTED].>During an interview conducted with the LPN (staff #153) caring for this resident on (MONTH) 10, 2019 at 10:38 a.m., she stated the resident was currently at the [MEDICAL TREATMENT] center. She stated she knows when the resident is scheduled for [MEDICAL TREATMENT] based on an appointment log that is reviewed every day and her report sheet that has the [MEDICAL TREATMENT] days and time. The LPN also stated that when the resident returns from [MEDICAL TREATMENT] an assessment is done which includes checking the site. She stated the site should be assessed and documented every shift, and that there should be an order to monitor the site. In an interview with the Director of Nursing (DON/staff #125) on (MONTH) 10, 2019 at 10:43 a.m., she stated there should be a physician's orders [REDACTED]. She also stated there should be an order to monitor the resident's [MEDICAL TREATMENT] site, whether it is a fistula or a port. Review of the facility's policy titled [MEDICAL TREATMENT] Access Care did not include physician's orders [REDACTED]. Per the DON, there was no other policy specific to [MEDICAL TREATMENT].",2020-09-01
512,"SAPPHIRE OF TUCSON NURSING AND REHAB, LLC",35099,2900 EAST MILBER STREET,TUCSON,AZ,85714,2019-01-10,725,E,0,1,V3CM11,"Based on resident and staff interviews, facility documentation and policies and procedures, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Findings include: Multiple resident interviews were conducted on (MONTH) 7, (YEAR) regarding facility staffing. Ten random residents stated that there was not enough staff and that they have to wait too long for staff assistance and for their call lights to be answered. An interview was conducted with a CNA (certified nursing assistant). The CNA stated that the A-1 unit for high acuity behavioral residents was usually staffed with 3 CNA's to care for 20-24 residents. The CNA stated that one CNA is supposed to be in the hall at all times to monitor to prevent resident to resident altercations, but that does not always happen because of call ins. An interview was conducted with another CNA, who stated that someone is always supposed to be monitoring the hallway on the A-1 unit, but that does not always happen and it's kind of irritating. The CNA stated we do the best we can, but if there is a call in there is no one to monitor the hallway and the residents get in to altercations. An interview was conducted with another CNA who stated that it is challenging to care for the residents when there are call ins. An interview was conducted with a fourth CNA, who stated that sometimes it is hard to care for the residents when there are call ins. An interview was conducted with another CNA, who stated that care and showers do not get done when there is not enough staff. The CNA further explained that care gets done but not like it should and showers get missed. An interview was conducted with another CNA, who stated that the facility attempts to staff adequately, but some days they are short. An interview was conducted with a seventh CNA, who stated that they used to have four CNA's for this hallway and now they have three. The CNA stated that it was hard to monitor the hallway, because most of the residents on this hallway require two staff to provide care. An interview was conducted with another CNA, who stated that she thought the afternoon shift could use more staff especially on the weekends. The CNA stated that they used to have a hall monitor, but do not anymore. An interview was conducted with a CNA, who stated that sometimes they only have two CNA's on 2nd shift for this hallway and it's hard because most of the residents on this hallway require two staff to provide care. The CNA stated that the facility is trying to staff adequately because they are now using agency staff. An interview was conducted with a LPN (licensed practical nurse). The LPN stated they could use more staff. The LPN stated that when they are short, I do not focus on my medications or paperwork and help the CNAs. An interview was conducted with another LPN, who stated that they used to have enough staff, but when the new management company took over they cut staff. The LPN stated we do the best we can. The LPN further stated that there are more CNAs scheduled today, because the surveyors are here for the annual survey. Review of the Resident Council Minutes from (MONTH) (YEAR) through (MONTH) (YEAR) revealed the following concerns from residents: -February 26: Not enough staff all shifts. -May 8: The residents are concerned with ratio of staff and residents. The lights are not being answered promptly. -July 9: Many say there's not enough staff (pending concern already). -August 30: Residents are concerned with lights not being answered promptly. Concerns with 7:00 a.m. - 3:00 p.m. B2 (long term care unit). -September 13: Residents feel like they lack staff. -October 12: Call lights are not answered quick and residents and family are waiting more than 15 minutes on B2. -November 8: Overworked and understaffed was stated by one resident. B2 (all shifts). CNA's do a very good job but most are exhausted. -December 6: B2 resident stated there have been 2 CNA's to 30 patients and needs are not being met. Residents stated staffing issues for the dining room have happened three times this week. Residents need help with feeding and passing food. According to the resident council meeting documentation, a meeting was held on (MONTH) 9, 2019 at 2:10 p.m., with six residents. Per the documentation, four of the six residents stated that there was not enough staff and that they had to wait extended periods of time for staff assistance. On the last page of the Resident Council Minutes for the above months was a section titled, Interventions to be implemented however, each month this section was blank. An interview was conducted with the activity director (staff #2) on (MONTH) 9, 2019 at 2:45 p.m. Staff #2 stated that she has been the activity director since (MONTH) (YEAR), and that she took the minutes for the resident council meeting. Staff #2 stated that she gave the staffing concerns to nursing and they are supposed to respond to the residents' concerns so that we could let the resident council know. Staff #2 stated that she had not received responses from nursing yet regarding staffing. An interview was conducted with the administrator (staff #20) on (MONTH) 10, 2019 at 9:25 a.m. Staff #20 stated that there should be a monitor in the hallways of the A1 and B1 units. Staff #20 stated that the facility is aware of the residents concerns regarding staffing. An interview was conducted with the managing partner of the facility (staff #220) on (MONTH) 10, (YEAR) at 10:40 a.m. Staff #220 stated that different units have different staffing needs. Staff #220 stated the facility has never had a resident to resident altercation that resulted in a serious injury, because of staffing. Staff #220 stated that ratio wise, there was enough staff and the concern could be the accountability of the staff. Staff #220 stated that he was not aware of the residents and staff concerns regarding staffing. Review of the facility's policy regarding Staffing revealed, Our facility provides sufficient numbers of staff with the skill and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment .Inquiries or concerns relative to our facility's staffing should be directed to the Administrator or his/her designee.",2020-09-01
513,"SAPPHIRE OF TUCSON NURSING AND REHAB, LLC",35099,2900 EAST MILBER STREET,TUCSON,AZ,85714,2019-01-10,758,D,0,1,V3CM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record review, staff interviews, and policies and procedures, the facility failed to ensure that one resident (#135) who was prescribed an antipsychotic medication upon admission, had indications for its use. Findings include: Resident #135 was admitted on (MONTH) 7, (YEAR) with [DIAGNOSES REDACTED]. The resident was discharged (MONTH) 26, (YEAR). Review of hospital records prior to the resident's admission, revealed a H&P (History and Physical) report dated (MONTH) 5, (YEAR) that the resident had a significant history of Alzheimer's dementia and [MEDICAL CONDITION] and was cooperative with normal mood and cognition. The hospital H&P included a list of medications that the resident was receiving in the hospital. The list did not include the [MEDICATION NAME] (antipsychotic) or any other antipsychotic medication. Continued review of the hospital records revealed a discharge summary dated (MONTH) 7, (YEAR) that included an order for [REDACTED]. Review of the closed clinical record revealed a physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. A discharge MDS (Minimum Data Set) assessment dated (MONTH) 26, (YEAR) included a BIMS (Brief Interview for Mental Status) score of 11 which indicated the resident had moderately impaired cognition. The assessment included the resident felt tired, depressed, had difficulty sleeping, and verbal behaviors directed at others. The assessment also included the resident received antipsychotic medications. However, the assessment did not include the resident had a psychiatric mood disorder. Further review of the closed record did not reveal any additional documented evidence that the [DIAGNOSES REDACTED]. An interview was conducted on (MONTH) 10, 2019 at 9:17 a.m. with the Director of Nursing (DON/staff #125). The Director stated that a [DIAGNOSES REDACTED]. The DON stated that when a resident is admitted from the hospital, the medications that are prescribed must verify with the physician by the nurse. The DON stated that an antipsychotic drug cannot be prescribed for dementia unless there is a [DIAGNOSES REDACTED]. The DON further stated that the use of the antipsychotic drug for resident #135 should have been clarified with the physician. During an interview conducted on (MONTH) 10, 2019 at 9:35 a.m. with a RN (Registered Nurse/staff #165), the nurse stated that if a [DIAGNOSES REDACTED]. The facility's policy and procedure titled Antipsychotic Medication Use included a policy statement that antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. The policy included residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective.",2020-09-01
514,"SAPPHIRE OF TUCSON NURSING AND REHAB, LLC",35099,2900 EAST MILBER STREET,TUCSON,AZ,85714,2019-01-10,842,D,0,1,V3CM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews and policies and procedures, the facility failed to ensure that electronic and paper health records for one resident (#225) were readily accessible to the State Survey Team. Findings include: Resident #225 was admitted on (MONTH) 22, (YEAR) with [DIAGNOSES REDACTED]. Resident #225 was discharged on (MONTH) 5, (YEAR). During random reviews of the facility electronic records conducted on (MONTH) 7, 2019 it was revealed the electronic health records for resident #225 were not accessible in the data base provided by the facility. An interview was conducted with the administrator (staff #20) on (MONTH) 7, 2019 at 10:15 a.m. The administrator stated that the facility did not have access to electronic records for resident #225, and that access to those records had been removed by the previous owner of the facility when the facility was purchased by the current owner in (MONTH) (YEAR). The Administrator stated that he would notify the previous owner that access to the records was needed, and that the facility staff were aware that they were supposed to have access to all electronic health records for resident #225. An interview was conducted with a corporate staff member (staff #220) on (MONTH) 7, 2019 at 1:45 p.m. Staff #220 stated that he was aware of the requirement that access to medical records was to be maintained for 7 years. Staff #220 also stated that staff were in communication with the previous owners of the facility to obtain access to the health records for resident #225. An interview was conducted on (MONTH) 8, 2019 at 8:30 a.m. with medical records (staff #184). Staff #184 stated that the paper records and electronic health records for resident #225 were not accessible, because the records had been removed by the previous owner of the facility. Staff #184 stated that the previous owner was scanning records to the facility. She stated that the process of uploading the documents would take hours and that the documents would be printed after the upload. Staff #184 stated that she did not know whether or not the records for resident #225 were being pre-screened by the previous owner prior to being uploaded. During an interview conducted with the administrator on (MONTH) 8, 2019 at 9:24 a.m., the administrator stated that they were unable to obtain access to electronic health records from the previous owner of the facility. In a follow-up interview with staff #184 conducted on (MONTH) 8, 2019 at 2:08 p.m., the staff #184 provided a stack of printed paper records for resident #225 and stated that there would be no access to electronic health records for resident #225. Review of the facility's policy and procedure titled Electronic Medical Records included a statement that authorized Federal and State survey agents as outlined in current regulations may be granted access to electronic medical records.",2020-09-01
515,"SAPPHIRE OF TUCSON NURSING AND REHAB, LLC",35099,2900 EAST MILBER STREET,TUCSON,AZ,85714,2019-01-10,867,E,0,1,V3CM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on concerns identified during the survey, staff interview and policy review, the quality assessment and assurance (QAA) committee failed to identify quality concerns and implement appropriate plans of action to correct the quality deficiencies. Findings include: During the facility's annual recertification survey, multiple concerns were identified in the following areas: -Pervasive odors throughout the facility. -Resident to resident abuse involving 5 residents. -One resident eloped from the facility. -Implement facility policy regarding reporting an allegation of neglect. -Report an allegation of neglect within two hours. -A physician's orders [REDACTED]. -Failed to maintain adequate staffing. -Failed to provide access to electronic records timely. An interview was conducted with the administrator (staff #20) on (MONTH) 10, 2019 at 2:26 p.m. Staff #20 stated that when staff identify a quality concern they bring their concerns to the QAA committee. Staff #20 stated that if a performance improvement plan is developed the QAA committee monitors the progress. The administrator further acknowledged there were no action plans regarding the quality concerns identified during the survey and that the QAA process had not identified the above issues. Review of the facility's policy regarding Quality Assurance and Performance Improvement (QAPI) Committee revealed .The primary goals of the QAPI Committee are to .Help identify actual and potential negative outcomes relative to resident care and resolve them appropriately .",2020-09-01
516,"SAPPHIRE OF TUCSON NURSING AND REHAB, LLC",35099,2900 EAST MILBER STREET,TUCSON,AZ,85714,2019-01-10,919,D,0,1,V3CM11,"Based on observations and staff interviews, the facility failed to ensure that two public restrooms, which were unlocked, were equipped to allow residents to call for staff assistance. Findings include: During an observation conducted on (MONTH) 7, 2019 at 10:30 a.m., two unlocked restrooms were observed near the front entrance of the facility. Neither restroom was equipped with a communication system to alert staff should a resident require assistance while in the restroom. Once inside of each restroom a deadbolt lock was observed on the doors. The deadbolt lock was unable to be unlocked from the outside of the door in the event of an emergency. Signs were posted on both of the restroom doors which stated Lobby restrooms are for visitors and staff only. Residents, please utilize resident restrooms. Thank you for your cooperation. Kind regards, Sapphire Management. Multiple residents passed by this area to go to the front lobby or to go outside of the facility. An interview was conducted with a receptionist (staff #191) on (MONTH) 8, 2019 at 9:25 a.m. Staff #191 stated that they ask the residents not to use the public restrooms but that some of the residents go in there anyway. Staff #191 stated that the residents probably use the public restrooms at night when no one is at the receptionist desk. Staff #191 further stated that the public bathroom doors used to be locked. Observations conducted on (MONTH) 8, 9, and 10, 2019 revealed the area near the public restrooms and front lobby continued to be a high traffic area with residents going to the front lobby or out of the facility. An interview was conducted with another receptionist (staff #194) on (MONTH) 10, 2019 at 11:00 a.m. Staff #194 stated that the residents were asked to not use the public restrooms. Staff #194 stated that the facility put the signs on the doors of the public restrooms due to the fact that residents could go in there and fall and they would not know that they were in there because there is no call light. Staff #194 further stated the doors used to be locked. An interview was conducted with the managing partner of the facility (staff #220) on (MONTH) 10, 2019 at 12:35 p.m. Staff #220 stated that the unlocked bathroom doors were his fault. Staff #220 stated that when he first came to the facility he thought it was a dignity issue to be in the restroom and have people knocking on the door when you were in there. Staff #220 stated that he felt installing the occupied/unoccupied deadbolts on the door would resolve the dignity issue. The facility did not have a policy regarding resident call systems.",2020-09-01
517,"SAPPHIRE OF TUCSON NURSING AND REHAB, LLC",35099,2900 EAST MILBER STREET,TUCSON,AZ,85714,2018-02-23,584,E,1,0,OUUM11,"> Based on observations, staff interviews and residents interviews, the facility failed to maintain an adequate supply of towels and washcloths for 150 residents. Findings include: A tour of the facility was conducted on (MONTH) 23, (YEAR) with the housekeeping account manager/staff #156 to determine the availability of towels and washcloths for resident use. At 8:35 a.m. the linen cart on the C1 hallway had 3 bath towels, 5 hand towels, and 3 washcloths available for resident use. An interview was conducted with the housekeeping account manager on (MONTH) 23, (YEAR) at 8:37 a.m The housekeeping account manager stated that linen carts are stocked two to three times per shift. The housekeeping account manager stated that the facility was waiting for a delivery of linen. The housekeeping account manager stated that towels and washcloths could be obtained from another hall if needed. At 8:40 a.m. the linen cart on the B1 hallway had 5 washcloths, 1 hand towel and 8 bath towels. At 8:42 a.m. the linen cart on the A1 hallway had 2 washcloths, 5 hand towels and no bath towels. At 8:45 a.m. the linen cart on the C2 hallway had no washcloths, hand towels or bath towels. At 8:47 a.m. the linen cart on the B2 hallway had 5 washcloths, 13 bath towels and 3 hand towels. At 8:49 a.m. the linen cart on the A2 hallway had no washcloths, hand towels or bath towels. An interview was conducted with a laundry staff person/staff #157 on (MONTH) 23, (YEAR) at 8:53 a.m. There were 11 bath towels, 8 hand towels, and 2 washcloths on a table in the laundry room. The laundry staff person stated there were more in the dryer but that she did not know how much. An interview was conducted with the housekeeping account manager/staff #156 on (MONTH) 23, (YEAR) at 8:55 a.m The housekeeping account manager stated that the facility could use more linen. An interview was conducted with the central supply manager/staff #84 on (MONTH) 23, (YEAR) at 9:00 a.m. The central supply manager stated that another housekeeping account manager thought the facility had enough washcloths. The central supply manager was only able to find 5 dozen more washcloths. The central supply manager provided the surveyor a requisition order which was placed on (MONTH) 22, (YEAR) for 288 hand towels and 216 bath towels. The central supply manager stated that the towels were expected to be delivered on (MONTH) 23, (YEAR). An interview was conducted with the administrator/staff #6 on (MONTH) 23, (YEAR). The administrator stated that he told central supply to double the order. An interview was conducted with a CNA (certified nursing assistant)/staff #141 on (MONTH) 23, (YEAR) at 10:02 a.m. The CNA stated that sometimes there were no towels or washcloths available for resident use. The CNA stated that she used wipes to bathe the residents. The CNA stated that the facility has been short on linen for about two months. An interview was conducted with a CNA/staff #70 on (MONTH) 23, (YEAR) at 10:06 a.m. The CNA stated that sometimes there were no towels or washcloths available for residents. The CNA stated that she used wipes to bathe the residents and bath blankets to dry the residents. The CNA stated that sometimes residents went without showers because of this. The CNA stated that she has asked laundry for more. The CNA further stated that her hallway was without bath blankets today. An interview was conducted with a CNA/staff #143 on (MONTH) 23, (YEAR) at 10:08 a.m. The CNA stated that linen was not delivered to her hallway on time. The CNA stated that there was a lack of towels and washcloths. The CNA stated that she sometimes used hand towels to bathe the residents and bath blankets to dry the residents. The CNA further stated that sometimes the residents had to have their showers the next day because of the shortage of linen. An interview was conducted with a CNA/staff #98 on (MONTH) 23, (YEAR) at 10:11 a.m. The CNA stated that she always had to got to other hallways to get towels and washcloths. The CNA further stated that it was not fair to the residents as sometimes they had to go without showers. An interview was conducted with a CNA/staff #128 on (MONTH) 23, (YEAR) at 10:14 a.m. The CNA stated that the facility ran out of towels and washcloths pretty often and sometimes staff stalled for showers because there is not enough. The CNA further stated that sometimes showers don't get done. An interview was conducted with a CNA/staff #131 on (MONTH) 23, (YEAR) at 10:17 a.m. The CNA stated that she was getting ready to give a resident a shower and there was no linen available. An interview was conducted with a CNA/staff #59 on (MONTH) 23, (YEAR) at 10:20 a.m. The CNA stated that about two days out of the week there is not enough linen. The CNA stated that she used wipes to give baths. An interview was conducted with an LPN (licensed practical nurse)/staff #85 on (MONTH) 23, (YEAR) at 10:23 a.m. The LPN stated that sometimes residents have to wait to get their showers until we get more linen but that they don't go without. An interview was conducted with the DON (director of nursing)/staff #56 on (MONTH) 23, (YEAR) at 10:31 a.m. The DON stated that she communicated with the housekeeping manager/staff #158 to ensure there were enough towels and washcloths. The DON stated that sometimes it was a timing issue as to when laundry delivered the linen to the units. The DON stated that if staff come to me if they can't find linen I get them some. The DON further stated that there were linen rooms on each hallway that had surplus linen stored. An immediate tour was conducted with the DON to determine how much linen was available in the linen rooms on each hallway. The linen rooms on C2, B2, A2, B1, and A1 hallways did not have any towels or washcloths available for resident use. The linen room on the C1 hallway had 8 hand towels, 6 washcloths and 4 bath towels. An interview was conducted with an LPN/staff #125 on (MONTH) 23, (YEAR) at 1045 a.m. The LPN stated that it's a problem, we always have to go find linen. I know the CNA's have been using wipes because they don't have enough washcloths and towels. Multiple resident interviews were conducted on (MONTH) 23, (YEAR). Most all of the residents interviewed stated they received their scheduled showers and staff were able to locate towels and washcloths for their showers. One resident stated that sometimes staff ran out of towels and then they used a blanket to dry him after his shower. The resident further stated that he didn't care as long as staff dried him with something. An interview was conducted with the DON/staff #56 on (MONTH) 23, (YEAR) at 2:09 p.m. The DON stated that the facility did not have a policy on how much linen the facility should have.",2020-09-01
518,"SAPPHIRE OF TUCSON NURSING AND REHAB, LLC",35099,2900 EAST MILBER STREET,TUCSON,AZ,85714,2018-02-23,732,B,1,0,OUUM11,"> Based on staff interviews, review of facility documentation, and review of facility policies and procedures, the facility failed to ensure that nurse staffing information was posted on the weekends. Findings include: A review of the facility's Daily Staff Posting from (MONTH) 9 through 23, (YEAR) was conducted on (MONTH) 23, (YEAR). Further review of the Daily Staff Postings revealed no evidence that staffing information was posted on the weekends. An interview was conducted with the staffing coordinator/staff #106 on (MONTH) 23, (YEAR) at 9:30 a.m. The staffing coordinator stated that he only posted nurse staffing information Monday through Friday and not on the weekends. An interview was conducted with the administrator/staff #6 on (MONTH) 23, (YEAR) at 10:00 a.m. The administrator stated that he just heard that nurse staffing information was not posted on the weekends but that it will be from now on. A review of the facility's policy Posting Direct Care Staffing Numbers documented Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents .",2020-09-01
519,"SAPPHIRE OF TUCSON NURSING AND REHAB, LLC",35099,2900 EAST MILBER STREET,TUCSON,AZ,85714,2019-09-13,603,E,1,0,0W2W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, clinical record review, resident interview, staff interviews, and review of facility policies and procedures, the facility failed to ensure that one of three sampled residents (#1) was not involuntarily secluded in a secured high acuity behavioral unit. Findings include: Resident #1 was admitted to the facility on (MONTH) 16, 2019 with [DIAGNOSES REDACTED]. A Baseline Careplan dated (MONTH) 16, 2019 revealed the resident planned on being discharged to his own home after the completion of occupational and physical therapy. Further review of the Baseline Careplan revealed the resident was not being administered any [MEDICAL CONDITION] medications. Review of an Evaluation Criteria for Behavioral Health Specialty Unit dated (MONTH) 16, 2019 revealed the resident did not have a behavioral health related [DIAGNOSES REDACTED]. Further review of the Evaluation Criteria for Behavioral Health Specialty Unit documented Resident is NOT a good candidate for residence in the Behavioral Health Program. Patient alert and oriented x 3. Pleasant . A Psychological-Social Evaluation dated (MONTH) 16, 2019 documented .(Resident's name) was able to communicate clearly and showed an alert and oriented x 4 .plans on going back home once he is discharged . A Medication Review Report dated (MONTH) 16, 2019 documented .Resident is capable of participating in own plan of care. Resident is capable of understanding and exercising rights, does have dementia, is redirectable . Review of the resident's admission MDS (Minimum Data Set) assessment dated (MONTH) 23, 2019 revealed the resident's BIMS (Brief Interview for Mental Status) score was a 13 or intact cognition. Review of a Notification of Change dated (MONTH) 24, 2019 revealed the resident was transferred to the facility's secure high acuity behavioral unit. The Reason for Move was Patient is moved to lock down unit. Review of the clinical record revealed no documentation in the nursing notes as to why the resident was moved to the facility's secured high acuity behavioral unit. A review of a Physician Extender Note dated (MONTH) 24, 2019 documented Awake and anxious, he is moving to another room. Per nursing he has been wandering and confused, walking into other rooms. Review of a careplan dated (MONTH) 30, 2019 documented The plan for the resident is to complete skilled nursing services and evaluate/plan for a safe discharge if appropriate .Secure unit indicated related to poor safety awareness, wandering, aggression, memory impairments. An intervention documented was Staff to assist and coordinate with the resident as needed for a safe discharge. Another care plan dated (MONTH) 30, 2019 documented (Resident's name) has a behavior problem including but not limited to wandering, pacing, following staff, needing frequent reassurance related to dementia. An intervention documented was Staff to discuss risks and benefits of negative behaviors and natural consequence as needed. An Elopement Risk assessment dated (MONTH) 31, 2019 revealed the resident did not have a history of escape or elopement, did not say that he wanted to leave or go home, and did not wander aimlessly. Further review of the Elopement Risk Assessment revealed the resident's elopement risk score was a 2 or low risk for elopement. A review of a Psychiatry Note dated (MONTH) 20, 2019 documented .During today's visit, patient appears to be mentally stable and capable of making his own decisions . Review of a Social Service Note dated (MONTH) 28, 2019 documented .The resident stated that he did not want to be at Sapphire .The resident stated that he wanted to continue to explore alternate options with the idea of going home still being his end goal . A review of a Health Professional's Report dated (MONTH) 29, 2019 revealed that it was the physician's recommendation that the resident should live in a supervisory care facility. A Nursing Note dated (MONTH) 30, 2019 documented .Later asked to use the phone again and apparently called 911 stating was being held against his will . Review of a Nursing Note dated (MONTH) 1, 2019 documented .Requested room change as 'I cannot stand my roommate. He's in and out 10 times a day. I cannot sleep.' Stated 'I'm leaving tomorrow anyway' when explained that there were no rooms to change . A Social Service Note dated (MONTH) 4, 2019 documented .Doctor .was given documents by daughter to complete to evaluate his cognitive function. Doctor .stated he would be back in the facility on 9/5/19 with completed documentation and stated that patient was 'just on the border' of cognitive decline, but that very clearly he was able to express in detail his wishes .This writer reported that since admission the resident has had improved cognitive ability to which Doctor .reported that it was 'probably due to not drinking.' The patient will continue to be monitored and assisted with safe discharge plan. An interview was conducted with the administrator (staff #2) on (MONTH) 12, 2019 at 8:15 a.m. Staff #2 stated that when the resident was admitted to the facility he was very confused but that he was now more alert. Staff #2 stated that the resident was residing in the facility's secured high acuity behavioral unit. An interview was conducted with the behavioral health operations manager (staff #1) on (MONTH) 12, 2019 at 9:30 a.m. Staff #2 stated that the resident's daughter wanted doctors to deem the resident incompetent but he is not. Staff #2 stated that the resident was transferred to the secured high acuity behavioral unit because he was screaming, yelling, and trying to kick his roommate's family out of the facility. Staff #2 further stated there were no rooms available in the facility's secured dementia unit. An interview was conducted with the resident on (MONTH) 12, 2019 at 10:00 a.m. The resident stated that he used to be in a room on the facility's second floor. The resident stated that he did not know why he was moved downstairs to the secured high acuity behavioral unit. The resident stated that his physical and occupational therapy had been discontinued and he just wanted to go back to his own home. An interview was conducted with a certified nursing assistant (CNA/staff #181) on (MONTH) 12, 2019 at 1:10 p.m. Staff #181 stated that the only behaviors the resident had was that he liked to hoard food in his room. Staff #181 further stated that the resident didn't have the behaviors like some of the other residents had on the secured high acuity behavioral unit. An interview was conducted with a CNA (staff #269) on (MONTH) 12, 2019 at 1:20 p.m. Staff #269 stated that she had not seen the resident exhibit any behaviors. An interview was conducted with another CNA (staff #88) on (MONTH) 12, 2019 at 1:25 p.m. Staff #88 stated this unit is a high acuity behavioral unit for residents who exhibit physical and verbal behaviors toward staff and other residents. Staff #88 stated that the resident didn't exhibit any behaviors other than he liked to hoard food, An interview was conducted with a registered nurse (RN/staff #270) on (MONTH) 12, 2019 at 1:32 p.m. Staff #270 stated that the resident's behaviors are not as acute as some of the other residents on the unit. Staff #270 stated that the resident had more dementia type behaviors. An interview was conducted with a licensed practical nurse (LPN/staff #92) on (MONTH) 12, 2019 at 2:00 p.m. Staff #92 stated that the resident should have probably been moved to the facility's dementia unit rather than the secured high acuity behavioral unit, if the only behavior he had was wandering into other resident's rooms. Another interview was conducted with the behavioral health operations manager (staff #1) on (MONTH) 12, 2019 at 2:45 p.m. Staff #1 stated that the resident was moved to the facility's secured high acuity behavioral unit because there was not a bed available in the dementia unit. Staff #1 stated that the criteria for the secured high acuity behavioral unit was all related to safety as a secured unit is a restraint and has to be evaluated on a case by case basis and risk for elopement. Another interview was conducted with the resident on (MONTH) 12, 2019 at 3:30 p.m. The resident stated that when he moved from upstairs to the secured high acuity behavioral unit he was not told that the unit was locked. The resident further stated I don't need to be here, I'm not getting therapy any more. Review of the facility's policy Admission Criteria for Behavioral Health Secure Unit dated (MONTH) (YEAR) documented To establish uniform guidelines for personnel to follow when admitting consumers to the unit .Consumers admitted to the unit typically have a [DIAGNOSES REDACTED]. Consumers admitted to the unit typically have a history of multiple inpatient psychiatric hospitalization s and not appropriate for the transitional living level of services .",2020-09-01
520,"SAPPHIRE OF TUCSON NURSING AND REHAB, LLC",35099,2900 EAST MILBER STREET,TUCSON,AZ,85714,2019-09-13,842,D,1,0,0W2W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, and review of facility policies and procedures, the facility failed to ensure that one resident's (#1) clinical record was accurately documented in accordance with accepted professional standards of practices. Findings include: Resident #1 was admitted to the facility on (MONTH) 16, 2019 with [DIAGNOSES REDACTED]. Review of the resident's admission MDS (Minimum Data Set) assessment dated (MONTH) 23, 2019 revealed the resident's BIMS (Brief Interview for Mental Status) score was a 13 or intact cognition. Review of a Notification of Change dated (MONTH) 24, 2019 revealed the resident was transferred to the facility's secure high acuity behavioral unit. The Reason for Move was Patient is moved to lock down unit. On (MONTH) 12, 2019, copies of the resident's clinical record were requested by licensing surveyor. When the copies were provided an unrequested copy dated (MONTH) 24, 2019 was provided to licensing surveyor. The form documented I (resident's name) consent that I agree to be housed in a locked unit at Sapphire of Tucson where no unauthorized visitors are allowed. The form was signed by the resident and dated (MONTH) 24, 2019. This form was not observed in the clinical record when copies of the clinical record were requested. An interview was conducted with the resident on (MONTH) 12, 2019 at 3:30 p.m. The resident stated that he was asked to sign the above form today and did not remember signing such a form when he transferred to the secured high acuity behavioral unit on (MONTH) 24, 2019. An interview was conducted with the medical records director (staff #15) on (MONTH) 12, 2019 at 3:45 p.m. Staff #15 stated that the above form had not been scanned into the computer yet and was on top of her file cabinet in a stack of papers to be scanned. An interview was conducted with the administrator (staff #2) on (MONTH) 13, 2019 at 8:30 a.m. Staff #2 stated the an LPN unit manager (staff #152) had the resident sign the form on (MONTH) 12, 2019 consenting to reside in a a locked unit and that she dated it (MONTH) 24, 2019. Staff #2 further stated that staff #152 did not have an answer as to why she did that but that she falsified a resident's clinical record by doing that. Staff #152 was unable to be interviewed. A review if the facility's policy Welcome to New Hire Orientation, undated, documented .Conduct which interferes with the safe operation of the facility, brings discredit to the facility, its residents or staff, and any act that is offensive to a resident, family member, visitor, or employee is unacceptable .falsifying or making a willful misstatement of facts on a resident's record .",2020-09-01
521,"SAPPHIRE OF TUCSON NURSING AND REHAB, LLC",35099,2900 EAST MILBER STREET,TUCSON,AZ,85714,2016-09-29,364,D,0,1,XFF511,"Based on observation, staff interviews, facility documentation and policy and procedures, the facility failed to ensure that pureed meat was prepared in a manner to conserve nutritive value. Findings include: An observation was conducted in the kitchen on (MONTH) 28, (YEAR) at 9:45 a.m. A cook (staff #192) was observed to place 30 ounces of roast beef into a [NAME]o Coupe (blender) to puree 15 servings. During the puree process, the cook added 3 quarts of beef broth and 36 ounces of thickener to the roast beef. An immediate interview was conducted with the nutrition services supervisor (staff #189), who stated that the cook used too much broth and thickener for the portions of roast beef. Staff #189 stated that the cook should have followed the recipe, which included 4-8 ounces of broth and 4-8 tablespoons of thickener. An interview was conducted with staff #192 on (MONTH) 28, (YEAR) at 10:15 a.m. The cook stated that he sometimes followed the recipe when he pureed foods, but that he usually just went by how it looked. Review of the facility's recipe for Pureed Plain Meats revealed to use 4-8 ounces of beef stock and 4-8 tablespoons of thickener, when pureeing 32 ounces or 16 servings of meat. The facility's policy regarding Puree Foods included Standardized recipes will be used for all foods requiring tenderization to promote optimal appearance, texture, flavor, and nutritional value .Food requiring blendarization will be processed according to available recipes and production needs .",2020-09-01
522,"SAPPHIRE OF TUCSON NURSING AND REHAB, LLC",35099,2900 EAST MILBER STREET,TUCSON,AZ,85714,2016-09-29,371,D,0,1,XFF511,"Based on observations, staff interview and policy review, the facility failed to ensure that two dietary staff wore beard restraints while in the kitchen. Findings include: During an observation in the kitchen on (MONTH) 26, (YEAR) at 3:10 p.m., a cook (staff #190) was observed in the food prep area without a beard restraint and a dietary aide (staff #191) was observed in the clean dish area without a beard restraint. An immediate interview was conducted with the nutrition service supervisor (staff #189) on (MONTH) 26, (YEAR). Staff #189 stated that the two dietary staff members should have worn beard restraints while in the kitchen. Staff #189 further stated that the dietary staff members had beard restraints on earlier, but had taken them off. A review of the facility's policy on Food Safety Standards and Requirements revealed .Facial hair longer than 1/4 will require beard restraints in food production areas to effectively keep facial hair from contacting exposed food, clean equipment, utensils, linens, and unwrapped single-service use articles as well as to minimize hand contact with facial hair .",2020-09-01
523,"SAPPHIRE OF TUCSON NURSING AND REHAB, LLC",35099,2900 EAST MILBER STREET,TUCSON,AZ,85714,2016-09-29,431,E,0,1,XFF511,"Based on observation, review of facility documentation, staff interview and policy review, the facility failed to ensure the medication refrigerator temperatures were consistently monitored and documented. Findings include: An observation was conducted with the unit manager (registered nurse/staff #34) on (MONTH) 27, (YEAR) at 1:40 p.m. of the medication refrigerator located in the second floor medication room. Posted on the outside of the medication refrigerator was a Medication Refrigerator/Room Daily Temperature Record for the Month of August. Per the instructions on the form, the refrigerator temperature was to be monitored and documented on the day shift and the night shift to maintain a desired temperature of 36 degrees-46 degrees F. Further review of the temperature log revealed the temperatures were only documented on (MONTH) 18 and 19, on the day shift. In addition there was no temperature log for the month of (MONTH) (YEAR). At this time, an interview was conducted with staff #34. Staff #34 stated that the night shift is responsible and the daily temperatures are checked and are recorded on the logs by the night shift. The Director of Nursing was unable to provide any documentation that the medication refrigerator temperatures were monitored and documented for (MONTH) (YEAR). Review of the policy regarding the Storage of Medications and Biologicals revealed that medications and biologicals are stored safely and properly. The policy included that medications requiring refrigeration or which require temperatures between 36 and 46 degrees F. are kept in a refrigerator with a thermometer to allow temperature monitoring.",2020-09-01
524,"SAPPHIRE OF TUCSON NURSING AND REHAB, LLC",35099,2900 EAST MILBER STREET,TUCSON,AZ,85714,2017-10-05,154,D,0,1,3WU211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility failed to ensure one resident (#249) was informed of the risks and benefits of a psychoactive medication. Findings include: Resident #249 was admitted to the facility on (MONTH) 14, (YEAR) and readmitted on (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 21, (YEAR) revealed the resident had a Brief Interview for Mental Status score of 12, which indicated the resident had moderate cognitive impairment. A physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the clinical record revealed no documentation that resident #249 had been informed of the risks and benefits related to the use of a psychoactive medication. In an interview conducted with the Unit Manager (licensed practical nurse/staff #81) on (MONTH) 5, (YEAR) at 3:39 p.m., staff #81 stated that there should be a consent in the record which includes the risks and benefits of using the [MEDICATION NAME], but it got missed.",2020-09-01
525,"SAPPHIRE OF TUCSON NURSING AND REHAB, LLC",35099,2900 EAST MILBER STREET,TUCSON,AZ,85714,2017-10-05,242,D,0,1,3WU211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews and policy review, the facility failed to honor one resident's (#35) choice to have coffee at various times of the day. Findings include: Resident #35 was admitted on (MONTH) 11, 2011 and readmitted on (MONTH) 26, (YEAR), with [DIAGNOSES REDACTED]. A review of the resident's behavioral care plan dated (MONTH) 16, (YEAR) revealed that because of the resident's deteriorating medical status and poor intake, the resident is allowed to have meals in her room and is allowed to have liberal snacks in her room, including snacks outside of the regularly scheduled snack times, in order to encourage increased intake. An annual MDS (Minimum Data Set) assessment dated (MONTH) 25, (YEAR) included the resident had a Brief Interview for Mental Status score of 11, which indicated the resident had moderate cognitive impairment. In Section F (preferences) of the MDS, the documentation included that snacks were very important to the resident. The MDS also included the resident needed encouragement and set up help only with eating. During an interview with resident #35 on (MONTH) 3, (YEAR) at 12:40 p.m., the resident stated that she can not get coffee between meals, and that staff tell her the kitchen is closed. An interview was conducted on (MONTH) 4, (YEAR) at 8:54 a.m., with the Behavior Program Manager (staff #107), who stated that the resident can have coffee at meal times or at scheduled snack times, but per the Clinical Psychologist residents can not have coffee between meals, outside of the scheduled snack times. Staff #107 stated that there was no coffee on the unit, because staff were fearful that residents would throw it at them. During an interview conducted on (MONTH) 4, (YEAR) at 9:21 a.m. with a CNA (certified nursing assistant/staff #105), staff #105 stated that coffee was available on unit and that residents could have it anytime, but only decaffeinated. An interview was conducted with a LPN (licensed practical nurse/staff #51) on (MONTH) 4, (YEAR) at 9:38 a.m. Staff #51 stated that to the best of her knowledge, residents can have coffee anytime. During an interview with the Unit Manager (licensed practical nurse/staff #116) on (MONTH) 4, (YEAR) at 11:21 a.m., staff #116 stated that the Clinical Psychologist doesn't want the residents to have coffee between meals, only at snack time and that residents could only have water in their rooms. Staff #116 stated she was not sure of the reasoning. The clinical record did not include any documentation that the resident could not have coffee throughout the day. A review of the facility's policy regarding Residents' Rights revealed that each individual admitted to the facility will be provided with reasonable accommodations, unless the health or safety of the resident or other residents is at risk. The policy included that residents will be permitted to choose activities and schedules consistent with the resident's interests that does not interfere with other residents.",2020-09-01
526,"SAPPHIRE OF TUCSON NURSING AND REHAB, LLC",35099,2900 EAST MILBER STREET,TUCSON,AZ,85714,2017-10-05,253,D,0,1,3WU211,"Based on observations and staff interview, the facility failed to ensure a chair in one resident's room was not stained. Findings include: During the initial interview with resident #94 on (MONTH) 3, (YEAR) at 9:34 a.m., a chair which was sitting along side the resident's bed was observed to have a brown stain in the center of the cloth seat, which appeared to be feces. The brown stain measured approximately 4 inches wide by 7 inches long. Another observation of the resident's room was conducted on (MONTH) 4, (YEAR) at approximately 2:15 p.m., and the same chair was in the room with the brown stain on the cloth seat. A third observation was conducted on (MONTH) 5, (YEAR) at 8:00 a.m., of the resident's room. The same chair was in the room and the brown stain remained on the cloth seat. In an interview conducted with the Manager of Housekeeping (staff #175) on (MONTH) 5, (YEAR) at 8:30 a.m., the Manager stated that the chair with the feces on it should never have been left in the room in that condition.",2020-09-01
527,"SAPPHIRE OF TUCSON NURSING AND REHAB, LLC",35099,2900 EAST MILBER STREET,TUCSON,AZ,85714,2017-10-05,280,D,0,1,3WU211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, resident and staff interviews and policy and procedures, the facility failed to ensure two residents (#35 and #166) were provided alternate times to attend care plan meetings. Findings include: -Resident #166 was admitted on (MONTH) 30, (YEAR) and readmitted on (MONTH) 21, (YEAR), with [DIAGNOSES REDACTED]. A review of the clinical record revealed the resident's face sheet included that she was her own responsible party, with a family member as an emergency contact. Review of the IDT (interdisciplinary team) care plan meeting documentation for (MONTH) 2, (YEAR) revealed the resident did not attend because she was eating. According to an admission MDS (Minimum Data Set) assessment dated (MONTH) 16, (YEAR), the resident had adequate hearing and clear speech. The MDS further documented a BIMS (brief interview for mental status) score of 15, which indicated the resident was cognitively intact. Review of the IDT care plan meeting documentation dated (MONTH) 22, (YEAR), revealed the resident did not attend, because she was in therapy. There was no clinical record documentation of any attempts to reschedule the care plan meetings at a time when the resident could attend. During an interview with resident #166 on (MONTH) 2, (YEAR) at 2:30 p.m., the resident stated that she was invited to a care plan meeting, but she had an outside appointment and no one talked to her about rescheduling the care plan meeting, when she was available. -Resident #35 was admitted on (MONTH) 11, 2011 and readmitted on (MONTH) 26, (YEAR), with [DIAGNOSES REDACTED]. A review of the resident's face sheet revealed the resident was her own responsible party. An annual MDS assessment dated (MONTH) 25, (YEAR) documented the resident had adequate hearing and clear speech. The MDS further documented that the resident had a BIMS score of 11, which indicated the resident had moderate cognitive impairment. Review of the IDT care plan meeting documentation for (MONTH) 19, (YEAR), (MONTH) 29, (YEAR), (MONTH) 27, (YEAR) and (MONTH) 31, (YEAR), revealed the resident did not attend any of the care plan meetings, as the resident was unable to attend. There was no documentation as to why the resident was unable to attend or if there were any attempts to reschedule the meetings at a time that was convenient for the resident. An interview with resident #35 was conducted on (MONTH) 3, (YEAR) at 12:30 p.m. When questioned if staff include her in decisions about her medications, therapies and other treatments, the resident stated that they do not. An interview was conducted on (MONTH) 4, (YEAR) at 9:54 a.m. with the social services assistant (staff #127), who stated that she was responsible for the documentation regarding the residents attending their care plan meetings. Staff #127 stated that the care plan meetings are usually held at noon time during lunch, so she documents that the residents are not available. Staff #127 further stated there was no documentation that the residents were asked about rescheduling the care plan meetings at a time which was convenient to the residents. A review of the facility policy regarding Residents' Rights revealed that residents have the right to participate in the planning or decisions concerning treatment, including development of the care plan.",2020-09-01
528,"SAPPHIRE OF TUCSON NURSING AND REHAB, LLC",35099,2900 EAST MILBER STREET,TUCSON,AZ,85714,2017-10-05,309,E,0,1,3WU211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure that care and services were provided to two residents (#302 and #296) receiving [MEDICAL TREATMENT], and failed to ensure that wound treatments were administered to one resident (#302) as ordered by the physician. Findings include: -Resident #302 was readmitted to the facility on (MONTH) 11, (YEAR), with [DIAGNOSES REDACTED]. The resident was discharged from the facility on (MONTH) 24, (YEAR). Regarding wound treatments: A review of a NP note dated (MONTH) 6, (YEAR) revealed the resident had a history of [REDACTED]. The weekly skin observation dated (MONTH) 1, (YEAR) included the resident's coccyx had red, flaky open areas. A physician's orders [REDACTED]. The wound care plan with a revision date of (MONTH) 3, (YEAR) included that the resident had moisture associated [MEDICAL CONDITION]. A goal was for the resident to maintain clean and intact skin. An intervention included for barrier cream to be applied to the buttocks every shift. Review of the (MONTH) (YEAR) Treatment Administration Record (TAR) revealed the above order. However, there were multiple dates with no documentation that the barrier cream was applied. There was also no documentation as to why the treatment was not administered. An interview with a licensed practical nurse (LPN/staff #74) was conducted on (MONTH) 4, (YEAR) at 2:12 p.m. She stated that the barrier cream should be administered as ordered. She stated that when she administers barrier cream she will put her initials in the appropriate box in the TAR. An interview with the Director of Nursing (DON/staff #55) was conducted on (MONTH) 4, (YEAR) at 2:50 p.m. She stated that if the boxes in the MAR/TAR or on the monitor sheets are blank and not initialed, it means that it was not documented that the medication or treatment was administered. In an interview with another LPN (staff #145) conducted on (MONTH) 5, (YEAR) at 10:07 a.m., he stated that when medications and/or treatments are administered, it is documented in the MAR indicated [REDACTED]. He stated the facility software reminds the nurses of any medications/treatments that need to be done during and at the end of the shift, so the nurse has ample reminders to administer the medication/treatment and to document it. Review of a policy titled, Administering Medications included that medications shall be administered in a safe and timely manner, and as prescribed. It also included that if a drug is withheld, refused or given at a time other than the scheduled time, the nurse shall initial and circle the MAR indicated [REDACTED]. The policy also included that topical medications used in treatment must be recorded on the resident's TAR. Regarding [MEDICAL TREATMENT]: Review of the clinical record revealed the resident goes out for [MEDICAL TREATMENT] three times a week. The documentation also noted that the resident had an AVF (arteriovenous fistula) to the left upper arm. However, review of the physician's orders [REDACTED]. A nurse practitioner (NP) note dated (MONTH) 6, (YEAR) included to continue [MEDICAL TREATMENT] three times a week. The quarterly MDS (Minimum Data Set) assessment dated (MONTH) 16, (YEAR) included a BIMS (Brief Interview for Mental Status) score of 15, indicating the resident was cognitively intact. The MDS also included the resident was receiving [MEDICAL TREATMENT] services. A comprehensive care plan identified the resident required [MEDICAL TREATMENT]. A goal included that the resident would have no signs or symptoms of any complications from [MEDICAL TREATMENT]. The care plan did not include to monitor the AVF shunt site for bruits/thrills, shunt site precautions, any bleeding or to monitor for any signs and symptoms of infection. Review of the clinical record revealed that from (MONTH) (YEAR) through (MONTH) (YEAR), pre [MEDICAL TREATMENT] assessments were not consistently done. In addition, the clinical record and the MARs/TARs for (MONTH) through (MONTH) (YEAR) did not include documentation that the AVF site was monitored consistently for complications. In an interview with a registered nurse (RN/staff #124) conducted on (MONTH) 4, (YEAR) at 11:09 a.m., she stated that she assesses the shunt site for bruit/thrill and any complications at least every shift and it should be documented in the clinical record. During an interview with a unit manager (staff #116) conducted on (MONTH) 4, (YEAR) at 1:30 p.m., she stated that pre and post [MEDICAL TREATMENT] assessments should include an assessment of the AVF site for bruit/thrill, signs and symptoms of bleeding and infection, and checking vital signs. Staff #116 stated that the assessment is to be documented in the clinical record. She also stated that when a resident on [MEDICAL TREATMENT] is admitted without any orders to monitor the AVF shunt site, the physician should be called for orders. Staff #116 stated that the admission nurse is responsible for ensuring there are orders for care, when the resident is admitted to the facility. An interview with a licensed practical nurse (LPN/staff #74) was conducted on (MONTH) 4, (YEAR) at 2:12 p.m. She stated an assessment of the AVF site includes checking vital signs, visually seeing the AVF site, checking for bruit/thrill, checking for bleeding and signs and symptoms of complications. Staff #74 stated the assessments should be conducted on [MEDICAL TREATMENT] days and at least every shift and documented in the clinical record. In an interview with another LPN (staff #145) conducted on (MONTH) 5, (YEAR) at 10:07 a.m., he stated that assessments of the AVF shunt are done on a daily basis and are documented in the clinical record on the monitor sheets. He stated that if the boxes on the monitor sheets are blank and are not initialed, it means that it was not done or the nurse forgot to document that it was done. -Resident #296 was admitted on (MONTH) 8, (YEAR), with a [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of a [MEDICAL TREATMENT] care plan dated (MONTH) 11, (YEAR) revealed the resident had end stage [MEDICAL CONDITION] and was dependent on [MEDICAL TREATMENT]. A goal included there would be no signs or symptoms of complications from [MEDICAL TREATMENT] through the next review date. Interventions included to check fistula and change dressings as per MD's orders and report to doctor as needed. According to an admission MDS assessment dated (MONTH) 15, (YEAR), the resident had a BIMS score of 14, indicating no cognitive impairment. The MDS further included the resident was receiving [MEDICAL TREATMENT] services. Review of the clinical record revealed no documentation that the resident was assessed prior to going out to [MEDICAL TREATMENT] on (MONTH) 13,15,18 and 27, (YEAR). In addition, there was no documentation that the resident was assessed after [MEDICAL TREATMENT] on (MONTH) 11,13,18, 22, 25 and 27, (YEAR). Review of the pre and post [MEDICAL TREATMENT] forms revealed areas to document the resident's vital signs, condition of the AV fistula shunt site, the presence of thrill/bruit, condition of the dressing to the AV shunt site and the resident's cognition. An interview was conducted with the Unit manager (LPN/staff #81) on (MONTH) 5, (YEAR) at 4:15 p.m. She stated the nursing staff are expected to document pre and post [MEDICAL TREATMENT] assessments in the clinical record, under the pre and post [MEDICAL TREATMENT] templates. She said that the nurses are to follow the physician's orders [REDACTED]. Review of the policy regarding [MEDICAL TREATMENT] Access Care revealed the care of the AVF involves the primary goal of preventing infection and maintaining patency of the catheter and preventing clots. The policy further included that to prevent infection and/or clotting, AVF's are checked for the following: -Signs of infection (warmth, redness, tenderness, [MEDICAL CONDITION]) at the access site when performing routine care and at regular intervals. -Patency of site at regular intervals by palpating the site to feel the thrill or use a stethoscope to hear the whoosh or bruit of blood flow through the access. The policy also included that the nurse should document in the medical record every shift the following: -Location of the catheter -Condition of dressing -If [MEDICAL TREATMENT] was done during shift -Any part of report from [MEDICAL TREATMENT] nurse post-[MEDICAL TREATMENT] -Post-[MEDICAL TREATMENT] observations .",2020-09-01
529,"SAPPHIRE OF TUCSON NURSING AND REHAB, LLC",35099,2900 EAST MILBER STREET,TUCSON,AZ,85714,2017-10-05,318,G,0,1,3WU211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review and staff interviews, the facility failed to ensure that one resident (#121) with limited range of motion received the appropriate treatment and services to prevent further decrease in range of motion to the left lower extremity, and failed to ensure a physician ordered treatment for [REDACTED]. Findings include: Resident #121 was admitted to the facility on (MONTH) 23, (YEAR) from another facility, with [DIAGNOSES REDACTED]. Regarding the left foot: Review of the clinical record revealed a History and Physical prior to admitted d (MONTH) 19, (YEAR), which included the resident had [MEDICAL CONDITION] right sided weakness from 2008, and bilateral lower extremities had limited range of motion (ROM) and diffuse [MEDICAL CONDITION]. The report further included the resident had right foot drop. There was no documentation that the resident had foot drop to the left foot. Review of a quarterly MDS (Minimum Data Set) assessment prior to admitted d (MONTH) 21, (YEAR), revealed the resident required extensive assistance with bed mobility, dressing and transfers. The MDS also included that ambulation did not occur and that the resident had impairment to both lower extremities. A nursing admission evaluation dated (MONTH) 23, (YEAR) included the resident was admitted for long term care and was alert and oriented to person, place, time, and situation. Per the documentation, the resident had a history of [REDACTED]. However, the documentation did not include the location of the contracture. The was also no documentation of any foot drop to the lower extremities. Review of the physical therapy (PT) plan of care dated (MONTH) 24, (YEAR) revealed the resident was referred to therapy, secondary to impaired functional mobility, muscle weakness and difficulty in changing positions. Underlying impairments included hypotonic muscle tone and severely impaired gross motor coordination to the right and left lower extremity. The documentation included that the resident's lower extremities had impaired limited ROM. The documentation also included that the resident refused further skilled physical therapy. The therapy plan of care notes did not identify that the resident had a contracture/foot drop to the left foot. A review of nurse practitioner's (NP) notes dated (MONTH) 24, (YEAR) revealed the resident had a [DIAGNOSES REDACTED]. Under the musculoskeletal/extremities section, the documentation included that the resident had a baseline ROM, with no tenderness to palpation. The documentation did not include identification of a contracture/foot drop to the left foot. A physician's note dated (MONTH) 25, (YEAR) included a [DIAGNOSES REDACTED]. The note included there were no deformities in the resident's extremities. The documentation did not include that the resident had a contracture/foot drop to the left foot. According to the admission MDS assessment dated (MONTH) 30, (YEAR), the resident had a Brief Interview for Mental Status (BIMS) score of 0, which indicated severe cognitive impairment. The MDS included the resident had [MEDICAL CONDITIONS] or [MEDICAL CONDITION], and had functional limitation in range of motion on one side to the upper and lower extremities. The MDS also identified that the resident required extensive assistance of two with dressing, bed mobility and transfers and that ambulation did not occur. Review of the resident's comprehensive care plans revealed that they did not identify that the resident had any contractures or foot drop to the left foot, nor were there any interventions to prevent a decline in range of motion. Review of the nursing notes from (MONTH) 25, (YEAR) through (MONTH) 4, (YEAR), revealed no evidence that the resident had a contracture or foot drop to the left foot. Further review of the clinical record revealed there was no documentation that the resident was re-evaluated by PT or that any preventative devices (such as Ankle Boot Orthosis devices or foot positioners) were put in place from (MONTH) 25, (YEAR) through (MONTH) 4, (YEAR) to prevent a decline in ROM to the left foot. During an observation conducted on (MONTH) 3, (YEAR) at 11:02 a.m., resident #121 was observed lying in bed, with pillows underneath both of her legs. The resident's feet were observed to be hyperextended and the toes were pointed in a downward direction. The resident did not have any preventative devices in place to the lower extremities. In an interview with a licensed practical nurse (LPN/staff #43) conducted on (MONTH) 3, (YEAR) at 11:03 a.m., she stated the resident does have contractures on both feet and there were no splint devices ordered or in place to prevent decline. She also said that the resident is currently not in therapy or in the RNA (restorative nursing assistance) program. Another observation was conducted on (MONTH) 5, (YEAR) at 8:26 a.m. of the resident lying in bed, with pillows underneath both legs. The resident's feet were observed to be hyperextended and the toes were pointed in a downward direction. There were no preventative devices in place to the resident's lower extremities. An interview with the Director of Rehab (staff #147) was conducted on (MONTH) 5, (YEAR) at 9:19 a.m. He stated that the resident previously received a physical therapy (PT) evaluation only, because the resident refused further therapy. After reviewing the PT documentation, staff #147 stated that based on the PT evaluation note, the resident had hypotonicity, but not rigidity on the left leg and there was no documentation of a contracture/foot drop identified on the left foot. An observation was conducted on (MONTH) 5, (YEAR) at 10:41 a.m., with a LPN (staff #197). The resident was observed lying on her bed, with both legs on top of a pillow. There were no preventative devices in place to the resident's lower extremities. Immediately following the observation, staff #147 stated the resident has weakness on the left side and has foot drop on both feet. He said that he does not know when the resident developed foot drop. He stated there are no splints or boots recommended or ordered for the resident's feet. In an interview with the unit manager (licensed practical nurse/staff #116) conducted on (MONTH) 5, (YEAR) at 11:09 a.m., she stated that both of the resident's feet look like foot drop and there are no boots in place. In a later interview this same day, staff #116 provided hospital documentation dated (MONTH) 19, (YEAR), which showed that the resident had right foot drop. After reviewing the clinical record documentation, staff #116 stated that she could not tell if the resident was admitted to the facility with a contracture/foot drop to the left foot. Another interview with the Director of Rehab (staff #147) was conducted on (MONTH) 5, (YEAR) at 3:58 p.m. He stated that his assessment now is that the resident has contractures on both feet. He stated that he can not tell if it is foot drop, because the resident did not want him to touch her. He stated that the contracture on the left foot must have started with foot drop, secondary to hypotonicity due to the [MEDICAL CONDITION], and in time, became a contracture. He stated this is the first time he has seen the resident and wishes that he had gotten this resident earlier, so he could have helped her condition from becoming what it is now. Regarding the left hand: The nursing admission evaluation dated (MONTH) 23, (YEAR) included the resident was admitted for long term care and was alert and oriented to person, place, time and situation. Per the documentation, the resident was status [REDACTED]. However, the documentation did not include the location of the contracture. Review of the occupational therapy (OT) evaluation dated (MONTH) 24, (YEAR) revealed the resident had hypertonic muscle tone and severely impaired fine and gross motor control to the left upper extremity. Per the documentation, rehab potential was poor and there was no therapy needed. A nursing note dated (MONTH) 28, (YEAR) included the resident had a contracted left hand, which was cleansed due to a foul odor. The admission MDS assessment dated (MONTH) 30, (YEAR) included a BIMS score of 0, indicating the resident had severe cognitive impairment. The MDS also included the resident had functional limitation in ROM to the upper extremity. Review of the (MONTH) (YEAR) physician's orders [REDACTED]. However, this order was not transcribed onto the (MONTH) and (MONTH) (YEAR) Medication Administration Records (MAR), Treatment Administration Record (TAR) or the monitor sheets. Review of the clinical record revealed no evidence that this order was consistently implemented, as ordered by the physician. A comprehensive care plan included the resident had a contracture to the left hand. An intervention included for the application of a therapy carrot to the left hand as tolerated. In an interview with a licensed practical nurse (staff #43) conducted on (MONTH) 3, (YEAR) at 11:03 a.m., she stated that the resident has a contracture to the left hand and there was no splint device ordered or in place. During an interview with the Director of Rehab (staff #147) conducted on (MONTH) 5, (YEAR) at 9:19 a.m., he stated the resident received an occupational therapy (OT) evaluation only, as the resident's functional level was the same as her prior level, so no further therapy was needed. He stated the resident has limitations to her left hand and therapy tried to put a rolled washcloth or carrot splint in her left hand, but the resident would take it off. An interview with a LPN (staff #197) was conducted on (MONTH) 5, (YEAR) at 10:41 a.m. He stated the resident has some contractures to the fingers of the left hand and has a carrot splint for this. An observation of the resident with staff #197 was conducted immediately following the interview. The resident was observed lying on her bed, with her left arm on top of a pillow. The fingers of the left hand were contracted and there was no carrot splint in place. At this time, staff #197 stated that the carrot splint was not in the resident's hand and he did not know why it was not in place. He further stated that the carrot splint must be placed in the resident's left hand every time the resident is awake. During an interview with the unit manager (staff #116) conducted on (MONTH) 5, (YEAR) at 11:09 a.m., she stated that if there is an order for [REDACTED]. An interview with the Director of Nursing (DON/staff #55) was conducted on (MONTH) 5, (YEAR) at 1:13 p.m. She stated that if the boxes in the MAR, TAR or the monitor sheets are blank and not initialed, it means the treatment was not documented as being administered. An interview was conducted on (MONTH) 5, (YEAR) at 5:20 p.m., with the administrator (staff #10), the corporate Director of Social Services, and activity (staff #203) staff. Staff #203 stated that the facility does not have a policy regarding contractures. In a later interview with staff #203 on (MONTH) 5, (YEAR) at approximately 6:00 p.m., she stated the facility does not have a policy regarding limited range of motion or rehabilitation.",2020-09-01
530,"SAPPHIRE OF TUCSON NURSING AND REHAB, LLC",35099,2900 EAST MILBER STREET,TUCSON,AZ,85714,2017-10-05,323,E,0,1,3WU211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews and policy review, the facility failed to ensure the environment was free from accident hazards, by failing to accurately assess two residents (#135 and #295) for safe smoking, and by failing to ensure fire safety equipment was available in an area where residents smoked. Findings include: -Resident #295 was readmitted to the facility on (MONTH) 9, (YEAR) and readmitted on (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. Review of a smoking assessment dated (MONTH) 11, (YEAR) revealed the resident was identified as a non smoker. The nursing admission evaluation dated (MONTH) 19, (YEAR) included the resident was alert and oriented to person, place, time and situation and had appropriate verbal skills. Per the documentation, the resident did not use tobacco and had previously quit smoking. A physician's note dated (MONTH) 20, (YEAR) included the resident had intact cognition and responds appropriately. The note also included that the resident was a smoker. A social services admission note dated (MONTH) 20, (YEAR) also included the resident was a current smoker. Review of a nurse practitioner (NP) note dated (MONTH) 25, (YEAR) revealed the resident was positive for tobacco use. Review of the admission MDS (Minimum Data Set) assessment dated (MONTH) 26, (YEAR), included a BIMS (Brief Interview for Mental Status) score of 7, which indicated that the resident had severe cognitive impairment. The MDS also included the resident required supervision of one person with bed mobility, transfers, toilet use and personal hygiene, and was independent with locomotion off the unit. Review of the resident's care plans revealed they did not address that the resident was a smoker, nor were there any interventions to address any smoking needs. Review of the clinical record revealed there was no evidence that a smoking assessment for this resident was conducted since (MONTH) (YEAR). On (MONTH) 2, (YEAR), the administrator (staff #10) provided a list of residents who smoked. Review of this list revealed that resident #295 was not included. However, during an interview with resident #295 conducted on (MONTH) 2, (YEAR) at 1:33 p.m., he stated that he goes out in front of the facility to smoke. An observation was conducted on (MONTH) 2, (YEAR) at 1:45 p.m., of resident #295 self-propelling himself in his wheelchair out of the facility to a desert lot, which was located beyond the parking lot. The lot consisted of dirt, dried weeds and bushes. The resident parked himself in an area near several bushes. The resident was then observed to light a cigarette. The resident smoked for approximately 10 minutes and no staff were present. During this time, the resident was observed to flick the cigarette ashes onto the ground. There were no other residents out smoking at this time. Further observations revealed that there were no smoking receptacles, nor any fire safety equipment found in the area. An interview with the resident was conducted on (MONTH) 2, (YEAR) at 2:50 p.m. He stated that he had been smoking outside in this lot to smoke since he was admitted . He stated that he has cigarettes and a lighter with him at all times and then pointed to his jean pocket. During an interview with the administrator (staff #10) conducted on (MONTH) 2, (YEAR) at 3:14 p.m., he stated that they were a non smoking facility, but they do have residents who smoke. He stated the residents who smoke go outside of the facility's property to the desert lot area, which is owned by the county. He said the cigarette butts are removed by the landscapers of this property. He further stated that there are no smoking schedules and there are no staff supervising these residents, because the facility is a non-smoking facility. He also stated that the security guard is supposed to walk by the area where the residents smoke. An observation was conducted of the desert lot on (MONTH) 2, (YEAR) at 4:40 p.m. There were four residents in their wheelchairs smoking and there were no staff present. There were no smoking receptacles and no fire safety equipment found in the area. The security guard was observed sitting at the bench located at the side of the main entrance door, which was approximately 300 feet from the area where the residents were smoking. A smoking screen dated (MONTH) 2, (YEAR) included that resident #295 smoked 5-10 times per day and can smoke unsupervised. Another interview with resident #295 was conducted on (MONTH) 3, (YEAR) at 9:23 a.m. He stated that he has always smoked in the desert lot, with no staff present. He also stated that he discards his cigarette butts anywhere on the ground. An interview with a licensed practical nurse (LPN/staff #192) was conducted on (MONTH) 3, (YEAR) at 9:57 a.m. She stated that resident #295 was alert and oriented, and propels his wheelchair off the unit to go outside to smoke. In an interview with another LPN (staff #193) conducted on (MONTH) 3, (YEAR) at 10:15 a.m., she stated that residents who smoke would go out by the desert area to smoke and no staff would be present. An interview with a certified nursing assistant (CNA/staff #56) was conducted (MONTH) 3, (YEAR) at 10:51 a.m., who stated that residents who smoke would go to the corner lot beyond the parking lot to smoke, with no supervision from staff. In an interview with a LPN (staff #43) conducted on (MONTH) 3, (YEAR) at 11:04 a.m., she stated that the facility has always been a no smoking facility and residents are informed upon admission that they are not supposed to smoke, while at the facility. She further stated that residents who smoke go out to the desert lot or somewhere else outside the facility to smoke. -Resident #135 was readmitted to the facility on (MONTH) 2, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed a Smoking Screen dated (MONTH) 18, (YEAR), which included that the resident could not obtain a cigarette if it were dropped. The documentation also included that the resident was able to smoke unsupervised. Review of a quarterly MDS assessment dated (MONTH) 26, (YEAR) revealed the resident had a BIMS score of 15, which indicated no cognitive impairment. The functional section of the MDS documented the resident required extensive assistance of one person with transfers, dressing and hygiene. The MDS also included the resident had no impairment to the upper extremities, but had impairment to bilateral lower extremities. On (MONTH) 2, (YEAR) at 3:00 p.m., resident #135 was observed outside smoking unsupervised. The resident was in a motorized wheelchair and had a tracheostomy in place. The resident was observed to be able to hold a cigarette without difficulty. While the resident was smoking, he was flicking ashes onto the ground. When asked if he always smoked unsupervised he gave a thumbs up, when asked where he kept his smoking material he pointed to his pocket, and when asked where he puts his cigarette butts, he pointed to the ground. There were no smoking receptacles, nor any fire safety equipment found in the area. A Smoking policy with a revision date of (MONTH) (YEAR) included to promote a healthy environment, the facility is smoke free, vapor free and tobacco free. It also included that the use of tobacco, tobacco products and vapor products (including e-cigarettes) were not permitted on facility grounds.",2020-09-01
531,"SAPPHIRE OF TUCSON NURSING AND REHAB, LLC",35099,2900 EAST MILBER STREET,TUCSON,AZ,85714,2017-10-05,329,E,0,1,3WU211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and policy and procedure, the facility failed to ensure one resident (#249) was monitored for behaviors related to the use of a psychoactive medication. Findings include: Resident #249 was admitted to the facility on (MONTH) 14, (YEAR) and readmitted on (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 21, (YEAR), revealed the resident had a Brief Interview for Mental Status score of 12, which indicated the resident had moderate cognitive impairment. A physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. However, there was no clinical record documentation that the resident was being monitored for any behaviors related to depression. An interview was conducted on (MONTH) 5, (YEAR) at 10:43 a.m. with a Licensed Practical Nurse (LPN/staff #145). Staff #145 stated that resident #249 should be monitored for increased depression, suicidal ideation and [MEDICAL CONDITION]. Staff #145 stated there was no monitoring of the resident's behaviors for the use of the antidepressant medication. In an interview conducted with the Unit Manager (LPN/staff #81) on (MONTH) 5, (YEAR) at 3:39 p.m., staff #81 stated the resident should have been monitored for behaviors each shift and the documentation should be on the MAR.",2020-09-01
532,"SAPPHIRE OF TUCSON NURSING AND REHAB, LLC",35099,2900 EAST MILBER STREET,TUCSON,AZ,85714,2017-10-05,520,E,0,1,3WU211,"Based on facility documentation, staff interview, and policy review, the facility failed to maintain a quality assessment and assurance (QA) committee, which identified and implemented appropriate plans of action to correct quality deficiencies regarding smoking. Findings include: During the survey, concerns were identified regarding failing to accurately assess two residents for safe smoking, and failing to ensure fire safety equipment was available in an area where residents smoked. Review of the facility's Smoking Process Performance Improvement Plan dated (MONTH) 23, (YEAR) revealed the facility had previously identified the following concerns: We have discovered smokers who are in the building going off sight to smoke and feel for their safety and rights that we needed to investigate turning the facility back into a smoking facility with policy's and process in place meeting fire safety protocols for State of Arizona .Interventions. Smoking equipment. There will be smoking at designated areas and smoking times. A staff member will be in attendance during all smoking periods. All smoking materials will be kept in a locked tackle box with resident name and lighters along with smoking aprons. We currently are waiting for the red lines to be applied to the areas to designate smoking vs. non smoking designation. Smoking signs have been ordered to place within smoking areas and non smoking .All smokers will have a smoking assessment completed prior to beginning process . An interview was conducted with the administrator (staff #10) on (MONTH) 2, (YEAR) at 3:55 p.m. The administrator stated the facility had identified concerns back on (MONTH) 23, (YEAR), regarding the facility being a non-smoking facility, but residents were smoking just off the facility property. The administrator stated the facility had ordered equipment for a supervised smoking area, however, nothing further had been done. The administrator further stated, It fell on the back burner. Review of the facility's Quality Assurance and Performance Improvement (QAPI) Committee policy revealed .The primary goals of the QAPI Committee are to: 1. Establish, maintain and oversee facility systems and processes to support the delivery of quality of care and services .3. Help identify actual and potential negative outcomes relative to resident care and resolve them appropriately .6. Coordinate the development, implementation, monitoring, and evaluation of performance improvement projects to achieve specific goals .",2020-09-01
533,HAVASU NURSING CENTER,35100,3576 KEARSAGE DRIVE,LAKE HAVASU CITY,AZ,86406,2019-02-06,600,G,1,1,R7F711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, resident and staff interviews, facility documents and policies and procedures, the facility failed to provide the necessary care and services to prevent neglect, by failing to ensure one resident (#9) was adequately supervised while outside and as a result, sustained prolonged sun exposure resulting in hospitalization . Findings include: Resident #9 was admitted on (MONTH) 12, (YEAR), with [DIAGNOSES REDACTED]. Review of a quarterly MDS (Minimum Data Set) assessment dated (MONTH) 12, (YEAR) revealed the resident had a BIMS (Brief Interview for Mental Status) score of 9, which indicated moderate cognitive impairment. The MDS included the resident used a wheelchair for locomotion on and off the unit and required supervision (oversight, encouragement or cueing). A care plan for cognitive loss related to impaired memory and forgetfulness was updated on (MONTH) 14, (YEAR). An intervention was the resident needed reminders to call for assistance. A care plan updated on (MONTH) 14, (YEAR) for the potential for falls related to weakness and impaired mobility, included to continue frequent checks, remind the resident to call for assistance and that the resident can be impulsive. According to a care plan for alteration in fluid intake updated on (MONTH) 25, (YEAR) included that resident #9 had two plus [MEDICAL CONDITION] in both legs. Interventions included to assure adequate fluid intake. An additional intervention initiated on (MONTH) 26, (YEAR) included to monitor the resident for side effects of diuretic use, including electrolyte imbalance and dehydration. A nurses note dated (MONTH) 1, (YEAR) at 5:00 p.m. revealed the resident had been found outside by a nurse on the patio, his color was flushed, skin dry, and he was unresponsive to verbal commands. Vital signs were as follows: temperature was 103.3, pulse was 107 and blood pressure was 96/69. Cooling measures were initiated and 911 was called, and the resident was transported to the hospital. A hospital physician's history and physical report dated (MONTH) 1, (YEAR) included that resident #9 had a history of [REDACTED]. The resident was found outside of the nursing facility after a period estimated to be a couple of hours. The resident had significant sunburns noted to the back of his neck, the anterior aspect of his upper chest, his arms, the medial aspect of his torso, and the anterior aspect of both thighs. The resident complained of generalized pain and weakness throughout his body. In the emergency department the resident was given a liter of chilled saline. The report further included the resident had heat exposure, heat stress and acute kidney injury, secondary to heat exposure and dehydration. A hospital discharge note dated (MONTH) 2, (YEAR) revealed the following discharge Diagnoses: [REDACTED]. A nurses note dated (MONTH) 2, (YEAR) included the resident returned to the facility. Review of the incident report revealed that on (MONTH) 1, (YEAR) at 5 p.m., the resident was found outside in the courtyard. The resident had memory impairment and impaired decision making ability, and self propelled his wheelchair in and out of courtyards frequently without difficulty. The report included the resident was sunburned, his face and neck were flushed and there was a fluid filled blister on the back of his neck. Cool compresses were applied. The resident was unresponsive to verbal commands and 911 was called. The type of incident documented was heat exposure/sunburn. Review of the facility's investigation report revealed that on (MONTH) 1, (YEAR) at approximately 4:30 p.m., resident #9 was found to be asleep outside in an interior courtyard. The resident was brought inside by a LPN (licensed practical nurse/staff #71). The resident was found to be lethargic and was not responding to verbal stimuli. The resident had a red face, neck and hands with blisters forming on his neck. Cool towels were placed over the resident's head, neck and arms and cool water was provided to the resident to drink. The resident was sent to the emergency department and was treated for [REDACTED]. The report included that the courtyard is visible from inside of the facility. Per the report, the day shift (6a-2p) CNA reported that the resident was in bed at shift change that afternoon, and the 2p-10p CNA reported that she saw the resident in the television room around 3:00 p.m., and in the hallway around 3:15 p.m. The report further included that staff did not visualize the resident again until he was found asleep in the courtyard at 4:30 p.m. Further review of the investigation report revealed a witness statement signed by staff #71. In the statement, staff #71 stated that the resident was last seen by staff at 3:00 p.m., and was found in the courtyard at 5:00 p.m. (which differs from the time documented in the investigation report at 4:30 p.m.). Review of the dispatch Pre-Hospital Care Report dated (MONTH) 1, (YEAR), revealed the call was received at 5:24 p.m., paramedics were on scene at 5:27 p.m., and the resident was transported to the hospital at 5:40 p.m. During an interview with resident #9 conducted on (MONTH) 4, 2019 at 12:10 p.m., he stated that last (MONTH) (he did not remember the exact date), he had fallen asleep while he was outside in the courtyard, but did not remember how long. The resident stated that he woke up when staff were carrying him inside and that he got burned pretty bad. An observation of the facility's non-smoking courtyard where the resident had been found revealed the courtyard had glass doors on two opposing sides. One set of glass doors lead into the main hallway and the other set of glass doors lead into the television room. The television room had multiple windows, so the courtyard was visible from this room and from the main hallway. In addition, the courtyard was surrounded by multiple resident rooms with windows that faced the courtyard. An Internet source (Time and Date.com) was reviewed on (MONTH) 5, 2019 at 2:36 p.m., and revealed the weather on (MONTH) 1, (YEAR) from 2:56 p.m. until 4:56 p.m. was sunny, with a temperature of 105 degrees F. An interview was conducted on (MONTH) 5, 2019, with the Director of Nursing (DON/staff #19). The DON stated that on (MONTH) 1, (YEAR), resident #9 was found sleeping out on the non-smoking courtyard. The DON said the resident was independently mobile with his wheelchair and was able to let himself in and out of the courtyard independently. The DON said at the time of the incident, staff were checking the courtyard hourly, but was done informally and was not documented, and no specific staff was assigned to check the courtyard. The DON also stated that the resident's assigned CNA (certified nursing assistant) should have known that he had gone out to the courtyard. An interview was conducted on (MONTH) 5, 2019 at 2:56 p.m., with a random CNA (staff #40). Staff #40 stated that in (MONTH) (YEAR), the facility air conditioning system maintained cool temperatures in the facility, and resident #9 was known by staff to go outside on the courtyard several times a day to warm up. Staff #40 said they were aware that resident #9 went outside frequently and they monitored him while in the courtyard. The CNA stated that staff would bring the resident inside after 10-15 minutes to prevent the resident from overheating. The CNA also stated that water was not maintained in the courtyard for residents to drink. An interview was conducted on (MONTH) 6, 2019 at 9:38 a.m., with a LPN (staff #71). Staff #71 stated she was walking down the hallway and noticed that resident #9 was out on the non-smoking courtyard asleep in his wheelchair, and his legs were stretched out in front of him and his head was tucked down onto his chest. She said she went out and attempted to wake the resident up, but he was non-responsive. Staff #71 said she immediately wheeled the resident to the nurses station and with additional staff assistance, placed cold towels around the residents neck. She said the resident had reddened skin on his face and neck and 911 was called. Staff #71 stated that staff monitored the courtyard by looking out onto the courtyard as they went by, but there was no structured program for monitoring the courtyard, there was no specific staff assigned to monitor the courtyard, and the monitoring was not documented. Staff #71 said resident #9 was able to use his wheelchair independently to go in and out of the courtyard, and he frequently went outside and napped in the sun, and this was common knowledge among the staff. She added that she was not his assigned nurse on (MONTH) 1, (YEAR) and did not know how long the resident had been outside when she found him. A policy and procedure titled, Resident Hydration and Prevention of Dehydration included This facility will endeavor to provide adequate hydration and to prevent and treat dehydration. An intervention included that nursing will assess for signs and symptoms of dehydration during daily care. Review of a policy and procedure titled, Safety and Supervision of Residents which was current on (MONTH) 1, (YEAR) revealed the following: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The policy included Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include: Outdoor safety (outings, courtyards, etc). Hourly courtyard checks. A policy and procedure titled, Abuse Prevention Program included the objective of the policy was zero tolerance of abuse and neglect by employees. Neglect was defined as the failure of the facility, its employees or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy included that resident's have the right to be free of abuse and neglect.",2020-09-01
534,HAVASU NURSING CENTER,35100,3576 KEARSAGE DRIVE,LAKE HAVASU CITY,AZ,86406,2019-02-06,607,D,0,1,R7F711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documents and policies and procedures, the facility failed to implement their Abuse policy, by failing to identify an incident of neglect involving one resident (#9), and by failing to report an incident of neglect to the State Survey Agency within two hours as required and to law enforcement. Findings include: Resident #9 was admitted on (MONTH) 12, (YEAR), with [DIAGNOSES REDACTED]. Review of a quarterly MDS (Minimum Data Set) assessment dated (MONTH) 12, (YEAR) revealed the resident had a BIMS (Brief Interview for Mental Status) score of 9, which indicated moderate cognitive impairment. The MDS included the resident used a wheelchair for locomotion on and off the unit and required supervision (oversight, encouragement or cueing). A nurses note dated (MONTH) 1, (YEAR) at 5:00 p.m. revealed the resident had been found outside by a nurse on the patio, his color was flushed, skin dry, and he was unresponsive to verbal commands. Vital signs were as follows: temperature was 103.3, pulse was 107 and blood pressure was 96/69. Cooling measures were initiated and 911 was called, and the resident was transported to the hospital. A hospital physician's history and physical report dated (MONTH) 1, (YEAR) included that resident #9 had a history of [REDACTED]. The resident was found outside of the nursing facility after a period estimated to be a couple of hours. The resident had significant sunburns noted to the back of his neck, the anterior aspect of his upper chest, his arms, the medial aspect of his torso, and the anterior aspect of both thighs. The resident complained of generalized pain and weakness throughout his body. In the emergency department the resident was given a liter of chilled saline. The report further included the resident had heat exposure, heat stress and acute kidney injury, secondary to heat exposure and dehydration. A hospital discharge note dated (MONTH) 2, (YEAR) revealed the following discharge Diagnoses: [REDACTED]. A nurses note dated (MONTH) 2, (YEAR) included the resident returned to the facility. Review of the incident report revealed that on (MONTH) 1, (YEAR) at 5 p.m., the resident was found outside in the courtyard. The resident had memory impairment and impaired decision making ability, and self propelled his wheelchair in and out of courtyards frequently without difficulty. The report included the resident was sunburned, his face and neck were flushed and there was a fluid filled blister on the back of his neck. Cool compresses were applied. The resident was unresponsive to verbal commands and 911 was called. The type of incident documented was heat exposure/sunburn. Review of the facility's investigation report revealed that on (MONTH) 1, (YEAR) at approximately 4:30 p.m., resident #9 was found to be asleep outside in an interior courtyard. The resident was brought inside by a LPN (licensed practical nurse/staff #71). The resident was found to be lethargic and was not responding to verbal stimuli. The resident had a red face, neck and hands with blisters forming on his neck. Cool towels were placed over the resident's head, neck and arms and cool water was provided to the resident to drink. The resident was sent to the emergency department and was treated for [REDACTED]. The report included that the courtyard is visible from inside of the facility. Per the report, the day shift (6a-2p) CNA reported that the resident was in bed at shift change that afternoon, and the 2p-10p CNA reported that she saw the resident in the television room around 3:00 p.m., and in the hallway around 3:15 p.m. The report further included that staff did not visualize the resident again until he was found asleep in the courtyard at 4:30 p.m. Further review of the investigation report revealed a witness statement signed by staff #71. In the statement, staff #71 stated that the resident was last seen by staff at 3:00 p.m., and was found in the courtyard at 5:00 p.m. (which differs from the time documented in the investigation report at 4:30 p.m.). Review of the dispatch Pre-Hospital Care Report dated (MONTH) 1, (YEAR), revealed the call was received at 5:24 p.m., paramedics were on scene at 5:27 p.m., and the resident was transported to the hospital at 5:40 p.m. The investigation report further revealed that the incident had not been identified as neglect, and that the incident was not reported to the State Survey Agency until (MONTH) 2, (YEAR) at 4:45 p.m., which was over the two hour time frame for reporting. In addition, there was no evidence that law enforcement was notified. An interview was conducted on (MONTH) 5, 2019 at 12:05 p.m., with the Director of Nursing (DON/staff #19). The DON stated that she did not know that the facility was supposed to report allegations of neglect or abuse to the State Survey Agency within 2 hours. Staff #19 said that she thought allegations of neglect or abuse were supposed to be reported within 24 hours. She also stated that she did not notify the police of the allegation of neglect, because she was not aware of the regulatory requirement to notify the police for allegations of neglect if there is bodily injury. An interview was conducted on (MONTH) 6, 2019 at 11:30 a.m., with the Administrator (staff #31) and the Director of Nursing (staff #19). Staff #31 stated that the police were not notified of the allegation of neglect, because serious bodily injury was not initially reported to him by the staff member, only that the resident had reddened skin. Staff #31 stated that an allegation of neglect is reported only if there is serious injury to the resident. Review of a policy titled, Abuse Prevention Program revealed the objectives included zero tolerance of abuse and neglect by employees, and to establish an atmosphere conducive to reporting any allegations of abuse and neglect. The policy included to develop and implement a system for identifying, investigating, preventing and reporting any incident or suspected incident of abuse, neglect and mistreatment. The policy defined neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy also included the following: -Incidents of abuse and neglect should be reported to the supervisor and immediately reported to the Director of Nursing/Administrator. -Reports are to be made as soon as the incident or potential incident is make known. -Authorities to be notified include: police department and the State Survey Agency. - If the events that cause the allegation involve abuse or result in serious bodily injury to a resident, a report must be made immediately, but not later that two hours after receiving the allegation. -The facility will report any allegation of abuse, neglect or a crime against a resident to the required government agencies and local law enforcement in accordance with the law.",2020-09-01
535,HAVASU NURSING CENTER,35100,3576 KEARSAGE DRIVE,LAKE HAVASU CITY,AZ,86406,2019-02-06,608,D,0,1,R7F711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documents and policies and procedures, the facility failed to report an incident of neglect to law enforcement involving one resident (#9), who sustained serious bodily injury requiring hospitalization . Findings include: Resident #9 was admitted on (MONTH) 12, (YEAR), with [DIAGNOSES REDACTED]. A nurses note dated (MONTH) 1, (YEAR) at 5:00 p.m. revealed the resident had been found outside by a nurse on the patio, his color was flushed, skin dry, and he was unresponsive to verbal commands. Vital signs were as follows: temperature was 103.3, pulse was 107 and blood pressure was 96/69. Cooling measures were initiated and 911 was called, and the resident was transported to the hospital. A hospital physician's history and physical report dated (MONTH) 1, (YEAR) included that resident #9 had a history of [REDACTED]. The resident was found outside of the nursing facility after a period estimated to be a couple of hours. The resident had significant sunburns noted to the back of his neck, the anterior aspect of his upper chest, his arms, the medial aspect of his torso, and the anterior aspect of both thighs. The resident complained of generalized pain and weakness throughout his body. In the emergency department the resident was given a liter of chilled saline. The report further included the resident had heat exposure, heat stress and acute kidney injury, secondary to heat exposure and dehydration. A hospital discharge note dated (MONTH) 2, (YEAR) revealed the following discharge Diagnoses: [REDACTED]. Review of the incident report revealed that on (MONTH) 1, (YEAR) at 5 p.m., the resident was found outside in the courtyard. The resident had memory impairment and impaired decision making ability, and self propelled his wheelchair in and out of courtyards frequently without difficulty. The report included the resident was sunburned, his face and neck were flushed and there was a fluid filled blister on the back of his neck. Cool compresses were applied. The resident was unresponsive to verbal commands and 911 was called. The type of incident documented was heat exposure/sunburn. Review of the facility's investigation report revealed that on (MONTH) 1, (YEAR) at approximately 4:30 p.m., resident #9 was found to be asleep outside in an interior courtyard. The resident was brought inside by a LPN (licensed practical nurse/staff #71). The resident was found to be lethargic and was not responding to verbal stimuli. The resident had a red face, neck and hands with blisters forming on his neck. Cool towels were placed over the resident's head, neck and arms and cool water was provided to the resident to drink. The resident was sent to the emergency department and was treated for [REDACTED]. The report included that the courtyard is visible from inside of the facility. Per the report, the day shift (6a-2p) CNA reported that the resident was in bed at shift change that afternoon, and the 2p-10p CNA reported that she saw the resident in the television room around 3:00 p.m., and in the hallway around 3:15 p.m. The report further included that staff did not visualize the resident again until he was found asleep in the courtyard at 4:30 p.m. Further review of the investigation report revealed a witness statement signed by staff #71. In the statement, staff #71 stated that the resident was last seen by staff at 3:00 p.m., and was found in the courtyard at 5:00 p.m. (which differs from the time documented in the investigation report at 4:30 p.m.). Review of the dispatch Pre-Hospital Care Report dated (MONTH) 1, (YEAR), revealed the call was received at 5:24 p.m., paramedics were on scene at 5:27 p.m., and the resident was transported to the hospital at 5:40 p.m. The investigation report further revealed there was no evidence that the incident of neglect with bodily injury was reported to law enforcement. An interview was conducted on (MONTH) 5, 2019 at 12:05 p.m. with the Director of Nursing (staff #19). Staff #19 stated that she did not notify the police of the allegation of neglect, because she was not aware of the regulatory requirement to notify the police for allegations of neglect if there was bodily injury. An interview was conducted on (MONTH) 6, 2019 at 11:30 a.m. with the Administrator (staff #31) and the Director of Nursing. Staff #31 stated that the police were not notified of the allegation of neglect for resident #9, because serious bodily injury was not initially reported to him by the staff member, only that the resident had reddened skin. Staff #31 stated that an allegation of neglect is reported only if there is serious injury to the resident. A policy titled, Abuse Prevention Program included that if the events that cause the allegation involve abuse or result in serious bodily injury to a resident, a report must be made immediately but not later that two hours after receiving the allegation. Authorities to be notified include the police department. The policy also included that the facility will report any allegation of neglect against a resident to local law enforcement in accordance with the law.",2020-09-01
536,HAVASU NURSING CENTER,35100,3576 KEARSAGE DRIVE,LAKE HAVASU CITY,AZ,86406,2019-02-06,609,D,0,1,R7F711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, facility documents, review of the State Agency Data Base and policies and procedures, the facility failed to report an incident of neglect to the State Survey Agency within two hours for one resident (#9). Findings include: Resident #9 was admitted on (MONTH) 12, (YEAR), with [DIAGNOSES REDACTED]. A nurses note dated (MONTH) 1, (YEAR) at 5:00 p.m. revealed the resident had been found outside by a nurse on the patio, his color was flushed, skin dry, and he was unresponsive to verbal commands. Vital signs were as follows: temperature was 103.3, pulse was 107 and blood pressure was 96/69. Cooling measures were initiated and 911 was called, and the resident was transported to the hospital. A hospital physician's history and physical report dated (MONTH) 1, (YEAR) included that resident #9 had a history of [REDACTED]. The resident was found outside of the nursing facility after a period estimated to be a couple of hours. The resident had significant sunburns noted to the back of his neck, the anterior aspect of his upper chest, his arms, the medial aspect of his torso, and the anterior aspect of both thighs. The resident complained of generalized pain and weakness throughout his body. In the emergency department the resident was given a liter of chilled saline. The report further included the resident had heat exposure, heat stress and acute kidney injury, secondary to heat exposure and dehydration. A hospital discharge note dated (MONTH) 2, (YEAR) revealed the following discharge Diagnoses: [REDACTED]. A nurses note dated (MONTH) 2, (YEAR) included the resident returned to the facility. Review of the incident report revealed that on (MONTH) 1, (YEAR) at 5 p.m., the resident was found outside in the courtyard. The resident had memory impairment and impaired decision making ability, and self propelled his wheelchair in and out of courtyards frequently without difficulty. The report included the resident was sunburned, his face and neck were flushed and there was a fluid filled blister on the back of his neck. Cool compresses were applied. The resident was unresponsive to verbal commands and 911 was called. The type of incident documented was heat exposure/sunburn. Review of the facility's investigation report revealed that on (MONTH) 1, (YEAR) at 4:30 p.m., resident #9 was found asleep outside in an interior courtyard. The resident was brought inside by a LPN (licensed practical nurse/staff #71). The resident was found to be lethargic and was not responding to verbal stimuli. The resident had a red face, neck and hands with blisters forming on his neck. Cool towels were placed over the resident's head, neck and arms and cool water was provided to the resident to drink. The resident was sent to the emergency department and was treated for [REDACTED]. The report included that the courtyard is visible from inside of the facility. Per the report, the day shift (6a-2p) CNA reported that the resident was in bed at shift change that afternoon, and the 2p-10p CNA reported that she saw the resident in the television room around 3:00 p.m., and in the hallway around 3:15 p.m. The report further included that staff did not visualize the resident again until he was found asleep in the courtyard at 4:30 p.m. Further review of the investigation report revealed a witness statement signed by staff #71. In the statement, staff #71 stated that the resident was last seen by staff at 3:00 p.m., and was found in the courtyard at 5:00 p.m. (which differs from the time documented in the investigation report at 4:30 p.m.). Review of the dispatch Pre-Hospital Care Report dated (MONTH) 1, (YEAR), revealed the call was received at 5:24 p.m., paramedics were on scene at 5:27 p.m., and the resident was transported to the hospital at 5:40 p.m. Review of the State Agency data base and the facility's investigation revealed that the incident of neglect occurred on (MONTH) 1, (YEAR), however, was not reported to the State Survey Agency until (MONTH) 2, (YEAR) at 4:45 p.m., which was over the two hour time frame for reporting. An interview was conducted on (MONTH) 5, 2019 at 12:05 p.m., with the Director of Nursing (DON/staff #19). The DON stated that she did not know that the facility was supposed to report allegations of neglect or abuse to the State Survey Agency within 2 hours. Staff #19 said that she thought allegations of neglect or abuse were supposed to be reported within 24 hours. Review of a policy and procedure titled, Abuse Prevention Program revealed that events which include abuse/neglect are to be reported as soon as the incident is made known. If the events that cause the allegation involve abuse or result in serious bodily injury to a resident, a report must be made immediately, but not later that two hours after receiving the allegation to the State Survey Agency.",2020-09-01
537,HAVASU NURSING CENTER,35100,3576 KEARSAGE DRIVE,LAKE HAVASU CITY,AZ,86406,2019-02-06,658,E,0,1,R7F711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy review, the facility failed to ensure a physician's order was in place regarding the crushing of medications per their policy for one resident (#96). Findings include: Resident #96 was admitted to the facility on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. The physician orders dated (MONTH) 9, (YEAR) revealed the resident was prescribed multiple medications that were to be administered orally. The medications included [MEDICATION NAME] (anti-[MEDICAL CONDITION]), [MEDICATION NAME] (anticoagulant), aspirin (nonsteroidal anti-[MEDICAL CONDITION] drug), Atorvastatin (reduces cholesterol levels), [MEDICATION NAME] (lowers blood sugar) and [MEDICATION NAME] (antihypertensive). Additional physician orders dated (MONTH) 9, (YEAR) revealed the resident was to be evaluated by speech therapy for swallowing. The orders included a pureed diet with thickened liquids, due to swallowing difficulties. Review of the nursing notes from (MONTH) 10 through (MONTH) 23, (YEAR) revealed on some occasions medications were crushed and on other occasions the mediations were administered to the resident whole. Review of the Medication Administration Record (MAR) dated (MONTH) (YEAR), revealed the medications were administered. Also included on the MAR was a handwritten note without a date to crush the resident's medications. However, review of physician orders through (MONTH) 23, (YEAR) revealed no evidence of an order to crush the resident's medications. An interview was conducted with a Licensed Practical Nurse (LPN/staff #67) on (MONTH) 6, 2019 at 11:37 a.m. She stated a resident with swallowing difficulties would be considered high risk for aspiration concerns. Staff #67 further stated resident #96 was on a pureed diet with thickened liquids and that would also indicate high risk for swallowing concerns, so the crushing of medications would be common. The LPN stated a physician's order was necessary for crushing medications prior to the nurses administering crushed medications. She also stated the order would be transcribed onto the MAR and all nurses would then know the oral medications have to be crushed. During an interview conducted with the Director of Nursing (staff #19) on (MONTH) 6, 2019 at 12:47 p.m., she stated a physician's order was needed for medications to be crushed before the resident is administered crushed medications. The facility's policy regarding crushing medications revealed medications shall only be crushed when it is consistent with physician orders. The policy also included the MAR or other documentation must indicate why it was necessary to crush the medication.",2020-09-01
538,HAVASU NURSING CENTER,35100,3576 KEARSAGE DRIVE,LAKE HAVASU CITY,AZ,86406,2019-02-06,695,E,0,1,R7F711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure a physician's order was in place prior to the administration of oxygen for one resident (#96). Findings include: Resident #96 was admitted to the facility on (MONTH) 9, (YEAR) with [DIAGNOSES REDACTED]. A review of nursing notes revealed the following regarding oxygen: -February 9, (YEAR) admission note: Oxygen on 2 Liters (L) via Nasal Cannula (NC). -February 9, (YEAR) afternoon shift: Oxygen on 2.5 [MI] -February 10, (YEAR) afternoon shift: Oxygen on 2.5 [MI] -February 10, (YEAR) night shift: Oxygen on 2.5 L via NC. -February 11, (YEAR): Oxygen on 2.5 L via NC. -February 12, (YEAR): Oxygen on 2 L via NC. -February 13, (YEAR): Oxygen on 2 L via NC. -February 20, (YEAR): Oxygen on 2 L via NC. -February 23, (YEAR): Oxygen on 2 L via NC. -February 25, (YEAR): Oxygen on 2 L via NC. -February 27, (YEAR): Oxygen on 3 L via NC. -February 22, (YEAR): Oxygen on 2 L via NC. Review of the Medication Administration Record [REDACTED]. However, review of the clinical record revealed no evidence of a physician's order for the administration of oxygen. An interview was conducted with a Licensed Practical Nurse (staff #67) on (MONTH) 6, 2019 at 11:37 a.m. She stated a physician's order needed to be obtained for the administration of oxygen. Staff #67 further stated the order would then be transcribed onto the MAR indicated [REDACTED]. During an interview conducted with the Director of Nursing (staff #19) on (MONTH) 6, 2019 at 12:47 p.m., she stated a physician's order is necessary for the continuous administration of oxygen. The facility's policy regarding oxygen administration included verifying that there is a physician's order and reviewing the physician's order for oxygen administration.",2020-09-01
539,HAVASU NURSING CENTER,35100,3576 KEARSAGE DRIVE,LAKE HAVASU CITY,AZ,86406,2019-02-06,761,E,0,1,R7F711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and policy and procedure, the facility failed to ensure expired medications were not available for use. Findings include: During a medication storage room observation conducted on (MONTH) 6, 2019 at 8:14 AM on hallway 1 with a registered nurse (staff #18), the following expired medications were observed: -[MEDICATION NAME] (antiulcer agent) 10 mg (milligrams) tablets with an expiration date of (MONTH) 2019 -Vitamin D (supplement) 400 IU (International Unit) capsules with an expiration date of (MONTH) (YEAR) -[MEDICATION NAME] inhalation suspension (anti-asthmatic/corticosteroid) 0.5 mg/2 mL (milliliters) with an expiration date of (MONTH) (YEAR) -[MEDICATION NAME] inhalation suspension 0.5 mg/2 mL with an expiration date of (MONTH) (YEAR) -[MEDICATION NAME] sulfate inhalation solution ([MEDICATION NAME][MEDICATION NAME]) 0.083% 2.5 mg/3 mL with an expiration date of (MONTH) (YEAR). Following the storage room observation, an observation was conducted of a medication cart on hallway 1. The following medications were observed expired for two different residents: -[MEDICATION NAME] (antihypertensive) 5 mg tablets with an expiration date of (MONTH) 31, (YEAR) -[MEDICATION NAME] (anxiolytic) 0.5 mg tablets with an expiration date of (MONTH) 31, (YEAR). An interview was conducted with a Licensed Practical Nurse (LPN/staff #25) on (MONTH) 6, 2019 at 9:27 AM. She stated that she restocks her medication cart from either the medication room or central supply. The LPN said her process was to sign the medication/supplement out on the sign-out sheet and then put the medication/supplement in her cart for use. At 12:28 PM on the same day, the LPN stated that before administering medications to residents, she checks the expiration date. She stated that she kept the expired medications in her cart in the lower drawer as overflow medications. The LPN stated So, when I run out, I would pull from them. She also stated that this procedure was not according to the facility policy that she should give the expired medications to the Director of Nursing (DON/staff #19). On (MONTH) 6, 2019 at 12:35 PM, an interview was conducted with the DON (staff #19). She stated that when medications are expired, they should be destroyed in a sharps container. The DON stated that expired medications clearly need to be pulled out of the cart. She also stated that if the medication has been discontinued, it may be returned to the pharmacy for credit. The DON stated that the pharmacy collects returns twice a month. The facility's policy on Storage of Medications states the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. The policy included all such drugs shall be returned to the dispensing pharmacy or destroyed.",2020-09-01
540,HAVASU NURSING CENTER,35100,3576 KEARSAGE DRIVE,LAKE HAVASU CITY,AZ,86406,2017-11-02,309,E,0,1,QFLP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and policies, the facility failed to have documented evidence one resident (#69) was provided with pre and post [MEDICAL TREATMENT] assessments. Findings include: Resident #69 was readmitted (MONTH) 4, (YEAR), with [DIAGNOSES REDACTED]. Review of the significant change of condition Minimum Data Set (MDS) assessment dated (MONTH) 22, (YEAR), revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The assessment also included the resident was receiving [MEDICAL TREATMENT]. A review of the current comprehensive Care Plan revealed the resident required [MEDICAL TREATMENT] 3 x week (Monday, Wednesday, and Friday) due to end stage [MEDICAL CONDITION]. The approaches included: monitor [MEDICAL TREATMENT] for complications (excessive bleeds, s/s of infection, etc.), monitor the [MEDICAL TREATMENT] for bruit and thrill, vital signs and oxygen saturation per facility protocol, assure resident bring snacks and lunch to [MEDICAL TREATMENT] per [MEDICAL TREATMENT] request, laboratory tests as ordered, and assess the resident for pain before the resident leaves for [MEDICAL TREATMENT] and medicate as ordered. Further review of the care plan revealed no timeframes regarding how often the resident [MEDICAL TREATMENT] was to be monitored for bruit and thrill. Review of the physician's orders [REDACTED]. Review of the Medication Administration Record (MAR) for (MONTH) (YEAR), revealed no evidence that pre [MEDICAL TREATMENT] vital signs were obtained prior to [MEDICAL TREATMENT] on Monday (MONTH) 2, (YEAR) and Fridays (MONTH) 6 and 27, (YEAR). The MAR also revealed no documented evidence the resident's [MEDICAL TREATMENT] was assessed for bruit and thrill prior to or after [MEDICAL TREATMENT]. A review of the Nurses Notes for (MONTH) (YEAR) revealed the resident [MEDICAL TREATMENT] was assessed for bruit and thrill on 17 of the 31 days in October. However, no documented evidence was found that the resident [MEDICAL TREATMENT] was assessed for bruit and thrill prior to or after [MEDICAL TREATMENT] on (MONTH) 6, (YEAR) and was not assessed prior to [MEDICAL TREATMENT] on (MONTH) 26, (YEAR). During an interview conducted with a licensed practical nurse (staff #18) (MONTH) 2, (YEAR) at 11:15 a.m., staff #18 stated the nurse was responsible for documenting the resident's vital signs prior to [MEDICAL TREATMENT] and assessing the [MEDICAL TREATMENT] for a bruit and thrill. She also stated the [MEDICAL TREATMENT] assessment for bruit and thrill is to be documented on the MAR. During an interview conducted with the Director of Nursing (DON/staff #26) (MONTH) 2, (YEAR) at 1:50 p.m., staff #26 stated the nurse was responsible for assessing the resident [MEDICAL TREATMENT] prior to [MEDICAL TREATMENT] and after [MEDICAL TREATMENT]. She also stated the nurse should document the assessment on the MAR. The policy Care of a Resident with [MEDICAL CONDITION] included Residents with [MEDICAL CONDITIONS] will be cared for according to currently recognized standards of care. The policy [MEDICAL TREATMENT] Access Care included the nurse should document in the resident's clinical record observations post-[MEDICAL TREATMENT].",2020-09-01
541,HAVASU NURSING CENTER,35100,3576 KEARSAGE DRIVE,LAKE HAVASU CITY,AZ,86406,2017-11-02,312,D,1,1,QFLP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, facility documentation, and policy, the facility failed to ensure one resident (#30) was provided showers as scheduled. Findings include: Resident #30 was admitted (MONTH) 3, (YEAR), with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set assessment dated (MONTH) 10, (YEAR), revealed the resident had a BIMS (brief interview for mental status) score of 11 which indicated the resident had moderate cognitive impairment. The MDS further included the resident was totally dependent on two staff for transfers and that she needed limited assistance of one staff for bathing. The care plan interventions included the resident required assistance with Activities of daily living (ADLs) including bathing. Review of resident #30's shower records and the CNA (Certified Nursing Assistant) computerized documentation for (MONTH) and (MONTH) (YEAR), revealed the resident was scheduled for a shower every Monday. However, there was no documentation the resident was provided showers between (MONTH) 28, (YEAR) and (MONTH) 7, (YEAR) and no documentation as to why the scheduled showers were not provided. An interview was conducted with a CNA (staff #27) (MONTH) 2, (YEAR) at 9:41 a.m. Staff #27 stated that each resident is provided two showers a week and if the resident requests more showers, staff would provide more showers. During an interview conducted with a Licensed Practical Nurse (staff #79) (MONTH) 2, (YEAR) at 12:38 p.m., staff #79 stated that residents are provided two showers a week and that requests for additional showers would be provided. An interview was conducted with the Director of Nursing (staff #26) (MONTH) 2, (YEAR) at 2:21 p.m. Staff #26 stated staff document showers provided or not provided in the electronic record or on a paper shower calendar record. She also stated anything unexpected that occurs would be documented on the shower record with a licensed nurse signature. Staff #26 further stated that if a shower was not documented then it was not provided. The policy Shower/Tub Bath included to document in the resident's ADL record and/or the resident's clinical record the date and time the shower was provided or the reason the resident refused and the intervention taken. The policy also included to report other information in accordance with the policy and professional standards of practice.",2020-09-01
542,HAVASU NURSING CENTER,35100,3576 KEARSAGE DRIVE,LAKE HAVASU CITY,AZ,86406,2017-11-02,431,E,0,1,QFLP11,"Based on observations, staff interviews, and policy, the facility failed to ensure multiple controlled medications were stored in a double locked container. Findings include: During multiple observations conducted (MONTH) 30, (YEAR) and (MONTH) 31, (YEAR), the door to the office of the Director of Nursing (staff #26) was observed unlocked or opened with no staff members observed inside of the office. An observation of the facility medication storage was conducted (MONTH) 31, (YEAR) at 10:25 a.m. During the observation two nurses #18 and #3 stated when controlled medications have been discontinued or when the resident who was prescribed the medication has been discharged , the controlled medications are delivered to the Director of Nursing (staff #26) for disposal. During an observation of staff #26 office conducted (MONTH) 1, (YEAR) at 10:00 a.m., an unlocked cabinet was observed in the office that contained a locked box affixed to the inside of the cabinet. Medications inside of the locked box included: Hydrocodone with Acetaminophen (narcotic analgesic) 325 milligrams (mg) 45 tablets, Alprazolam (anti-anxiety) 0.25 mg 23 tablets, Lorazepam (anti-anxiety) 1.0 mg 17 tablets, and Lorazepam 0.5 mg 23 tablets. An interview was conducted with staff #26 (MONTH) 1, (YEAR) at 10:00 a.m. Staff #26 stated the controlled medications were being stored in the locked box in her office prior to being destroyed. Staff #26 also stated that although the cabinet that stored the locked box was unlocked, there was a lock available to place on the cabinet. The policy Storage of Medications included All controlled drugs are stored under double-lock and key.",2020-09-01
543,HAVASU NURSING CENTER,35100,3576 KEARSAGE DRIVE,LAKE HAVASU CITY,AZ,86406,2017-11-02,441,E,0,1,QFLP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff record review, staff interviews, and policy, the facility failed to ensure one physical therapy assistant (staff #104) had documented evidence that staff #104 was free of infectious TB ([DIAGNOSES REDACTED] bacterium.) Findings include: Review of staff #104 record revealed a hire of (MONTH) 25, (YEAR). The record included a chest x-ray dated (MONTH) 16, (YEAR) that staff #104 had no evidence of TB. Further review of the record revealed an Annual TB Questionnaire to Be Completed by Employees Who Have Had Positive PPD form dated (MONTH) 21, (YEAR). The questionnaire was signed by staff #104. However, additional review of the questionnaire revealed the written statement was not signed by a medical practitioner. An interview was conducted with the Therapy Director (staff #92) (MONTH) 1, (YEAR) at 1:05 p.m. Staff #92 stated the therapy corporate office maintains employee records. She further stated she did not know staff #104 did not have the required evidence of freedom from TB statement signed by a medical practitioner. During an interview conducted with the receptionist (staff #104) (MONTH) 2, (YEAR) at 11:44 a.m., staff #104 stated she was responsible for maintaining employee records. She also stated staff #104 record was maintained by the contracted therapy company and that she did not know the questionnaire had no written statement of freedom from TB signed by a medical practitioner. During an interview conducted with the administrator (staff #41) (MONTH) 2, (YEAR) at 12:30 p.m., staff #41 stated the facility utilizes the [DIAGNOSES REDACTED] Screening regulation as the policy for staff TB screening. [DIAGNOSES REDACTED] Screening regulation/policy included if staff has had a positive Mantoux skin test or other [DIAGNOSES REDACTED] screening test, a written statement that the staff is free from TB signed by a medical practitioner is required dated within 30 calendar days before or after the anniversary date of the most recent TB screening test or written statement.",2020-09-01
544,HAVASU NURSING CENTER,35100,3576 KEARSAGE DRIVE,LAKE HAVASU CITY,AZ,86406,2017-11-02,514,E,0,1,QFLP11,"Based on clinical record review, staff interviews, and policy, the facility failed to ensure accurate documentation of meal percentages on 33 residents. Findings include: Review of the resident meal percentage documentation on Wednesday (MONTH) 1, (YEAR) revealed that meal percentage was completed on the resident food and fluid intake forms dated (MONTH) 3, (YEAR) through (MONTH) 31, (YEAR) for 4 days beyond (MONTH) 31, (YEAR) on 33 residents which would correspond to (MONTH) 1 - 4, (YEAR). Further review of the records revealed no form for (MONTH) in the meal percentage book. An interview was conducted with a certified nursing assistant (CNA/staff #27) (MONTH) 2, (YEAR) at 8:58 a.m. Staff #27 stated that she did not know who completed the meal percentages for the 4 days beyond (MONTH) 31, (YEAR) which would be (MONTH) 1 - 5, (YEAR). She stated that they were either filling in holes or they were confused about the dates. During an interview conducted with the Director of Nursing (staff #26) on (MONTH) 2, (YEAR) at 9:29 a.m., staff #26 stated the last 4 days of the meal percentage form should not have been completed. She stated that pre-charting is absolutely prohibited. Staff #26 further stated she expects the staff to chart at the time of service to assure accuracy. An interview was conducted with a CNA (staff #64) on (MONTH) 2, (YEAR) at 2:33 p.m. Staff #64 stated that she was the CNA that completed the meal percentages for the 4 days past (MONTH) 31, (YEAR). She stated she just filled them in and that she was unable to answer where she obtained the information. The policy Serving Meals included the following information should be documented in the resident's clinical record; the date and time the procedure was performed, the name and title of the staff who performed the procedure, and how much food the resident ate.",2020-09-01
545,HAVASU NURSING CENTER,35100,3576 KEARSAGE DRIVE,LAKE HAVASU CITY,AZ,86406,2016-11-17,223,D,0,1,381T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, resident and staff interviews, and policy and procedures, the facility failed to ensure that one resident (#41) was free from verbal abuse by a staff member. Findings include: Resident #41 was admitted to the facility on (MONTH) 5, 2012, with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment dated (MONTH) 28, (YEAR) revealed the resident had a Brief Interview for Mental Status score of 12, which indicated the resident had moderate cognitive impairment. A care plan for behaviors was updated on (MONTH) 28, (YEAR) and included a [DIAGNOSES REDACTED]. The goals included to meet the needs of the resident and for her to accept staff assistance with care. Interventions included to explain all care to the resident before rendering it and reassure her that her needs will be met. A physician's orders [REDACTED]. The nursing notes also dated (MONTH) 12, (YEAR) indicated that the urine sample had been obtained by the nurse on duty. Review of a facility's investigative report revealed that on (MONTH) 12, (YEAR), there was an incident between a licensed practical nurse (LPN/staff #117) and the resident during the evening shift, which was witnessed by a Certified Nursing Assistant (CNA/staff #119). Per the report, the nurse had threatened to either shove something in the resident's mouth or cover it, because the resident was screaming, while a urine sample was being collected. Further review of the investigation revealed that the resident had provided a statement that the nurse said that if she did not shut her mouth, she would cover it. There was also a statement from a CNA (staff #119) who had witnessed the incident. Per the statement, staff #119 was helping the nurse obtain a urine sample and as they were holding the resident, she was yelling. The nurse kept asking the resident to stop and then told her that she wished she had something to cover her mouth with, if she did not stop yelling. The CNA stated that at this point, the resident stopped screaming. Another CNA (staff #120) provided a statement which included that when she came on the night shift on (MONTH) 12, (YEAR), the resident told her about the incident and said that the nurse had threatened to stuff her mouth, if she did not stop yelling. A statement from another CNA (staff #118) included the resident told her that the nurse had threatened to cover her mouth, if she did not stop yelling. The investigation also included a statement from staff #117. Staff #117 reported that the resident was screaming and at one point she said, You make me feel like covering your mouth with all that screaming. Staff #117 finished the procedure and left the room. According to the facility's investigative report, they substantiated the allegation of verbal abuse and staff #117 was terminated. An interview was conducted with resident #41 at 8:50 a.m. on (MONTH) 16, (YEAR). She stated that she did remember the event, however, she did not want to talk about it. In an interview with the LPN (staff #117) at 9:50 a.m. on (MONTH) 16, (YEAR), she stated that she did not recall saying anything to the resident about her screaming and wanting to cover or stuff her mouth. She stated the resident often screamed and does so for attention. During an interview with the Director of Nursing (DON/staff #28) at 10:15 a.m. on (MONTH) 16, (YEAR), she stated that she substantiated this incident because the resident stated it happened, the nurse provided a written statement that described it happening, and there was a witness who stated it happened. Staff #28 stated that the nurse's conduct was not appropriate and was not the kind of care that residents are to receive in the facility. She also stated that the nurse's conduct certainly bordered with abusive behavior. An interview was conducted with a CNA (staff #118) at 12:30 p.m. on (MONTH) 16, (YEAR). She stated that she remembered this event, as it was a day she cannot forget because it was traumatic. She stated that she came on duty on the night shift on (MONTH) 12, (YEAR) and another CNA told her about the incident. She stated that she went to the resident's room to check on her and the resident was very upset. She stated that the resident told her that the nurse had threatened to cover her mouth, if she did not stop screaming. She stated the resident can sometimes be difficult and would yell out quite a bit, but the approach is very important with her. She said that with a nice approach, she will calm down. An interview with the CNA (staff #119) who witnessed the incident was conducted at 2:30 p.m. on (MONTH) 16, (YEAR). Staff #119 stated that she was in the room with the nurse and they were trying to obtain a urine sample. She stated the resident was yelling and screaming, which is not something that is unique about her, as she would often yell out. She stated the nurse got upset with the resident and told her that she wished she had something to cover the resident's mouth with, if she did not stop yelling. She said the resident stopped yelling at this point and was upset. She said that they finished getting the sample and then left the room. In an interview with a CNA (staff #120) at 8:35 a.m. on (MONTH) 17, (YEAR), she stated that the resident told her about the incident at the beginning of her night shift on (MONTH) 12, (YEAR). She stated that the resident told her that the nurse had said she would put medicine in her mouth if she did not stop yelling. She stated that she felt bad for the resident, because she did not deserve to be treated that way. Review of the facility's abuse policy revealed that the residents have the right to be free from abuse and that the facility is committed to protecting the residents from abuse by anyone including facility staff, and that there is zero tolerance for abuse in the facility. Abuse is defined as the willful infliction of intimidation or punishment resulting in mental anguish. Verbal abuse is defined as any use of oral, written, or gestured language that willfully includes disparaging terms to a resident; examples of verbal abuse include threats of harm and saying things to frighten a resident.",2020-09-01
546,HAVASU NURSING CENTER,35100,3576 KEARSAGE DRIVE,LAKE HAVASU CITY,AZ,86406,2016-11-17,281,D,0,1,381T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documentation, review of the Manual of Nursing Practice-8th Edition and policy and procedures, the facility failed to ensure that physician orders [REDACTED].#139). Findings include: Resident #139 was admitted on (MONTH) 4, (YEAR), with a [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A review of the MAR (Medication Administration Record) for (MONTH) (YEAR), revealed the above order. However, there was no documentation that Accuchecks were done on (MONTH) 7 at 11:30 a.m. and at 9:00 p.m. In addition, there was no documentation that the Accuchecks were done on (MONTH) 13 and 14 at 9 p.m. Review of the clinical record revealed there was no documentation as to why the Accuchecks were not performed. On (MONTH) 17, (YEAR) at 12:33 p.m., an interview was conducted with a Licensed Practical Nurse (staff #60), who worked on the hallway where resident #139 resided. Staff #60 reviewed the (MONTH) (YEAR) MAR and stated that he wasn't sure why the Accuchecks had not been performed and/or documented and that he hadn't noticed it or he would have notified the Director of Nursing. An interview was conducted on (MONTH) 17, (YEAR), with the Director of Nursing (staff #28). Staff #28 stated that the MARs are audited on a regular basis, usually monthly. Staff #28 stated that the oncoming nurse usually will report missing documentation by the previous shift, but she had not been notified. Staff #28 further stated that nurses were to follow the physician's orders [REDACTED]. According to the facility policy regarding charting and documentation, all observations, medications administered, and services performed, must be documented in the resident's clinical record. A review of the facility's job description for a licensed nurse revealed that the nurse was to prepare and administer medications and treatments, per the physician's orders [REDACTED]. A review of the Manual of Nursing Practice - 8th Edition, by Lippincott,[NAME], and Wilkens revealed that the standards of professional nursing practice included standards of care and standards of professional performance that include implementing a physician's orders [REDACTED].",2020-09-01
547,HAVASU NURSING CENTER,35100,3576 KEARSAGE DRIVE,LAKE HAVASU CITY,AZ,86406,2016-11-17,329,E,0,1,381T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, and review of policy and procedures, the facility failed to ensure resident's drug regimens were free of unnecessary drugs, by failing to ensure that as needed (PRN) pain medications included parameters for administration for two residents (#9 and #36). Findings include: -Resident #9 was admitted on (MONTH) 14, (YEAR) and readmitted on (MONTH) 26, (YEAR), with [DIAGNOSES REDACTED]. An admission MDS (Minimum Data Set) assessment dated (MONTH) 21, (YEAR) documented the resident had a BIMS (brief interview for mental status) score of 15, which indicated the resident was cognitively intact. A physician's order dated (MONTH) 26, (YEAR) included for [MEDICATION NAME] (narcotic pain medication) 10/325 milligrams (mg) 1 tablet by mouth, every four hours, as needed for pain and [MEDICATION NAME] ([MEDICATION NAME]) 325 mg 2 tablets by mouth, every six hours, as needed for pain or fever. Review of the MARs (medication administration record), nurses' notes and pain flow sheet, revealed documentation that the resident had been administered the [MEDICATION NAME] numerous times from (MONTH) 26, (YEAR) through (MONTH) 17, (YEAR). There was no documentation that [MEDICATION NAME] was ever administered. The physician orders did not include any pain parameters, in order to determine when to administer [MEDICATION NAME] versus [MEDICATION NAME]. -Resident #36 was admitted on (MONTH) 7, (YEAR), with a readmission on (MONTH) 31, (YEAR). [DIAGNOSES REDACTED]. Review of a change of condition MDS assessment dated (MONTH) 21, (YEAR), revealed the resident had a BIMS score of 15, indicating the resident was cognitively intact. A physician's order dated (MONTH) 9, (YEAR) included for [MEDICATION NAME] (narcotic pain medication) 5/325 mg 1 tablet by mouth, twice a day, as needed for pain and [MEDICATION NAME] 325 mg, two tablets by mouth, every four hours, as needed, for pain or fever. Physician orders dated (MONTH) 31, (YEAR) included for [MEDICATION NAME] 5/325 mg 1 tablet by mouth, every four hours, as needed for pain and [MEDICATION NAME] 325 mg 2 tablets by mouth, every four hours, as needed for pain or fever. A review of the MARs, nurses' notes, and pain flow sheets from (MONTH) through (MONTH) (YEAR), revealed there were multiple times when the resident was administered [MEDICATION NAME]. There was no documentation that [MEDICATION NAME] had been administered. The physician orders did not include any pain parameters, in order to determine when to administer [MEDICATION NAME] versus the [MEDICATION NAME]. On (MONTH) 16, (YEAR) at 11:58 a.m., an interview was conducted with a registered nurse, (staff #80), who stated that she administered resident #36's pain medication based on the resident's request and that there was no physician's order regarding what medication to administer to the resident based on identified pain levels. On (MONTH) 16, (YEAR) at 12:30 p.m., an interview was conducted with the Director of Nursing (staff #43), who stated that the facility physician doesn't write parameters for as needed pain medications, if the resident is able to make pain needs known. Staff #43 stated the nurse is to document if the resident requests specific pain medication, but if there are no pain parameter orders then it is up to the nurse to determine what medication should be administered. A review of a facility policy regarding medication orders revealed that PRN medication orders must specify the type of medication, route, dosage, frequency, strength, and reason for administration, including the level of pain.",2020-09-01
548,HAVASU NURSING CENTER,35100,3576 KEARSAGE DRIVE,LAKE HAVASU CITY,AZ,86406,2016-11-17,431,D,0,1,381T11,"Based on observation, staff interviews, and review of policy and procedures, the facility failed to ensure that an expired medication was discarded. Findings include: During an observation of medication administration conducted on (MONTH) 16, (YEAR) at 8:40 a.m. with a licensed practical nurse (LPN/staff #1), staff #1 removed a multi-vitamin tablet from a bottle, which was in the 200 hall medication cart. The LPN then placed the tablet into a resident's medication cup. Further observations revealed that the expiration date on the multi-vitamin bottle was (MONTH) (YEAR). At this time, an interview was conducted with staff #1, who stated that she did not see that the multi-vitamin bottle was outdated. She stated that it is the responsibility of the nurses who work on the medication cart each day to remove outdated medications. An interview was conducted with the DON (Director of Nursing/staff #28) on (MONTH) 16, (YEAR) at 11:00 a.m. The DON stated the nurses assigned to the duties of medication administration are responsible to make sure medications are not outdated, and if they are outdated they are to be discarded. A review of the facility policy for the Storage of Medications revealed the purpose of this procedure is to ensure that medications are stored in a safe, secure, and orderly manner and that no discontinued, outdated, or deteriorated medications are available for use in this facility.",2020-09-01
549,HAVASU NURSING CENTER,35100,3576 KEARSAGE DRIVE,LAKE HAVASU CITY,AZ,86406,2016-11-17,514,D,0,1,381T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews and review of policy and procedures, the facility failed to maintain clinical records that were complete and accurately documented for two residents (#35 and #84). Findings include: -Resident #84 was admitted to the facility on (MONTH) 2, (YEAR), with [DIAGNOSES REDACTED]. Review of the nurses admission note dated (MONTH) 2, (YEAR) revealed the resident was admitted with an open area to the coccyx. Admission physician orders included for wound treatment to the coccyx wound. Per the weekly pressure ulcer healing assessment dated (MONTH) 15, (YEAR), the pressure ulcer was a stage II. A review of a physician's progress note dated (MONTH) (YEAR) (exact date was unreadable) revealed that the note did not have a resident's name or any other identifier on the note. The note included there were no skin concerns. The note was signed by the physician. A physician's note dated (MONTH) 20, (YEAR) also did not include a name or any other identifier on the note. The documentation did include that the resident had a pressure ulcer to the coccyx. The note was signed by the physician. An interview was conducted with a RN (registered nurse/staff #80) on (MONTH) 16, (YEAR), at 1:15 p.m. Staff #80 stated that it is the responsibility of the nurse that care for a resident to fill in the identifiers when filing the forms in the resident's chart. An interview was conducted with the DON (Director of Nursing/staff #28) on (MONTH) 16, (YEAR), at 2:50 p.m. Staff #28 stated that she would expect that identifiers on the form would be filled in by either the nurse on the hall where the resident resides or the nurse that is working with the doctor making rounds. -Resident #35 was admitted to the facility on (MONTH) 20, (YEAR), with [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed an activities evaluation which listed the resident's date of birth as (MONTH) 30, 1968. However, review of the documentation in resident #35's clinical record including the facesheet revealed a different date of birth. In an interview with staff #28 on (MONTH) 17, (YEAR) at 12:20 p.m., she confirmed that the resident's date of birth on the activities evaluation was incorrect. An interview was conducted with the Activities Director (staff #52) on (MONTH) 17, (YEAR) at 1:20 p.m. regarding the incorrect date of birth. Staff #52 stated that she must have been charting on another resident and put the wrong date in. A review of the facility policy for Charting and Documentation revealed, All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record.",2020-09-01
550,CHANDLER POST ACUTE AND REHABILITATION,35101,2121 WEST ELGIN STREET,CHANDLER,AZ,85224,2018-02-02,580,D,0,1,ML1Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff and resident interviews, and the facility's policy, the facility failed to notify the physician, in a timely manner, of a change in condition for one resident (#7). Findings include: Resident #7 was admitted on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed a physician's order dated (MONTH) 1, (YEAR), to keep the incision to the pelvic/thigh area clean and dry and to cover the incision for showers. Additional review of the clinical record revealed a physician's order dated (MONTH) 6, (YEAR), for the resident to have a weekly skin evaluation every Saturday night. Review of the admission Minimum Data Set assessment dated (MONTH) 8, (YEAR) revealed the resident had no short or long term memory problems and that her cognitive skills for daily decision making were consistent and reasonable. A physician's order dated (MONTH) 28, (YEAR), revealed an order to daily cleanse the left thigh with wound cleanser, pat dry, apply an [MEDICATION NAME] gauze soaked in 1/4 strength Dakins solution in the wound base, and cover with a dry dressing. A skilled nursing note dated (MONTH) 30, (YEAR), revealed the resident had a surgical wound and received daily wound care and that the dressing was clean, dry, and intact. Review of a nursing progress note dated (MONTH) 30, (YEAR), revealed the resident reported to the registered nurse (staff #13) that she had a lump on the left upper thigh that had been present for approximately 2 weeks and that had increased in size. The note also included that the mass was hard and fixed upon palpation with no redness, warmth, or drainage noted and that the resident denied pain. The note further included the lump will be monitored and will be reported to the a.m. nurse for follow up. A Nurse Practitioner progress note dated (MONTH) 30, (YEAR), revealed the resident had an infection of the left thigh, to continue the wound care, and to monitor for any acute changes. The progress note did not include any information regarding a new lump on the resident's left upper thigh/groin area. Review of a change of condition nursing note dated (MONTH) 2, (YEAR), revealed the physician (staff #136) was notified that the resident had accidentally pulled out part of her peripherally inserted central catheter line and that the line was exposed. Further review of the note revealed no notification of the lump found on the resident's left upper thigh/groin area. Further review of the daily skilled and nursing progress notes from (MONTH) 1 - 4, (YEAR), did not reveal any documentation regarding the lump. A review of a Skin/Non-Pressure Ulcer weekly note dated (MONTH) 4, (YEAR), revealed the resident had a surgical wound on the left thigh, was seen by the physician, and was scheduled for a skin graft later that week. Continued review of the clinical record revealed the physician's (staff #136) progress note dated (MONTH) 4, (YEAR), that the physician assessed the lump after the resident complained about the lump to the physician. The note included that the lump was not red and was possibly scar tissue. A nursing note dated (MONTH) 6, (YEAR) revealed the resident was sent to the hospital for a left groin abscess. A telephone interview was conducted with staff #13 on (MONTH) 1, (YEAR) at 10:03 a.m. Staff #13 stated she was unable to recall the assessment but that if she documented she would report the assessment to the oncoming nurse, then she did report it to the nurse and that nurse would be expected to report the assessment to the resident's physician. An interview was conducted with resident #7 on (MONTH) 1, (YEAR) at 10:28 a.m. The resident stated that the nurse assessed the lump in November. She also stated no other staff assessed the lump after that until she went to the hospital due to the lump increasing more and more in size. An interview was conducted with a certified nursing assistant (staff #46) on (MONTH) 2, (YEAR) at 10:38 a.m. Staff #46 stated that she reported the lump to the wound nurse several times. She also stated the lump was larger than when the resident first reported it to her. During an interview conducted on (MONTH) 2, (YEAR) at 11:51 a.m. with the wound nurse (staff #109), she stated she observed the left thigh lump and reported it to the floor nurses and that the floor nurses should have notified the physician. However, staff #109 was unable to find any documentation that she had observed or assessed the lump. An interview was conducted on (MONTH) 1, (YEAR) at 12:00 p.m. with staff #136. Staff #136 stated she believed nursing did report the lump to her. She further stated she thought another physician had assessed the lump and decided to monitor the lump for changes. However, review of the physician's notes did not reveal any further documentation regarding the lump except for the (MONTH) 4, (YEAR) note and no physician's order was found to monitor the lump. The facility's policy Change of Condition Reporting included that all changes in the resident's condition would be communicated to the physician The licensed nurse would inform the primary physician (alternate physician or Medical Director) of the resident's status as soon as possible once the resident's needs have been met and the immediacy of nursing care was completed. All nursing actions, physician contacts, and resident assessment information would be documented in the nursing progress notes.",2020-09-01
551,CHANDLER POST ACUTE AND REHABILITATION,35101,2121 WEST ELGIN STREET,CHANDLER,AZ,85224,2018-02-02,686,E,0,1,ML1Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and the facility's policies and procedures, the facility failed to treat a pressure ulcer in accordance with professional standards by failing to obtain orders and begin treatment upon admission and failing to provide consistent treatments for existing pressure ulcers for one resident (#239). Findings include: Resident #239 was readmitted on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. A wound assessment dated (MONTH) 10, (YEAR), revealed the resident was admitted with the following pressure wounds: - A stage 3 pressure wound on the coccyx that measured 2 cm x 2 cm and had 0.2 cm depth. - An unstageable pressure wound on the left heel that measured 2 cm x 1 cm and had depth that was unable to be determined due to the presence of eschar on the wound. A care plan initiated on (MONTH) 10, (YEAR), for pressure ulcers present on admission revealed the following interventions: - Low air loss mattress. - Float heels - Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Further review of the clinical record not reveal any documented evidence that upon admission physician's orders [REDACTED]. Review of physician's orders [REDACTED]. - An order to clean the coccyx pressure ulcer with wound cleanser, apply [MEDICATION NAME], and covered the wound with a dry dressing every shift. - An order to paint the pressure ulcer on the left inner heel with [MEDICATION NAME] and leave open to air every day on the day shift. - An order to float the heels while in bed on every shift. - an order for [REDACTED].>Review of the treatment records for (MONTH) (YEAR), revealed the treatments for the coccyx and left heel pressure ulcers were not initiated until (MONTH) 13, (YEAR). Further review of the clinical record revealed no documented evidence that the stage 3 pressure ulcer on the coccyx and the unstageable pressure wound on the left heel received treatments prior to (MONTH) 13, (YEAR). Additional review of the treatment records and the nursing progress notes did not reveal evidence the coccyx and left heel treatments had been provided on (MONTH) 18 and 19, (YEAR). An admission MDS (Minimum Data Set) assessment dated (MONTH) 16, (YEAR), revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15, which indicated the resident was cognitively intact. The assessment also included the resident had two unhealed pressure ulcers, was receiving pressure ulcer care, and had a pressure ulcer relieving device for the bed. Continued review of the clinical record revealed the resident was discharged to the hospital on (MONTH) 23, (YEAR) and readmitted on (MONTH) 28, (YEAR). A weekly pressure ulcer assessment dated on (MONTH) 1, (YEAR), revealed that the resident had been admitted with the following pressure ulcers: - An unstageable pressure ulcer on the sacrum that measured 1.2 cm x 1.2 cm with slough. - An unstageable pressure ulcer on the left heel that measured 3 cm x 2 cm and had eschar. A physician's history and physical dated (MONTH) 2, (YEAR), included that the resident had a stage 3 sacral pressure ulcer, but did not include a left heel pressure ulcer. A physician's orders [REDACTED].#239, which included treatments to the left heel and coccyx (sacrum) pressure ulcers. Review of the treatment records revealed the ordered pressure ulcer treatments for the left heel and the coccyx (sacrum) were not initiated until (MONTH) 4, (YEAR). Further review of the treatment records and the nursing progress notes did not reveal evidence the treatments had been provided on (MONTH) 5, (YEAR). An admission 5-day MDS assessment dated (MONTH) 6, (YEAR), included that the resident had been readmitted with 2 unhealed and unstageable pressure ulcers. A weekly skilled note dated (MONTH) 8, (YEAR), revealed the resident had an unstageable pressure ulcer on the coccyx that measured 3 cm x 2 cm, had slough and serous drainage, and an unstageable pressure ulcer on the left heel that measured 2 cm x 1 cm and had eschar. Resident #239 was discharged from the facility on (MONTH) 15, (YEAR). An interview was conducted on (MONTH) 31, (YEAR) at 12:30 p.m. with a wound nurse (staff #109). Staff #109 stated upon admission a skin assessment is completed and if there are wounds, the wound nurse will assess the wound the next day. She also stated that upon admission any existing treatment orders from the transferring hospital are reviewed with the physician and the orders are transcribed. Staff #109 stated wound treatments are initiated immediately upon admission. During an interview conducted on (MONTH) 1, (YEAR), at 8:40 a.m. with the Director of Nurses (staff #135), staff #135 stated when a resident is admitted from the hospital, the hospital orders for wound treatments are verified with the physician and wound treatments are provided upon admission. The facility's policy Physicians Orders included that admission orders [REDACTED]. The facility's policy Wound Management included that a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new avoidable sores from developing. Also, once a wound is identified, assessed and documented, nursing shall administer treatment to each affected area as per the physician's orders [REDACTED].>",2020-09-01
552,CHANDLER POST ACUTE AND REHABILITATION,35101,2121 WEST ELGIN STREET,CHANDLER,AZ,85224,2018-02-02,698,E,0,1,ML1Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure pre and post [MEDICAL TREATMENT] assessments and daily [MEDICAL TREATMENT] related assessments were completed for one resident (#42). Findings include: Resident #42 was admitted (MONTH) 11, (YEAR) and readmitted on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set assessment dated (MONTH) 18, (YEAR) revealed the resident had short and long term problems. Physician orders [REDACTED]. Review of the Treatment Administration Record (TAR) revealed the following additional treatments: -Check the vital signs (respiration, temperature, pulse, and blood pressure) pre and post [MEDICAL TREATMENT] -Resident has [MEDICAL TREATMENT] on Tuesday, Thursday, and Saturday with pick-up time between 10:15 a.m. and 10:30 a.m. Send Hoyer sling and sack lunch with resident. Review of the [MEDICAL TREATMENT] care plan initiated on (MONTH) 9, (YEAR) included the following interventions: -Check and change the dressing at the access site daily and document. -Check arteriovenous fistula every day for bruit and thrill. -Monitor/document/report any signs and symptoms of infection to access site that included redness, swelling, warmth, or drainage. -Obtain vital signs and weight per protocol and report significant changes in vital signs immediately. (MONTH) use weight obtained at [MEDICAL TREATMENT] Review of the TAR for (MONTH) (YEAR) revealed the following: -No documented monitoring of the shunt/fistula for bruit and thrill on (MONTH) 3, 9, 11, 13, 18, 23, 28, and 30. -No documented assessment of the access site for signs and symptoms of infection on (MONTH) 3, 9, 11, 13, 18, 23, 28, and 30 -Pre-[MEDICAL TREATMENT] vital signs obtained at 1:21 a.m. on (MONTH) 9, (YEAR) -No post-[MEDICAL TREATMENT] vital signs were obtained on (MONTH) 13, (YEAR). -Pre-[MEDICAL TREATMENT] vital signs obtained at 1:42 a.m. on (MONTH) 16, (YEAR) -No post-[MEDICAL TREATMENT] vital signs were obtained on (MONTH) 16, (YEAR). -No post-[MEDICAL TREATMENT] vital signs were obtained on (MONTH) 18, (YEAR). -No pre- or post-[MEDICAL TREATMENT] vital signs assessments were completed on (MONTH) 23, (YEAR) -No pre-dialyses vital signs were obtained on (MONTH) 30, (YEAR) Review of the nurses' progress notes, TAR, and vital signs records did not reveal the resident was unavailable for assessment or that the resident refused [MEDICAL TREATMENT] on any of the days with missing documentation. In an interview conducted with resident #42 on (MONTH) 31, (YEAR) at 3:21 p.m., the resident stated he has a fistula for [MEDICAL TREATMENT] and that the staff check the fistula every day. During an interview conducted on (MONTH) 1, (YEAR) at 11:50 a.m. with a Licensed Practical Nurse (LPN/staff #53), staff #53 stated that prior to [MEDICAL TREATMENT] the resident's weight and vital signs are obtained. Staff #53 further stated that the resident has a fistula in the left arm and that he checks for a bruit and thrill each day. Staff # 53 also stated as soon as the resident returns from [MEDICAL TREATMENT], the fistula is assessed for bleeding and vital signs are obtained. In an interview conducted on (MONTH) 2, (YEAR) at 8:24 a.m. with the Registered Nurse/Director of Nursing (staff #135), staff #135 stated vital signs are obtained before the resident goes to [MEDICAL TREATMENT] and when the resident returns from [MEDICAL TREATMENT]. Staff #135 also stated the [MEDICAL TREATMENT] site is monitored daily for a bruit and thrill and signs of infection. Staff #135 further stated when a resident returns from [MEDICAL TREATMENT] with a pressure dressing to the [MEDICAL TREATMENT] site, the site is monitored for bleeding. Staff #135 stated an acceptable time frame to obtain vital signs before [MEDICAL TREATMENT] is about an hour. The facility's policy [MEDICAL TREATMENT] (Renal), Pre and Post Care included to assist the resident in maintaining homeostasis pre and post [MEDICAL TREATMENT], assess and maintain the patency of the [MEDICAL TREATMENT] access, and assess the resident daily for function related to [MEDICAL TREATMENT]. The policy also included obtaining a blood pressure in the non-shunt arm prior to being transported to the [MEDICAL TREATMENT] unit and assessing the [MEDICAL TREATMENT] access for patency and any unusual redness or swelling when the resident returns from [MEDICAL TREATMENT]. The policy further included that the [MEDICAL TREATMENT] care given, the condition of the [MEDICAL TREATMENT] access, and all assessments are documented in the clinical records.",2020-09-01
553,CHANDLER POST ACUTE AND REHABILITATION,35101,2121 WEST ELGIN STREET,CHANDLER,AZ,85224,2018-02-02,921,D,0,1,ML1Q11,"Based on observations, resident and staff interviews, and the facility's policy, the facility failed to ensure two residents' (#27 and #33) bathroom door was in good repair. Findings include: During an initial observation of residents' #27 and #33 room on (MONTH) 29, (YEAR) at 11:23 a.m., the bathroom door was observed to be scratched with chunks of wood missing. During a follow-up observation on (MONTH) 31, (YEAR) at 10:40 a.m., the bathroom door was observed to be opened and the side that faces the bathroom had large chunks of the wood laminate surface missing for approximately 18 inches near the door handle area and the exposed wood underneath was rough and splintering. Resident #27 was observed moving the door with his hand at the area where the facing on the door was missing and the door was rough and the wood splintering. The resident declined to be interviewed. An interview was conducted with the Maintenance Supervisor (staff #2) on (MONTH) 31, (YEAR) at 10:49 a.m. Staff #2 stated when staff identifies something that needs repaired, they have access to enter a repair order into the electronic system. Staff #2 also stated all maintenance requests have to be put into the electronic system even if they verbally notify him of a problem. Staff #2 stated no one had entered a request for the bathroom door. During a follow up interview conducted on (MONTH) 31, (YEAR) at 12:50 p.m. with the staff #2, he stated the nursing staff or the housekeeping staff should have identified the bathroom door problem and reported it. Staff #2 stated the maintenance department makes rounds of the residents' rooms but did not identify the bathroom door problem. He further stated the bathroom door problem was missed multiple times. In an interview conducted with a Housekeeper (staff #146) on (MONTH) 31, (YEAR) at 1:22 p.m., staff #146 stated she did not notice the door was gouged up, but then stated when she wipes down the bathroom door, her cleaning cloth catches on the door. She stated when something needs repaired she is to report it to her supervisor, but that she did not report it to her supervisor. Staff #146 further stated the door has been in that condition for at least one week. During an interview conducted on (MONTH) 31, (YEAR) at 1:24 p.m. with the Housekeeping Manager (staff #137), staff #137 stated he was not informed about the door. He further stated that he is a contractor and does not have access to enter a repair order but when he is made aware of something that needs to be repaired, he will notify a staff member. In an interview conducted with resident #33 on (MONTH) 1, (YEAR) at 11:43 a.m., resident #33 stated the bathroom door had been broken and nailed back together. He stated the door is broken up and very heavy to move. Resident #33 stated he did not receive any injuries from the door. The facility's policy Maintenance Request/Work Orders, included the facility is to maintain a clean, well repaired building, and that staff will report any issues needing attention. The policy further included that all work requests must be in the form of work orders that can be accessed electronically. The policy also included giving complete information on all work orders, including what, where, and who is reporting.",2020-09-01
554,CHANDLER POST ACUTE AND REHABILITATION,35101,2121 WEST ELGIN STREET,CHANDLER,AZ,85224,2019-04-19,578,D,0,1,J85C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure 1 of 3 sampled residents (#20) code status was consistent in the clinical record. The census was 101. This deficient practice could result in residents receiving services, which are not in accordance with their wishes. Findings include: Resident #20 was initially admitted on (MONTH) 17, (YEAR) and readmitted on (MONTH) 13, 2019 with [DIAGNOSES REDACTED]. Review of the clinical record revealed the following: -Nurse progress notes dated (MONTH) 17, (YEAR) that the resident has a history of dementia and is oriented to self and that the resident's representative gave verbal consent for a Do Not Resuscitate (DNR) order. -A physician's orders [REDACTED]. -An Advance Directive/Medical Treatment Decisions form dated (MONTH) 18, (YEAR) that the resident's choice was not to be resuscitated. -An orange form titled Prehospital Medical Care Directive (DNR) signed by the resident's representative and a Licensed Health Care Provider on (MONTH) 18, (YEAR). The signature for the witness to the directive was blank. -A quarterly Minimum Data Set (MDS) assessment dated (MONTH) 24, 2019 that included a Brief Interview for Mental Status (BIMS) score of 6 which indicated the resident had severe cognitive impairment. Continued review of the clinical record revealed readmission physician's orders [REDACTED]. However, review of the Advance Directive/Medical Treatment Decisions form dated (MONTH) 13, 2019 revealed the resident's choice was not to be resuscitated. Review of the Initial Admission Record signed by the Licensed Practical Nurse (LPN/staff #146) on (MONTH) 16, 2019 revealed the resident's advanced directive was full code status. Review of the initial care plan signed by the LPN (staff #146) on (MONTH) 16, 2019 revealed the resident was a DNR. During an interview conducted with the admission LPN (staff #146) on (MONTH) 17, 2019 at 3:00 p.m., the LPN stated that when a resident is admitted she discusses advance directives with the resident and/or the resident's representative in detail. She stated that after the discussion, the Advanced Directive/Medical Treatment Decisions form is completed and signed by the resident or the resident's representative. She stated that once the form is signed, she will put the resident's advance directive wishes into the computer, notify the physician, and that the physician will write the order the next day. The LPN also stated that she will ask the resident or the resident's representative if they have any other advance directive and if so, will ask that they bring it to the facility. The admission nurse stated that when a resident is discharged to the hospital and readmitted back to the facility, she will repeat this process. She stated that resident #20 is a full code and has always been a full code. She stated that when the resident was readmitted , she spoke with the resident's representative and that the resident is a full code. An interview was conducted with the Director of Nursing (DON/staff #159) on (MONTH) 17, 2019 at 3:32 p.m. The DON stated that regardless of the paperwork, until the orange Prehospital Medical Care Directive (DNR) form is signed with the required signatures, a resident will be treated as a full code status. The DON stated that whenever a resident is readmitted and their wish is to be a DNR, another orange form has to be signed. She stated that resident #20's representative has been informed that he needs to sign the orange form but that he has not come into the facility to sign the form. She stated that if resident #20 was to stop breathing, they would call 911 and initiate CPR (cardiopulmonary resuscitation). The DON stated that this is the facility's policy. The facility's policy titled Advance Directives (revised ,[DATE]) revealed a resident's choice about advance directives will be recognized and respected. The policy included that once the advance directive or information regarding resident preferences regarding treatment options is received by the facility, it will be confirmed in the resident medical record and communicated to members of the care plan team. The facility will also notify the attending physician of advance directives so that, if necessary, appropriate orders can be documented in the resident's medical record and plan of care.",2020-09-01
555,CHANDLER POST ACUTE AND REHABILITATION,35101,2121 WEST ELGIN STREET,CHANDLER,AZ,85224,2019-04-19,641,D,0,1,J85C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, and the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure that the Minimum Data Set (MDS) assessments for 2 of 21 sampled residents (#75 and #57) accurately reflected their status. The deficient practice has the potential to affect continuity of care. Findings include: -Resident #75 was admitted to the facility on (MONTH) 1, 2012, with [DIAGNOSES REDACTED]. A quarterly MDS assessment with an Assessment Reference Date (ARD) of (MONTH) 17, (YEAR), revealed a score of 13 on the Brief Interview for Mental Status which indicated the resident had intact cognition. Review of the current care plan revealed the resident was at risk for falls related to impaired mobility, impaired cognition, and narcotic [MEDICATION NAME] use. The goal was for the resident to be free from falls. Interventions included ensuring the call light is within reach, floor mats at bedside, and following the fall protocol. The care plan also included the resident had a fall on (MONTH) 31, (YEAR). Review of a nursing note dated (MONTH) 31, (YEAR) revealed the resident was found on the floor facing down. The note also revealed the resident was assessed and had a skin tear to his wrist measuring 3 centimeters (cm) by 3.5 cm that was cleaned and covered with a Band-Aid. However, review of the quarterly MDS assessment with an ARD of (MONTH) 19, 2019, revealed the resident had no falls since the prior MDS assessment. An interview was conducted on (MONTH) 19, 2019 at 12:13 p.m. with the MDS coordinator (staff #46). The MDS coordinator stated the look-back period for falls on a quarterly MDS assessment is 3 months. Staff #46 stated that the fall risk management reports includes all resident falls and the injuries sustained and is used to find out how many falls a resident has had when coding the MDS assessment. After reviewing the report, staff #46 stated that resident #75 did have a fall on (MONTH) 31, (YEAR) and the fall should have been coded on the quarterly MDS assessment dated (MONTH) 19, 2019. An interview was conducted on (MONTH) 19, 2019 at 12:40 p.m. with the Director of Nursing (DON/staff#159). The DON stated the expectation is that the MDS assessments are coded according to the Resident Assessment Instrument (RAI) manual. The RAI manual revealed the review period for falls is from the day after the ARD of the last MDS assessment to the ARD of the current assessment. The manual instructs to review all available sources including incident reports, fall logs, and the clinical record, for any fall since the last assessment, no matter whether the fall occurred while out in the community, in the hospital, or in the nursing home. The manual also instructs to code yes if the resident has fallen since the last assessment. -Resident #57 was admitted to the facility on (MONTH) 5, (YEAR), with [DIAGNOSES REDACTED]. Review of the annual MDS assessment dated (MONTH) 12, 2019, revealed a BIMS score of 15 which indicated the resident was cognitively intact. The MDS assessment also included the resident received an anticoagulant medication for 7 days during the 7 look-back period. Review of the physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. An interview was conducted on (MONTH) 19, 2019 at 12:31 p.m. with the MDS Coordinator (staff #46). She stated that she follows the RAI manual when coding MDS assessments. She stated that she reviews the resident's MAR indicated [REDACTED]. Staff #46 stated that she had been coding [MEDICATION NAME] as an anticoagulant, but after reviewing the RAI manual, she realized it should not have been coded as an anticoagulant on the assessment. An interview was conducted on (MONTH) 19, 2019 at 12:43 p.m., with the DON. She stated the facility's policy is to follow the RAI manual when coding the MDS assessment. The DON stated that her expectation is that the RAI manual be followed when coding MDS assessments. The RAI manual instructs to review the resident's clinical record for documentation that anticoagulant medications were received by the resident during the 7 day look-back period and record the number of days the resident was administered an anticoagulant medication. The RAI manual also instructs to not include antiplatelet medications such as [MEDICATION NAME].",2020-09-01
556,CHANDLER POST ACUTE AND REHABILITATION,35101,2121 WEST ELGIN STREET,CHANDLER,AZ,85224,2019-04-19,677,D,0,1,J85C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documentation, and policy and procedures, the facility failed to ensure 1 of 8 sampled residents (#200) received an adequate number of showers. The deficient practice could result hygiene needs not being met. The census was 101. Findings include: Resident #200 was admitted to the facility on (MONTH) 3, 2019, with [DIAGNOSES REDACTED]. Review of a care plan imitated (MONTH) 3, 2019 revealed the resident had an Activities of Daily Living (ADL) self-care performance deficit related to right sided [MEDICAL CONDITION]. The goal was that the resident would maintain the current level of function in grooming and personal hygiene with one person physical care. Interventions included encouraging the resident to participate to the fullest extent possible with each interaction. Review of the paper Skin Monitoring: Comprehensive CNA (Certified Nursing Assistant) Shower Review forms revealed refused on (MONTH) 6 and 11, 2019. Review of the electronic CNA documentation for what types of bathing activity was completed revealed the resident did not receive a shower until (MONTH) 15, 2019. During an observation conducted of resident #200 on (MONTH) 15, 2019 at 2:34 PM, the resident appeared unclean and his hair appeared greasy. An interview was conducted with the resident's spouse on (MONTH) 16, 2019 at 8:33 AM. The spouse stated she had a concern regarding showers being provided to the resident. The spouse stated that she had requested the resident be showered on Mondays, Wednesdays, and Fridays. An interview was conducted with a CNA (staff #127) on (MONTH) 18, 2019 at 12:21 PM. The CNA stated that the residents receive showers twice a week. The CNA said if a resident wants a specific schedule or an extra shower, they will provide it. Staff #127 stated that if a resident refuses a shower, they will have the resident sign the shower sheet and write refused on it. The CNA stated that resident #200 is scheduled for showers on Monday and Thursday evenings and that the resident should receive a shower tonight. Staff #127 further stated that it is documented electronically if the resident receives a shower, bed bath, or refuses. An interview was conducted with resident #200 on (MONTH) 19, 2019 at 10:38 AM. The resident stated that the scheduled shower was not provided last night. The resident stated that only one shower has been provided since admission. The resident stated that he is supposed to be provided showers three times a week. Resident #200 stated that his hair is dirty and he feels yucky and he wants a shower. During an interview conducted with a staff member during the survey, the staff member stated that if they are short staffed, showers are the first thing that will not get done. During an interview conducted with another staff member during the survey, the staff member stated that if staff calls out or they are short staffed, showers are not provided. The staff member also stated that the bed linens are changed when the resident receives a shower and that the linens are not changed if the resident does not get a shower. An interview was conducted with the Director of Nursing (DON/staff #159) on (MONTH) 19, 2019 at 11:03 AM. She stated that her expectation is that the residents receive showers twice a week. She stated they will try to accommodate the resident if they request showers more often. The DON said if the resident refuses, they can offer a bed bath but that the resident has the right to refuse. The facility's policy and procedure for Activities of Daily Living revealed that if a resident is unable to carry out activities of daily living, the necessary services to maintain good nutrition, grooming and personal oral hygiene will be provided by qualified staff. Bathing will be offered at least twice weekly and PRN per resident request. The policy included ADL care will be documented in the medical record accordingly.",2020-09-01
557,CHANDLER POST ACUTE AND REHABILITATION,35101,2121 WEST ELGIN STREET,CHANDLER,AZ,85224,2019-04-19,684,D,1,1,J85C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, and policy review, the facility failed to ensure medications were administered in accordance with professional standards of practice for 1 of 4 sampled residents (#26). The deficient practice could result in a resident missing doses of physician ordered medications. Findings include: Resident #26 was admitted to the facility on (MONTH) 21, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed physician's orders [REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated (MONTH) 1, (YEAR) revealed a score of 12 on the Brief Interview for Mental Status which indicated the resident had moderate impaired cognition. Review of a physician's note dated (MONTH) 17, (YEAR), revealed the resident has had an overall expected decline with her dementia both physically and mentally and that the resident continues to have approximately 2 [MEDICAL CONDITION] a month which is her baseline. The note revealed there has been several days where the resident has pocketed her medications including her [MEDICAL CONDITION] medications, and has thrown them under her bed or in the trash can. Staff has found the medications several times. The note also included that the physician had spoken with the nursing staff in depth about making sure the resident is taking her medications without pocketing them. An interview was conducted with a Certified Nursing Assistant (CNA/staff #81) on (MONTH) 17, 2019 at 1:53 PM. The CNA stated that resident #26 does have a habit of spitting out her medications and that she usually finds the pills in the resident's bed. The CNA stated that it happens every now and then and that each time it happens she notifies the nurse. An interview was conducted with a Licensed Practical Nurse (LPN/staff #92) on (MONTH) 17, 2019 at 2:10 PM. The LPN stated that she has never seen resident #26 spit out or pocket her pills. The LPN also stated that resident #26 refuses to take her medications in front of the nurse, so she leaves them at the bedside and returns later to make sure the resident has taken the medications. During an interview conducted with resident #26 on (MONTH) 18, 2019 at 11:10 AM., the resident stated that she always takes her pills and the nurse watches her take her medications. An interview was conducted with the Director of Nursing (DON/staff #159) on (MONTH) 18, 2019 at 2:37 PM. The DON stated that there were no long term care residents who were able to self-administer medications. She stated that the nurse is expected to stand there and make sure the resident takes their medications. The DON also stated that if the resident refuses to take the medications in front of one nurse, another nurse can try to get the resident to take the medications. The DON stated that the medications cannot be left at the bedside for the resident to take whenever they want. The facility's policy for Administration of Drugs states that medication shall be administered as prescribed by the attending physician. The policy included that if a medication is withheld, refused or given other than at the scheduled time, the documentation will be reflected in the clinical record. The policy also included right documentation included documenting the refusal of the medication or the attempt and noting any concerns.",2020-09-01
558,CHANDLER POST ACUTE AND REHABILITATION,35101,2121 WEST ELGIN STREET,CHANDLER,AZ,85224,2019-04-19,880,E,0,1,J85C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on personnel record reviews, staff interviews, and policy review, the facility failed to ensure 3 of 10 sampled staff members (#19, #38, and #85) had current evidence of freedom from [MEDICAL CONDITION] (TB). The deficient practice could result in the potential exposure of infectious TB. Findings include: -Review of the personnel record for staff #19 (housekeeping staff) revealed a hire date of (MONTH) 5, (YEAR), for full time employment. A form titled [MEDICATION NAME] Skin Test for Employees revealed the staff member received a TB skin test on (MONTH) 3, (YEAR), and the results were read on (MONTH) 5, (YEAR). The form did not indicate whether the skin test results were positive or negative. -Review of the personnel record for staff #38 (dietary aide) revealed a hire date of (MONTH) 20, (YEAR), for full time employment. A form titled [MEDICATION NAME] Skin Test for Employees revealed the staff member received a TB skin test on (MONTH) 20, (YEAR), and the results were read to be negative on (MONTH) 22, (YEAR). The form indicated that the [MEDICATION NAME] purified protein derivative (PPD) used to administer the skin test had expired in (MONTH) (YEAR). -Review of the personnel record for staff #85 (Registered Nurse) revealed a hire date of (MONTH) 16, (YEAR), for full time employment. A form titled [MEDICATION NAME] Skin Test for Employees revealed the staff member received a TB skin test on (MONTH) 30, 2019, and the results were read on (MONTH) 1, 2019. The form did not indicate whether the skin test results were positive or negative. An interview was conducted on (MONTH) 16, 2019 at 3:37 p.m., with the Human Resources Manager (staff #111), the Administrator (Staff #158), and the Director of Nursing (DON/staff#159). Staff #111 stated she was responsible for maintaining employee files. She stated the facility's policy was for staff to provide evidence of freedom from TB upon hire and annually thereafter. She also stated that she kept a spreadsheet to track the due dates for staff members to submit renewals of their TB testing documentation. All 3 staff members (#111, #158, and #159) stated that because expired PPD was used to administer a TB skin test for staff #38, they would not be able to tell if the results of the test were valid. All 3 staff members (#111, #158, and #159) stated they are pretty sure that staff #19 and #85 TB skin tests were negative, because if the results had been positive there would have been immediate follow-up actions taken. They stated that since there were no additional actions taken, the test results were most likely negative. Review of the facility's policy for TB Screening-Staff revealed that each employee hired by the facility shall be screened for TB, and receive screening at least annually. The policy states acceptable documentation would include documentation of a negative skin test.",2020-09-01
559,CHANDLER POST ACUTE AND REHABILITATION,35101,2121 WEST ELGIN STREET,CHANDLER,AZ,85224,2016-12-08,154,D,0,1,Z0MP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and policy review, the facility failed to ensure one resident (#287) was explained the risks and benefits of an antipsychotic medication, prior to administering. Findings include: Resident #287 was admitted to the facility on (MONTH) 2, (YEAR), with [DIAGNOSES REDACTED]. An initial admission record dated (MONTH) 2, (YEAR), included that the resident was alert and oriented to time, place, person, and was able to follow simple commands. A physician's orders [REDACTED]. A care plan dated (MONTH) 2, (YEAR) indicated the resident was using antipsychotic medication related to [MEDICAL CONDITION], as evidenced by yelling out. Interventions included to administer the medication as ordered and to educate the resident about risks, benefits and side effects of the medication. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. However, the consent form which included an explanation of the risks, benefits, and purpose of the medication was signed by the resident on (MONTH) 3, (YEAR). There was no clinical record documentation which showed that the resident was explained the risks and benefits of the medication prior to being administered. In an interview with a licensed practical nurse (LPN/staff #6) on (MONTH) 7, (YEAR) at 12:10 p.m., she stated the residents should sign a consent form before a [MEDICAL CONDITION] medication is administered. Review of a facility policy regarding psychoactive medication revealed the use of psychoactive medication must first be explained to the resident, family member, or legal representative and that a consent is to be obtained either from the resident or responsible party. A verbal consent may be obtained if no responsible person is available.",2020-09-01
560,CHANDLER POST ACUTE AND REHABILITATION,35101,2121 WEST ELGIN STREET,CHANDLER,AZ,85224,2016-12-08,248,D,0,1,Z0MP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and review of policies and procedures, the facility failed to provide an ongoing activities program consistent with one resident's interests. The sample size was two. Findings include: Resident #140 was admitted to the facility on (MONTH) 16, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident was on isolation precautions due to [MEDICAL CONDITION]. Review of an Activity Admission Evaluation which was undated revealed the resident was oriented to person and place. The documentation included Does not speak English. Preferred language: Arabic. The resident's activity interests included Arabic music, television, reminiscing and talking. According to another Activity Admission Evaluation dated (MONTH) 22, (YEAR), the resident will not be attending activities as she prefers to do her own independently . An Activities care plan dated (MONTH) 22, (YEAR) documented that per a family member, the resident will not be attending the facility activities as she prefers to do her own independently . Resident does not speak English. Resident's preferred language is Arabic . A goal included that the resident will express satisfaction with type of activities and level of activity involvement when asked. Interventions included .Encourage participation and/or provide with needed materials for in room activities which incorporate life roles and hobbies of her choice and interests which include TV .Music-Arabic . An activities progress note dated (MONTH) 22, (YEAR) included .Resident has been given an activity calendar, activity information and was offered in room activity items .Resident does not speak English. Resident's preferred language is Arabic. A review of the admission Minimum Data Set assessment dated (MONTH) 23, (YEAR) revealed in Section F: Preference for Customary Routine and Activities that it was somewhat important for the resident to do her favorite activities. An observation was conducted on (MONTH) 5, (YEAR) at 10:25 a.m. of the resident in her room. The resident was laying on her back on a low bed which was against the wall. The resident was observed to be singing in Arabic. In the room, there was a television on the opposite wall, which was off and there was no music playing. An observation of the resident was conducted on (MONTH) 5, (YEAR) at 12:10 p.m. The resident was laying on her left side facing the wall, speaking in Arabic. The television was off and there was no music playing. An observation was conducted of the resident on (MONTH) 6, (YEAR) at 9:30 a.m. The resident was awake and was laying in bed. The TV was not on, nor was there any music playing. On (MONTH) 7, (YEAR) at 10:30 a.m. and 12:25 p.m., the resident was again observed in the low bed, which was against the wall. The resident was facing the wall speaking in Arabic. The television on the opposite wall was on, however, the volume was very low. An interview was conducted with a CNA (certified nursing assistant/staff #89) on (MONTH) 7, (YEAR) at 12:37 p.m. The CNA stated that the resident was on isolation, because of [MEDICAL CONDITION]. The CNA stated that the resident did not participate in activities, but therapy went into the resident's room sometimes to sit the resident up in a chair. The CNA stated that the resident could not communicate very well. An interview was conducted with the activity director (staff #38) on (MONTH) 7, (YEAR) at 1:22 p.m. Staff #38 stated that the resident's preferred language was Arabic and that the family reported that the resident enjoyed television. Staff #38 further stated that the resident liked Arabic music, but did not know if she had a radio in her room. She stated that the facility did not have any Arabic music. An interview was conducted with an activity assistant (staff #3) on (MONTH) 7, (YEAR) at 2:00 p.m. Staff #3 stated that the resident watched television. She stated that the resident did not have any Arabic music in her room, but she could get her a radio. Staff #3 stated that she goes into the resident's room each day and says hi and makes sure the television is turned on. The facility was unable to provide any documentation that the resident was receiving ongoing activities, based on the resident's interests. A facility policy regarding Activities documented, It is the policy of this facility to ensure that residents have the right to choose the types of activities and social events in which they wish to participate .Some activities can be adapted to accommodate the resident's change in functioning due to physical or cognitive limitations .Cognitive impairment .Language barrier (translation tools, audio/video in the resident's language, etc .",2020-09-01
561,CHANDLER POST ACUTE AND REHABILITATION,35101,2121 WEST ELGIN STREET,CHANDLER,AZ,85224,2016-12-08,281,E,0,1,Z0MP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, and policy and procedures, the facility failed to ensure professional standards were met regarding the administration of prescribed treatments for two residents (#204 and #285) and failed to administer tube feeding orders as prescribed for one resident (#26). Findings include: -Resident #204 was admitted on (MONTH) 16, (YEAR), with [DIAGNOSES REDACTED]. The resident was also admitted with a gastrostomy tube and a central line catheter. Regarding the central line: Review of the admission orders [REDACTED]. If site is not visible for assessment, change dressing every 48 hours. Change injection caps to each lumen upon admission, every 7 days and after blood draws, every day shift on Sunday. However, a review of the (MONTH) (YEAR) TAR (Treatment Administration Record) and nursing notes revealed no documented evidence that the prescribed treatments had been administered on (MONTH) 19 and 20. Regarding the gastrostomy tube site dressing: A physician's orders [REDACTED]. However, a review of the (MONTH) (YEAR) TAR and nursing notes revealed no documented evidence that the prescribed treatment had been administered on (MONTH) 19 and 21. An interview was conducted on (MONTH) 8, (YEAR) at 8:30 a.m., with the Director of Nursing (staff #140), who stated that licensed staff were suppose to sign the TARs to indicate that the treatment was administered. She further stated that if it was not signed, then it was not done. -Resident #285 was admitted to the facility on (MONTH) 15, (YEAR), with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Pat dry. Cover with dry dressing. Change daily and as needed. A review of the (MONTH) (YEAR) TAR also revealed an order dated (MONTH) 15, (YEAR) to Monitor right hip incision every shift for signs and symptoms of infection. Further review of the (MONTH) (YEAR) TAR revealed there was no documentation that the wound care to the resident's right hip was provided on (MONTH) 17. A Nurses Note dated (MONTH) 18, (YEAR) included Late entry for (MONTH) 17, (YEAR) 2:00 a.m. The note included .Right hip incision intact and well approximated with no signs and symptoms of infection noted . However, the Nurse's Notes did not include documentation that the wound treatment to the resident's right hip was completed on (MONTH) 17. An interview was conducted with the DON (Director of Nursing/staff #140) on (MONTH) 7, (YEAR) at 8:30 a.m. The DON stated that if an order was unable to be administered, the reason why should be documented in the resident's clinical record. -Resident #26 was admitted to the facility on (MONTH) 2, (YEAR), with [DIAGNOSES REDACTED]. The resident was discharged from the facility on (MONTH) 19, (YEAR). A care plan was developed on (MONTH) 6, (YEAR) which included the resident had swallowing difficulties related to aspiration pneumonia, as evidenced by NPO (nothing by mouth) status with tube feeding. An intervention included to provide tube feedings. A physician's orders [REDACTED]. Review of the (MONTH) (YEAR) MAR (Medication Administration Record) revealed the rate of the tube feeding was documented two times a day at 8 a.m. and 12 p.m. as follows: -November 7: 70 and 80 -November 8: 90 and 90 -November 9: 90 and 90 -November 10: 90 and the number 1490 -November 11: the number 1490 is documented twice -November 12: 90 and 90 -November 13: 90 and 90 -November 14: 0 and 90 -November 15: no rate was documented, however, the number 550 is documented -November 16: no rate was documented -November 17: 95 and 95 Per the documentation, the rate was not increased by 10ml every hour for a goal rate of 95ml/hr as ordered. The goal rate of 95 ml/hr was not reached until (MONTH) 17. There was no documentation in the clinical record to show that the resident was having any type of adverse effect from the tube feeding. There was also no explanation regarding what the numbers (1490 and 550) indicated. In an interview with the Director of Nursing (DON/staff #140) on (MONTH) 8, (YEAR) at 12:57 p.m. regarding the numbers 1490 and 550, she stated that perhaps the nurse who documented it was totaling the number of milliliters that were administered. Regarding why the tube feeding rate was not implemented as ordered, she stated that the resident may have had an adverse reaction or residual from the tube feeding (however, no documentation regarding this was found in the clinical record). She stated that usually the nurses indicate with a check mark that the tube feeding is running and when it is turned off, without having to document the rate that the tube feeding is running. Review of a facility policy regarding physician orders [REDACTED]. The policy included Medication, treatment or related orders are transcribed in the eMAR (electronic Medication Administration Record), eTAR (electronic Treatment Administration Record) accordingly. Review of the facility's policy regarding Documentation and Charting revealed, It is the policy of this facility to provide: 1. A complete account of the resident's .treatment .",2020-09-01
562,CHANDLER POST ACUTE AND REHABILITATION,35101,2121 WEST ELGIN STREET,CHANDLER,AZ,85224,2016-12-08,309,D,0,1,Z0MP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, staff interviews, and review of policies and procedures, the facility failed to ensure that a prescribed fluid restriction was implemented for one resident (#137). Findings include: Resident #137 was admitted on (MONTH) 2, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident was receiving [MEDICAL TREATMENT] treatments. A physician's orders [REDACTED]. A [MEDICAL TREATMENT] care plan included as a goal that the resident would have immediate intervention should any signs/symptoms of complications from [MEDICAL TREATMENT] occur. One of the interventions included for the 1200 cc fluid restriction. Review of a nutritional progress note dated (MONTH) 17, (YEAR) revealed documentation that a 1200 cc fluid restriction was in place. In addition, [MEDICAL TREATMENT] assessments for (MONTH) through the first week in (MONTH) also included that the resident was on a fluid restriction. However, a continued review of the clinical record revealed no documented evidence that the prescribed 1200 cc fluid restriction had been implemented from (MONTH) 27, (YEAR) through the first week in (MONTH) (YEAR). An interview was conducted on (MONTH) 6, (YEAR) at 3:00 p.m. with a LPN (Licensed Practical Nurse/staff #142), who stated that he was not aware of any fluid restriction for this resident. Immediately following this interview, an interview was conducted with the DON (Director of Nursing/staff #140). Staff #140 stated that the charge nurses on each unit were responsible for the verification of the physician's orders [REDACTED]. Following a review of the clinical record, staff #140 stated that the 1200 cc fluid restriction had not been transcribed or implemented. Staff #140 stated that the 1200 cc fluid restriction should have been scheduled in the facility's computer system, so that the order would show up on the Medication Administration Record. A facility policy titled Fluid Restriction included, It is the policy of this facility to provide residents who have a written physician order [REDACTED]. The policy also included the following: 2. For a diet with fluid restrictions, the following distribution is used by nursing and dietary for a 1200 cc fluid restriction: total nursing 300 cc and total dietary 900 cc. Another facility policy titled, Physician order [REDACTED]. Medication, treatment or related orders are transcribed to the eMAR or eTAR accordingly. A policy titled, Documentation and Charting included It is the policy of this facility to provide: 1. A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care. Review of a policy titled, Care Planning included: 9. The resident's plan of care, goals, and interventions are communicated and implemented by the members of the health care continuum accordingly.",2020-09-01
563,CHANDLER POST ACUTE AND REHABILITATION,35101,2121 WEST ELGIN STREET,CHANDLER,AZ,85224,2016-12-08,314,E,0,1,Z0MP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, staff interview and policies and procedures, the facility failed to ensure that pressure ulcer care and services were consistently provided to one resident (#87). Findings include: Resident #87 was admitted on (MONTH) 28, (YEAR), with [DIAGNOSES REDACTED]. The admission Braden risk assessment identified that the resident was a high risk for the development of pressure ulcers. Review of the clinical record revealed there were discrepancies regarding the presence of pressures ulcers upon admission. The admission nursing note dated (MONTH) 28, (YEAR), included that pressure ulcers were present on the resident's sacrum/coccyx and right posterior thigh. Another nursing note dated (MONTH) 28, (YEAR), included that the resident had an open, draining, red wound on the coccyx and open areas on the back of both thighs. The initial nursing admission assessment dated (MONTH) 28, (YEAR), included the resident had the following skin concerns: a large open wound to the right rear thigh with detached edges and slough throughout; and the sacrum/coccyx area had a large open wound with slough. The assessment did not address any pressure ulcer to the left thigh. Per the note the physician was notified and an order was obtained for the use of a wound vac to the coccyx wound. However, a pressure ulcer care plan dated (MONTH) 28, (YEAR) identified the resident had an unstageable pressure ulcer on the left ankle (the left ankle was not included in the above nursing assessment) and right posterior thigh, and a stage 4 pressure ulcer on the coccyx. The care plan did not include a pressure ulcer to the left thigh, as identified in the above nursing note. Interventions included to administer treatments as ordered and monitor for effectiveness, assess/record/monitor wound healing, measure length, width and depth where possible and assess and document status of wound perimeter, wound bed and healing progress, and follow facility policies/protocols for the prevention/treatment of [REDACTED]. Upon admission, there was no documentation that the pressure ulcers to the left thigh and left ankle were thoroughly assessed, nor were there measurements of any of the identified pressure ulcers. A review of the physician's orders [REDACTED]. -Weekly skin assessments -Wound consultation -Cleanse the posterior right thigh with wound cleanser, pat dry, apply Honeygel to wound bed and cover with dry dressing. Change daily and prn (as needed). However, there were no admission treatment orders for the pressure ulcers to the coccyx/sacrum, left thigh or left ankle. A nursing note dated (MONTH) 30, (YEAR), included that the resident was seen by the physician and that the use of the wound vac was discontinued. However, an order for [REDACTED]. Review of the nursing pressure ulcer assessment dated (MONTH) 30, (YEAR) (two days after admission) now included the following pressure ulcers were present upon admission on (MONTH) 28: -Coccyx: stage 4 which measured 8 by 6 by 1.6 cm (centimeters) with tunneling of 3.2 at 9:00 o'clock. -Right Upper Thigh: stage 2 which measured 6 by 0.3 cm. -Left Upper Thigh: stage 2 which measured 9 by 1 cm. -Left Outer Ankle: UTD (Unable to Determine) stage which measured 1 by 0.3 cm. -Right Outer Ankle-Distal: DTI (deep tissue injury) which measured 0.3 by 0.3 cm. -Right Outer Ankle-proximal: DTI which measured 0.3 by .03 cm. However, the (MONTH) 28, (YEAR), nursing notes and admission nursing assessment did not include that pressure ulcers were present on the resident's right ankles and only the pressure ulcer care plan identified that a pressure ulcer was present on the resident's left ankle. There was no further pressure ulcer assessment documentation regarding the pressure ulcers identified in the nursing pressure ulcer assessment from (MONTH) 30, which included a description of the wound bed, condition of the surrounding skin, or if any drainage or odor was present. Furthermore, the (MONTH) (YEAR) recapitulation of physician's orders [REDACTED]. On (MONTH) 4, (YEAR), the initial wound consultation was provided. The documentation included the following: -Coccyx: stage 4 pressure ulcer which measured 8 by 8.5 by 0.9 cm. No tunneling or undermining. A slight amount of serous drainage was present. The wound bed had 20% slough present and the periwound was normal. The treatment plan included to cleanse with normal saline/water, loosely pack wound with Dakin's solution soaked gauze, and dressing. Change the dressing every 12 hours. -Left lateral malleolus (ankle): Unstageable pressure ulcer which measured 3 by 1 with 100% slough present in the wound bed. The periwound was normal. The treatment plan included to cleanse with normal saline/water, apply Alginate with [MEDICATION NAME], island dressing and to change the dressing daily and prn (as needed). -Right posterior thigh: Unstageable pressure ulcer which measured 1 by 10.5 by 0.2 cm with 50% slough and 50% eschar present in the wound bed. The treatment plan included to cleanse with normal saline/water, apply [MEDICATION NAME], island dressing and to change daily and prn. However, the initial wound consultation did not include any documentation of the pressure ulcers on the resident's left thigh or right ankles, which were identified on (MONTH) 30. Review of an admission MDS (Minimum Data Set) assessment dated (MONTH) 5, (YEAR) revealed a BIMS (Brief Interview for Mental Status) score of 15, which indicated the resident was cognitively intact. The MDS also assessed the resident to require extensive assistance of two, with most activities of daily living. In addition, the MDS assessed the resident to be at risk for pressure ulcer development and had two unstageable pressure ulcers upon admission. Further review of the weekly wound consultation assessments from (MONTH) 13, through 31, (YEAR), revealed no additional assessments of the pressure ulcer on the right posterior thigh, the right ankles or left thigh. According to the wound consultation assessments from (MONTH) 7, (YEAR), through (MONTH) 5, (YEAR), the pressure ulcer on the left lateral ankle had resolved on (MONTH) 7, but the stage 4 pressure ulcer on the coccyx still remained. There was no documentation regarding the left thigh or the right ankle pressure ulcers, or if the pressure ulcers had healed. There was also no clinical record documentation that physician ordered treatments had ever been provided to the pressure ulcers on the resident's right ankles or the left thigh. A pressure ulcer observation was conducted on (MONTH) 7, (YEAR) at 10:00 a.m. During this observation, the resident was identified to have stage 4 pressure ulcer on the sacrum, which measured 6 by 8 by 2 cm, with tunneling of 2.7 cm at the 3:00 o'clock position. No slough, odor or drainage was observed. No other pressure ulcers were observed. An interview was conducted on (MONTH) 8, (YEAR) at 12:30 p.m., with the DON (staff #140). Following a review of the clinical record, staff #140 stated that the licensed staff were responsible to provide a head to toe assessment of the resident upon admission and to document what they observed. Staff #140 also stated that the wound nurse was suppose to provide a complete assessment, inclusive of the staging of any wounds, within 24 hours of admission or within 72 hours if the admission occurred on a Friday night. At this time, staff #140 confirmed that since (MONTH) 28, (YEAR) was a Wednesday, the wound nurse should have conducted a complete assessment of the resident's wounds the next day. She also agreed that not all of the pressure ulcers were identified on admission and that treatment orders had not been obtained and/or administered consistently. A facility policy titled Documentation and Charting included, It is the policy of this facility to provide: 1. A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care. Another facility policy titled Pressure Ulcers included, It is the policy of this facility that: 1. A resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and 2. A resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. The policy also included the following: D. Assessment of the ulcer. -Type. -Stage. -Characteristics. -Dressing and treatments.",2020-09-01
564,CHANDLER POST ACUTE AND REHABILITATION,35101,2121 WEST ELGIN STREET,CHANDLER,AZ,85224,2016-12-08,327,D,0,1,Z0MP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, staff interviews and policy review, the facility failed to ensure that one resident (#87) was provided IV (Intravenous) fluids as ordered. Findings include: Resident #87 was admitted on (MONTH) 28, (YEAR), with [DIAGNOSES REDACTED]. A review of the clinical record revealed physician orders [REDACTED]. Care plans were developed to address the IV therapy and the potential for fluid deficit. The IV therapy care plan included as an intervention to infuse the fluids as physician ordered. A care plan for the potential for fluid deficit included as an intervention to provide D5 1/2 normal saline solution at 60 cc/hour. However, during an observation conducted on (MONTH) 8, (YEAR) at 9:30 a.m., the resident's IV solution was observed to be set at a rate of 50cc/hour and not 60 cc/hour, as physician ordered. According to the documentation on the IV solution bag, it was started at 9:00 p.m. the night before. On (MONTH) 8, (YEAR) at 9:45 a.m., the ADON (Assistant Director of Nursing/staff #62) reviewed the clinical record and then conducted an observation of the resident. At this time, staff #62 confirmed that the IV solution was not at the prescribed rate of infusion. Staff #62 stated that the IV solution was set at 50 cc/hour and not the 60 cc /hour that had been ordered. An interview was conducted on (MONTH) 8, (YEAR) at 10:00 a.m. with a LPN (Licensed Practical Nurse/staff #117). She stated that she had started her shift at 6:00 a.m., but had not yet assessed the resident's IV. Staff #117 stated that she usually checks the IV to confirm that the correct solution is infusing at the correct rate of flow, but she had not yet conducted that assessment because so many residents had requested pain medications today. A facility policy titled, Intravenous Therapy included to set the flow rate as directed.",2020-09-01
565,CHANDLER POST ACUTE AND REHABILITATION,35101,2121 WEST ELGIN STREET,CHANDLER,AZ,85224,2016-12-08,328,D,0,1,Z0MP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations and staff interviews, the facility failed to ensure that podiatry care was provided for one resident (#87). Findings include: Resident #87 was admitted on (MONTH) 28, (YEAR), with [DIAGNOSES REDACTED]. A review of the admission orders [REDACTED]. An observation of the resident's feet was conducted on (MONTH) 7, (YEAR) at 1:30 p.m. At this time, the resident was observed to have extremely long, thick, jagged, crusty yellowish toenails. The right foot was observed to be worse than the left foot. However, the clinical record did not include any documented evidence that podiatry care had been provided or was scheduled. An interview was conducted with the Social Service Director (staff #131) on (MONTH) 7, (YEAR) at 1:40 p.m. She stated that she had not received a podiatry referral from nursing staff. Staff #131 stated that the facility did have a new podiatrist who comes to the facility to see residents and that residents were able to be seen fairly quick. An interview was conducted on (MONTH) 7, (YEAR) at 1:45 p.m., with a CNA (Certified Nursing Assistant/staff #74), who stated that she was aware of the condition of the resident's toenails and had discussed it with licensed staff approximately one to two months ago. She stated that she thought that they would have scheduled a podiatry appointment. On (MONTH) 7, (YEAR) at 1:50 p.m., an interview was conducted with a LPN (Licensed Practical Nurse/staff #87), who stated that he had provided weekly skin checks to the resident, but never noticed any problem with the resident's feet/toenails. At this time, staff #87 made an observation of the resident's feet and stated that he needed to notify social services, as a podiatry consultation was needed. According to the Director of Nursing (staff #140), the facility did not have a policy regarding podiatry consultations.",2020-09-01
566,CITADEL POST ACUTE,35103,5121 EAST BROADWAY ROAD,MESA,AZ,85206,2018-08-10,679,D,0,1,0J2O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, review of the residents chart, and review of the facility's policy and procedures, the facility failed to ensure that the resident received individual activities as she can no longer participate with group activities. Findings include: Resident #71 was admitted to the facility on (MONTH) 17, (YEAR) with [DIAGNOSES REDACTED]. Observation was made on (MONTH) 6, (YEAR) on the first day of the survey was that the resident was in bed and no television or radio was on for any stimulation. The blinds to the window were closed and the room was dark. Review on (MONTH) 9, (YEAR) of the resident's minimum data set (MDS) dated (MONTH) 24, (YEAR), revealed that activities that are somewhat important to her were listening to music she liked and attend religious services. The MDS also revealed that the resident is extremely cognitively impaired with a BIMS (brief interview for mental status) score of 3. Resident was care planned for one on one in room visits, television watching, in room visits from Catholic clergy, and listening to classical music. Several observations were made on (MONTH) 9, (YEAR) and besides the pressure ulcer dressing change did not observe any other stimulus for the resident. No televisions were on in the room including her roommates. The resident's television was actually on a night stand behind her. No music was played for the resident and no visitation was made by activities' staff. On (MONTH) 9, (YEAR) at 12:39 PM an interview was conducted with the Activities director staff #74 who said that the resident is no longer able to come to group activities so they try to do stimulation for her in her room. She says that once a week, and according to the documents, they play music, staff member from activities plays the ukulele to her. They say she enjoys watching her roommates TV. On occasion she has a priest from the Catholic church visit but she doesn't always consent to see them every time. Documentation of activities reveals that during the month of (MONTH) (YEAR) she watched TV 4 times. During the same period she had 6 one on one activities. For the this month the resident has been charted as watching TV 2 times and has had 4 one on one visits during the first 8 days of August. The one on one visits usually last no more than 14 minutes. Interview was conducted with a certified nursing assistant (CNA) on (MONTH) 9, (YEAR), at 1:32 PM working on the 100 Hall where the resident resides, said that the resident's roommate has not been feeling well lately so they have not been putting her TV on. The resident usually watches her roommates, thus no TV watching for the resident. The resident's bed is facing the window but the shades have been down all day so cannot even look out the window and watch the outside world go by. Interview conducted with Director of Nurses (MONTH) 9, (YEAR) at 2:36 PM staff #147 asked about activities and she said the resident gets stimulus from the CNAs coming in and saying hello from time to time to her plus they talk to her when they feed her meals. Review of the facility's policy and procedure for Activities its states: It is the policy of this facility to ensure that residents have the right to choose the types of activities and social events in which they wish to participate. Some activities can be adapted to accommodate the resident's change in functioning due to physical or cognitive limitations .terminally ill (life review, spiritual support, touch, massage, music reading to the resident, etc.",2020-09-01
567,CITADEL POST ACUTE,35103,5121 EAST BROADWAY ROAD,MESA,AZ,85206,2018-08-10,812,D,0,1,0J2O11,"Based on observation, staff interviews, and facility documents and policy, the facility failed to ensure one ice machine was clean and sanitary. Findings include: On 08/07/18 at 10:10 AM, an observation of the ice machine in the 200 hall noted the machine is kept in a room with an open door and accessed by residents, visitors, and staff for ice and water dispensing. The ice machine has sensor activated drop chute for ice and water dispensing. The inside of the chutes for ice and water dispensing were noted to be heavily coated with beige/white water scale and a pinkish colored substance that came off with a white towel when wiped. The drip collection tray below the chutes was also heavily coated on the sides and parts of the bottom with a beige/white scale with some areas of pinkish substance and small amounts of debris. This is the only public ice machine for all patient care areas. Multiple residents, visitors, and staff were observed obtaining ice and water from the machine with various personal containers. In an interview conducted with the Director of Food Services (staff #52) conducted on 08/07/18 at 2:00 PM, staff #52 stated the kitchen staff were not responsible for cleaning of the ice machine and that maintenance was responsible for the cleaning. In an interview conducted with the Director of Maintenance (staff #142) on 08/07/18 at 02:15 PM, staff #142 stated the ice machine is cleaned once each month by taking out the filters on the sides and cleaning them and wiping off the chutes and drip tray. During the interview with the Director of Maintenance, one staff member and one resident came to the ice machine to obtain ice and water with their personal cups. In an interview conducted with the Registered Nurse/Director of Nursing (DON/staff #147) on 08/07/18 at 02:25 PM, the DON stated the ice machine could probably be cleaned better, but after observing the coating inside the water and ice dispensing chutes, asked the Maintenance Director to shut down the machine and deep clean it. Review of the cleaning logs from maintenance revealed monthly cleaning documented for the steps of the style ice machine in the kitchen, but not the 200 hall. Review of the facility policy titled Cleaning Instructions: Ice Machine and Equipment, the policy stated documented the ice machine and equipment will be cleaned and sanitized on a regular basis. The procedure steps for the policy documented how to clean the ice machine with the large holding bin in the kitchen, but not the dispensing ice machine on the 200 hall. Review of the manufacturer's guidelines for cleaning of this type of machine documented the dispense area, sprouts, sink, grill, and splash panel will need periodic cleaning and maintenance. The guidelines included that the ice chute may be pulled down to remove it for cleaning and sanitizing. The procedure was also identified for the sink grill, splash panel, and sink.",2020-09-01
568,CITADEL POST ACUTE,35103,5121 EAST BROADWAY ROAD,MESA,AZ,85206,2019-10-03,554,D,0,1,I4KK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, interviews and policy review, the facility failed to ensure that one resident (#196) was assessed to determine clinical appropriateness to self administer medications. The deficient practice could result in medications not being taken as ordered, possible complications as a result of an inability to follow directions and unsafe storage of medications. The facility census was 103 residents. Findings include: Resident #196 was admitted to the facility on (MONTH) 19, 2019, with [DIAGNOSES REDACTED]. A care plan dated (MONTH) 19, 2019 included the resident was at risk for impaired thought processes related to end stage liver disease. The goal was for the resident to maintain the current level of cognitive function. Interventions included to face the resident when speaking, reduce distractions, use simple directive sentences, and provide the resident with necessary cues. Review of the admission Minimum Data Set assessment dated (MONTH) 26, 2019, revealed a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. An observation was conducted on (MONTH) 30, 2019 at 9:30 a.m., of the resident in her room. At this time, a small cup containing four pills was observed on the resident's bedside table. The resident stated that she was planning on taking the pills soon, but had not gotten around to it yet. Review of the physician's orders [REDACTED]. Review of the clinical record revealed no evidence that an assessment for self administration of medications was completed. An interview was conducted with a registered nurse (RN/staff #27) on (MONTH) 1, 2019 at 12:26 p.m. He said in order for a resident to self-administer medication, an assessment for safety would need to be completed, and there needs to be a physician's orders [REDACTED]. An interview was conducted with a RN (staff #110) on (MONTH) 1, 2019 at 12:40 p.m. She said there would need to be a physician's orders [REDACTED]. She said the resident would need to be observed for safety of self administration, and there would need to be some type of secure storage in the resident's room, if the resident planned to keep the medications at the bedside. An interview was conducted on (MONTH) 1, 2019 at 2:08 p.m., with the Director of Nursing (DON/staff #171). She said if a resident wanted to self administer medication, they would need a physician's orders [REDACTED]. She said the resident would receive education and would provide a demonstration of how to self-administer, as well as when to administer and have an understanding of side effects and risks and/or benefits. She said the medications could be stored at the bedside with a lockbox and a key in the resident's possession. During a follow-up interview at 2:39 p.m. on (MONTH) 1, 2019, staff #171 stated her expectation is that when nurses administer medications to residents, they will observe the residents actually taking the medications. Review of the facility's policy for self administration of medications revealed that if a resident wished to self administer medication, the interdisciplinary team would assess and periodically re-evaluate the resident based on change in the resident's status. The resident's cognitive, communication, visual, and physical ability to carry out this responsibility would be evaluated. If a resident was a candidate for self administration of medications, this would be indicated in the chart. The resident would receive instruction from the nurse regarding proper administration of medication.",2020-09-01
569,CITADEL POST ACUTE,35103,5121 EAST BROADWAY ROAD,MESA,AZ,85206,2019-10-03,641,D,0,1,I4KK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record reviews, staff interviews and policy review, the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of 2 residents (#3 and #76). The deficient practice could affect continuity of care. The census was 103 residents. Findings include: -Resident #3 was admitted to the facility on (MONTH) 21, (YEAR), with [DIAGNOSES REDACTED]. A care plan included the resident had a [MEDICATION NAME] and used a Foley urinary drainage bag overnight. Review of the quarterly MDS assessment dated (MONTH) 24, 2019, revealed documentation that the resident had an indwelling catheter and an ostomy. However, during an observation of the resident on (MONTH) 1, 2019 at 10:17 a.m., the resident was observed to have a [MEDICATION NAME], but did not have an indwelling catheter. An interview was conducted with the MDS coordinator (staff #41) on (MONTH) 1, 2019 at 10:26 a.m. She stated that to code the portion of the MDS assessment that referred to indwelling catheters and ostomies, she would review the nurse aide documentation, nursing notes, physician's orders [REDACTED]. She said the documentation on the MDS assessment for an indwelling catheter was a mistake, because resident #3 only had a [MEDICATION NAME]. -Resident #76 was admitted to the facility on (MONTH) 23, (YEAR), with [DIAGNOSES REDACTED]. Review of a wound assessment dated (MONTH) 15, 2019, revealed the resident had a stage 3 pressure ulcer on the right heel. The assessment stated the wound was facility acquired. However, review of the quarterly MDS assessment dated (MONTH) 20, 2019, revealed the resident had a stage 3 pressure ulcer that was present on admission. An interview was conducted with the MDS coordinator (staff #41) on (MONTH) 1, 2019 at 10:26 a.m. She said that to code the portion of the MDS assessment related to wounds, she would review physician's orders [REDACTED]. She said if a wound was present on admission, it would be documented in the wound rounds. She said the wound on the right heel of resident #76 was facility acquired. She said that she planned to file a correction for the MDS assessment for resident #76. An interview was conducted on (MONTH) 1, 2019 at 2:08 p.m., with the Director of Nursing (DON/staff #171). She said she expected that the chart would be thoroughly reviewed and any data that needed to be captured would be included in the MDS assessment. The facility's policy for accuracy of assessments stated that the MDS assessment should accurately reflect the resident's status. Each individual who completed a portion of the assessment must sign and certify accuracy of that portion of the assessment.",2020-09-01
570,CITADEL POST ACUTE,35103,5121 EAST BROADWAY ROAD,MESA,AZ,85206,2019-10-03,684,E,0,1,I4KK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy review, the facility failed to ensure medications were administered in accordance with professional standards of practice for 1 sampled resident (#65). The deficient practice could place residents at risk for increased complications related to infections. Findings include: Resident #65 was admitted to the facility on (MONTH) 10, 2019, with [DIAGNOSES REDACTED]. A care plan dated (MONTH) 11, 2019 included the resident had an infection related to intra-abdominal abscess and is on intravenous (IV) antibiotics. An intervention was to administer antibiotic per MD orders. A quarterly Minimum Data Set (MDS) assessment dated (MONTH) 10, 2019 revealed a score of 15 on the Brief Interview for Mental Status, which indicated the resident was cognitively intact. The MDS also noted that resident #65 was on IV antibiotics. Review of the physician orders [REDACTED]. -[MEDICATION NAME] Solution (antibiotic) 2.25 gm/50 ml, use 2.25 ml IV every 6 hours for intra-abdominal infection (administration time was midnight, 6 a.m., 12 p.m. and 6 p.m.) with a start date of (MONTH) 10, 2019 and a stop date of (MONTH) 25, 2019. -Caspofungin Acetate Solution (antibiotic) reconstituted 50 mg, use 50 mg IV one time a day for intra-abdominal infection (administration time was 5 p.m.), with a start date of (MONTH) 10, 2019 and a stop date of (MONTH) 25, 2019. -Sodium Chloride Solution (used for hydration), use 1000 ml IV every evening shift for supplement x1 liter bolus daily started on (MONTH) 11, 2019 with no stop date. Review of the (MONTH) and (MONTH) 2019 IV Medication Administration Records (MARs) for [MEDICATION NAME] revealed the following missing doses: (MONTH) 13 at 6 p.m., (MONTH) 14 at 12 p. m., (MONTH) 15 at 6 p.m., (MONTH) 17 at 12 p.m., (MONTH) 19 at 12 a.m., (MONTH) 20 at 6 p. m., (MONTH) 21 at 6 a.m., (MONTH) 22 at 6 p.m., (MONTH) 28 at 12 pm., (MONTH) 29 at 12 a. m., (MONTH) 30 at 12 a.m. and 6 a.m., (MONTH) 2 at 6 p. m., (MONTH) 3 at 6 a.m. and 6 p. m., (MONTH) 6 at 6 p. m., (MONTH) 8 at 12 a. m., (MONTH) 13 at 6 p.m., (MONTH) 15 at 12 a.m., (MONTH) 16 at 12 p.m. and 6 p.m., (MONTH) 17 at 12 a.m., 6 a.m. and at 6 p.m., (MONTH) 18, 19 and 20 at 6 p. m., (MONTH) 21 at 12 a.m. and 6 p.m., (MONTH) 22 at 12 p.m., and (MONTH) 24 at 12 p.m. Review of the IV MARs regarding Caspofungin Acetate revealed missing doses on (MONTH) 13, 15, 20, 21 and 22, 2019 and (MONTH) 2, 3, 6, 13, 16, 17, 18, 19, 20 and 21 at 5 p.m. Review of the IV MARs regarding the sodium chloride solution revealed missing doses on (MONTH) 20, and on (MONTH) 6, 13, 17, 21 and 27. Further review of the clinical record including the nurses progress notes revealed no documentation as to why the IV medications were not administered and there was no documentation the physician was notified that the IV medications were not administered. There was also no documentation that the resident refused the IV medications. An interview was conducted with a Licensed Practical Nurse (LPN/staff #141) on (MONTH) 2, 2019 at 10:23 a.m. The LPN stated the IV MAR lists the medications that are due. She stated that when she administers medication she signs for it and if the medication is not given, she documents the reason why. She said they can't leave the MAR blank, and they have to notify the provider if any IV antibiotics are not given and should document it in the progress notes. An interview was conducted with a LPN (staff #110) on (MONTH) 2, 2019 at 10:41 a.m. The LPN stated that the IV medications which are due, will show up on the IV MAR. She stated when she administers a medication she documents it in the electronic MAR. She said if the medication is not administered, she documents that it was not given and the system will ask the reason why it was not given. She stated that she also notifies the provider if an IV medication was not given. The LPN stated that they cannot hold medication without notifying the provider. She said that she would document that the provider was notified in the IV MAR under the progress note section. Staff #110 stated they cannot leave holes in the MAR documentation regarding medications. An interview was conducted with the Director of Nursing (DON/staff #171) on (MONTH) 3, 2019 at 10:56 a.m. The DON stated that she expects the nurses to sign for medications in the IV MAR in a timely manner and if for some reason the medication is not given, they should document it in the IV MAR and the nurses progress notes. She stated the physician has to be notified and it should be documented. The DON also stated that resident #65 tends to go out of the facility in her electric wheelchair for extended hours, and in that event she expects the physician should have been notified and the IV medications should have been adjusted, so they could be administered when she came back to the facility. She stated the nurses should have documented the reason why the medications were not administered. The facility's policy for Administration of Medication included that medications shall be administered in accordance with the written orders of the attending physician. The policy included that if a medication is withheld, refused or given other than at the scheduled time, the documentation will be reflected in the clinical record. The policy also stated that the documentation should include documenting the refusal of the medication or the attempt, and any concerns.",2020-09-01
571,CITADEL POST ACUTE,35103,5121 EAST BROADWAY ROAD,MESA,AZ,85206,2019-10-03,697,D,0,1,I4KK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observations, clinical record reviews, interviews and policy review, the facility failed to provide pain management according to professional standards of practice for 2 residents (#195 and #397). The deficient practice could result in residents experiencing unrelieved pain and the potential for decline. Findings include: -Resident #195 was admitted to the facility on (MONTH) 15, 2019, with [DIAGNOSES REDACTED]. A care plan was initiated on (MONTH) 15, 2019, for acute pain related to surgery [MEDICAL CONDITION]. The goal was that the resident would voice a level of comfort, with interventions to evaluate the effectiveness of pain interventions, monitor and record pain characteristics, and notify the physician if interventions were unsuccessful. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 22, 2019, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The assessment also stated the resident had received scheduled and as needed (PRN) pain medication, and that the resident experienced frequent pain. Review of the physician's orders [REDACTED]. During an interview with the resident on (MONTH) 30, 2019 at 9:00 a.m., she stated that she had waited one time for pain medication for almost 2 hours. She said at that time her pain had been around a 7 or 8 and that she had been crying. She said this had only occurred once, and normally she did not have to wait that long for pain medication. Another interview was conducted with the resident on (MONTH) 2, 2019 at 9:54 a.m. She said that she had just requested pain medication, because she was beginning to feel some discomfort. A follow up interview was conducted with the resident at 10:42 a.m. She said no one had come to address her pain yet. She said, I am doing ok, the pain is not too intense. An interview was conducted with a registered nurse (RN/staff #110) on (MONTH) 2, 2019 at 10:55 a.m. She stated that she was the nurse for resident #195. She said that she had not received any reports recently of the resident being in pain. An interview was conducted with a Certified Nursing Assistant (CNA/staff #103) on (MONTH) 2, 2019 at 10:56 a.m. She said that she was the one who had answered the resident's call light, and the resident had requested pain medication. She said she went to tell the resident's nurse, but the nurse was talking to another nurse. She said the resident had turned her call light on again, and another staff member had answered the light. She said she thought that maybe the resident had requested pain medication again and the other staff member had taken care of it. She said that she meant to go back and tell the nurse later about the resident's pain, but it had slipped her mind. Review of the Medication Administration Record [REDACTED]. A follow up interview was conducted with the resident's nurse (staff #110) on (MONTH) 2, 2019 at 1:08 p.m. She said that she normally tries to respond to a resident's request for pain medication within 15 minutes. She said sometimes she has to finish preparing and administering medication for another resident before she can respond to a resident's request, but it usually does not take more than 15 minutes. She said pain management was a top priority. An interview was conducted with the Director of Nursing (DON/staff #171) on (MONTH) 3, 2019 at 8:49 a.m. She said when a resident reports pain to staff, her expectation is that staff notify the nurse and the nurse addresses the pain as quickly as possible. She said if the nurse was preparing medications for another resident, the nurse should finish administering the medications before preparing pain medications for another resident, in order to avoid errors. -Resident #397 was admitted on [DATE] with [DIAGNOSES REDACTED]. According to a Pain Management Review dated 9/29/19, the resident was interviewable and stated that she had pain now, and experienced pain daily or several times a day, and had back pain, neck pain and pain related to recent femur surgery. Per the assessment, the resident described the pain as aching/sharp and that physical activity and turning and repositioning made the pain worse. Non drug approaches included that cold packs helped to relieve pain and medication used in the past was [MEDICATION NAME], and that her pain had been managed well over the last three months. A care plan dated 9/29/19 revealed the resident has acute/chronic pain. The goal included to voice a level of comfort through the review date. Interventions included the resident was able to call for assistance when in pain, reposition self, ask for medication, tell you how much pain is experienced and tell you what increases or alleviates pain. The interventions also included to monitor pain characteristics, severity, location, onset, duration, aggravating factors and relieving factors, monitor/record/report to nurse any signs/symptoms of non-verbal pain, pain assessment every shift and to reposition for comfort. Review of the physician's orders [REDACTED]. Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. For each administration, the documentation included that the medication was effective. An interview was conducted with resident #397 on 9/30/19 at 11:30 a.m. The resident stated that her pain was not being controlled since admission. The resident stated they were giving her pain medicine, but it was not helping. The resident stated she told the nurses and they told her that she would have to wait for the physician to come in for different pain medication. Further review of the (MONTH) 2019 MAR indicated [REDACTED]. There was no clinical record documentation that the physician/nurse practitioner had been called regarding the resident's ongoing pain. According to the (MONTH) 2019 MAR, the resident was given [MEDICATION NAME]/[MEDICATION NAME] 7.5-325 mg, two tablets at 1 a.m. for a pain level of 5 and at 5:03 a.m. for a pain level of 5. Another interview with resident #397 was conducted on 10/1/19 at 10:00 a.m. and she stated that her physician had come in to see her and was changing the pain medication. Review of the physician orders [REDACTED]. An interview with a licensed practical nurse (LPN/staff #69) was conducted on 10/2/19 at 11:17 a.m. Staff #69 said when the nurses call the physicians on-call in the evening, they will not change the pain medication orders and are told to wait until the regular physician sees the resident. She stated not everyone documents that in the record. During an interview with a LPN (staff #34) on 10/3/19 at 9:15 a.m., he stated that he has called physicians and they don't want to change the pain medication and have been told to wait until the attending physician comes in to see the resident. He said they tell the residents that they must wait for their physician to see them. An interview with the Director of Nursing (DON/staff #171) was conducted on 10/3/19 at 9:33 a.m. Staff #171 stated her expectation is that if a resident's pain medication is not effective, the resident's physician should be called. Staff #171 said if the physician does not change the medication or respond to the information that the medication was ineffective, the nurse should call her and she will call the Medical Director. Staff #171 said that she expects the nurses to document calls to the physicians. Staff #171 stated that she had no information regarding resident #397's pain medication not being effective. Another interview was conducted with resident #397 on 10/3/19 at 9:57 a.m. The resident was lying in bed with two ice packs on both of her knees, as she said she was having pain. The resident confirmed that on 9/30/19 she was in pain and the pain medication was ineffective and that she was told by the nurses that she would have to wait until her physician came in to see her regarding a change in pain medication. A review of the facility's Pain Management policy and procedure revised in (MONTH) (YEAR) revealed to provide an environment and programs that assist each resident to maintain their highest practicable physical, mental and psychosocial well being. Residents are provided and receive the care and services needed according to established practice guidelines. Resident's pain is assessed and managed by an interdisciplinary team who work together to achieve the highest practicable outcome. Further the policy included to consult physician for additional interventions if pain is not relieved by currently ordered treatment modalities and comfort measures.",2020-09-01
572,CITADEL POST ACUTE,35103,5121 EAST BROADWAY ROAD,MESA,AZ,85206,2019-10-03,755,D,0,1,I4KK11,"Based on review of facility documentation, staff interviews and manufacturer's recommendations, the facility failed to ensure corrective action was implemented after performing a control solution test on one blood glucose monitor, when the results were outside of the recommended ranges. The deficient practice could result in inaccurate blood glucose readings. Findings include: Review of the Quality Control Record for (MONTH) 2019 for the glucometer on the 200 hall revealed sections to document that the glucometer was tested daily. This form included sections to document the normal control range and the test result and the high control range and the test result. Further review of this form revealed the control solution test for the glucometer was done on (MONTH) 2. The normal control range on the Control Record was 85-106 milligrams per deciliter (mg/dL). However, the result of the normal control test was documented at 134 mg/dL, which was outside of the normal control range. There was no evidence of any corrective action which was taken as a result of the control solution test result being outside of the normal parameters. According to the directions on the control solution bottle, the normal control range was 85-106 mg/dl. Review of the Medication Administration Record [REDACTED]. An interview was conducted on (MONTH) 2, 2019 at 10:42 a.m. with the 200 hall nurse (Licensed Practical Nurse/staff #141). She stated the blood glucose monitor control testing is completed by the night shift nurses. She stated that she had taken the blood sugars of eight residents that morning. An interview was conducted on (MONTH) 3, 2019 at 8:33 a.m., with the Director of Nursing (DON/staff #171). She stated that she expects the nurses to perform the control solution test on the blood glucose monitors correctly and make sure they are in the normal range. The DON said if the glucose monitor results are not in range, the nurses are expected to retest the monitor and discard it if it is still malfunctioning. Review of the manufacturer's user instruction manual for performing a control solution test revealed the control range should fall between the guidelines on the control solution bottle. The policy included that the monitor should not be used if the control solution result is out of range.",2020-09-01
573,CITADEL POST ACUTE,35103,5121 EAST BROADWAY ROAD,MESA,AZ,85206,2019-10-03,880,D,0,1,I4KK11,"Based on observations, staff interview and policy review, the facility failed to implement infection control procedures for the handling of clean and soiled clothing and linens. The deficient practice could result in the spread of infection. Findings include: An observation was conducted on (MONTH) 3, 2019 at 8:25 a.m., of the facility's laundry services. At this time, a laundry staff member (staff #84) was in the clean laundry area. In the clean laundry area was a cart which was piled with clean resident clothing. On top of the clean resident clothing was staff #84's lunch bag and a paper plate with a wrapped burrito. Staff #84 was observed transferring the burrito from the paper plate into her lunch bag and then put the lunch bag on a shelf by the wall. Staff #84 stated that the pile of laundry that she had her food on was clean laundry and she shouldn't have food on top of the clean laundry. During another observation conducted on (MONTH) 3, 2019 at 9:14 a.m., staff #84 was observed with gloves on and had on a cotton patient gown with sleeves that came above her elbows. Staff #84 then pulled a red isolation bin to the washing machine and took a yellow bag out and placed it in the washer. She then tore the yellow bag open and removed all of the soiled clothing and linens. During this process, her arms were exposed from the elbows to her wrists and they were touching the soiled laundry. After this, staff #84 proceeded to untie her gown with the dirty gloves on. As she was trying to untie the gown, she touched the back of her neck and her clothing with the dirty gloves. Once the gown was untied, she removed it and put it in the washer and then removed the dirty gloves and washed her hands. Staff #84 stated that her arms above the wrist were touching the dirty isolation laundry and that dirty isolation laundry should always be handled with gloves and should not be touching bare skin. An interview was conducted on (MONTH) 3, 2019, at 10:35 a.m. with the Director of Nursing (DON/ staff #171), who stated the laundry staff member should have been wearing a yellow gown that has full sleeves when sorting and loading the dirty laundry, so that the dirty clothes are not touching the skin. Review of a policy titled, Infection Prevention and Control Program revealed to implement infection control measures to prevent the spread of communicable diseases and conditions. Standard precautions including contact precautions include putting gloves on immediately before anticipated contact with non-intact skin or blood and other body fluids or when touching surfaces soiled with blood or other body fluids. Remove gloves when the specific task is completed and wash hands immediately. The policy also stated to wear gowns when it is anticipated that there would be contact with blood or other body fluids or soiled surfaces. For linens, the policy stated that all contaminated linens should be handled appropriately whether their source was an isolation room or non-isolation room. All linens should be handled as if it were highly infectious. Healthcare workers play an important role in reducing the potential for transmission of infectious microorganisms.",2020-09-01
574,SHEA POST ACUTE REHABILITATION CENTER,35105,11150 NORTH 92ND STREET,SCOTTSDALE,AZ,85260,2017-07-19,253,E,0,1,M5YE11,"Based on observations, staff and resident interviews, facility documentation and policy review, the facility failed to ensure resident rooms were safe and in good repair. Findings include: An observation of the bathroom in room #312 was conducted on (MONTH) 17, (YEAR) at 9:09 a.m. and the hot water faucet handle in the bathroom was stuck and would not turn. At this same time, the bathroom in room #206 had a towel bar which was missing. The supports for the towel bar were on the wall, however, they were very loose. An observation was conducted on (MONTH) 17, (YEAR) at 9:32 a.m., of the bathroom in room #213. The towel bar was missing and the supports for the towel bar were on the wall, but were very loose. An observation of room #306 was conducted on (MONTH) 17, (YEAR) at 9:58 a.m. In the room, there were multiple 18 inch square boxes which were stacked approximately 3 1/2 feet high. The boxes were against the wall by the head of a resident's bed and appeared to be unsteady. In addition, the stack of boxes partially blocked the wall plate where the resident's call light was attached to the bed and the call light cord was bent behind the boxes. During an observation of the bathroom in room #313 on (MONTH) 17, (YEAR) at 10:54 a.m., the handle on the hot water faucet was broken. The handle was clear plastic and approximately 25% of the plastic was broken off, leaving the stem of the handle exposed, with jagged plastic edges on each side of the opened area. During the environmental tour conducted on (MONTH) 18, (YEAR) at 1:30 p.m. with the Administrator (staff #129), Maintenance Supervisor (staff#14), Housekeeping Supervisor (staff#138) and Corporate Facility Resource (staff #139), the broken items listed above in the resident rooms remained unrepaired. In addition, the unsteady stack of boxes in room #306 were still present. At this time, staff #14 and staff #139 both stated that the call light cord which was behind the boxes was unsafe, as pulling on the cord could cause the stack of boxes to fall over. An interview was conducted on (MONTH) 18, (YEAR) at 1:45 p.m. with a resident from room #213, who stated the towel bar fell out about a month ago. In an interview conducted on (MONTH) 18, (YEAR) at 1:50 p.m. with staff #138, he stated that when housekeepers find something in need of repair they are to inform him, so a repair request can be made in the electronic report system. In an interview with staff #139 conducted on (MONTH) 18, (YEAR) at 2:01 p.m., staff #139 stated that any staff member can enter a report in the electronic system regarding a repair that is needed. Staff #139 further stated the electronic system was a new system installed several months ago and staff have been getting trained on using the system. Review of the repair work orders from (MONTH) 18, (YEAR) to (MONTH) 18, (YEAR), revealed there were no work orders for any of the broken items. Review of the staff meeting agenda and sign-in sheets from February, March, (MONTH) and (MONTH) (YEAR), revealed the topic of using the electronic system for repairs was discussed at each staff meeting. The information discussed included that all repair needs must be inputted into the system to inform maintenance that repairs are needed. The information also included that all computers and wall kiosks are equipped to be able to enter the repair orders.",2020-09-01
575,SHEA POST ACUTE REHABILITATION CENTER,35105,11150 NORTH 92ND STREET,SCOTTSDALE,AZ,85260,2017-07-19,281,E,1,1,M5YE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on closed clinical record review and staff interview, the facility failed to ensure that nursing services met professional standards of quality, by failing to ensure that one resident (#215) did not receive medication to which he was allergic. Findings include: Resident #215 was admitted on (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. Review of a physician's History and Physical dated (MONTH) 15, (YEAR), revealed the resident had been in the hospital prior to admission, and had been treated for [REDACTED]. The documentation also included that the resident had an allergy to [MEDICATION NAME] ([MEDICATION NAME]/benzodiazepine). Review of the (MONTH) (YEAR) MAR (Medication Administration Record) revealed a section to list the resident's allergies [REDACTED]. A nurses note dated (MONTH) 8, (YEAR) at 12:05 a.m. documented that resident #215 was extremely agitated, refused to go to his room, had become aggressive, combative and was yelling. The physician was contacted and an order was obtained to administer [MEDICATION NAME]. A physician's orders [REDACTED]. Another physician's orders [REDACTED]. Review of the (MONTH) (YEAR) MAR indicated [REDACTED] (MONTH) 8: -1 mg by mouth at 10:00 p.m. -1 mg intramuscularly at 11:05 p.m. -1 mg by mouth at 1:13 a.m. August 9: -1 mg by mouth at 2:00 p.m. -1 mg by mouth at 10:00 p.m. During an interview conducted on (MONTH) 19, (YEAR) at 11:00 a.m. with the DON (Director of Nursing/staff #130), she stated that resident #215 had received [MEDICATION NAME] even though there was clear documentation in the clinical record that the resident was allergic to it. The DON stated the nurse should have clarified the allergy with the physician, prior to giving the medication. The DON was unable to provide any documentation that the allergy to [MEDICATION NAME] had been clarified with the physician, prior to administering the medication.",2020-09-01
576,SHEA POST ACUTE REHABILITATION CENTER,35105,11150 NORTH 92ND STREET,SCOTTSDALE,AZ,85260,2017-07-19,356,B,0,1,M5YE11,"Based on observations, staff interview and review of policy and procedures, the facility failed to ensure that the Nurse Staffing Information was posted on a daily basis and contained the resident census. Findings include: An observation was conducted on (MONTH) 16, (YEAR) at 9:00 a.m., of the posted Nurse Staffing Information. The information posted was for (MONTH) 14, (YEAR). There was no Nurse Staffing Information for (MONTH) 15 or (MONTH) 16. Multiple observations were conducted on (MONTH) 17, (YEAR), of the posted Nurse Staffing Information. The information was dated (MONTH) 17, (YEAR), however, it did not contain the resident census. During an interview conducted on (MONTH) 18, (YEAR) at 3:20 p.m. with the DON (Director of Nursing/staff #130), she stated that the Nurse staffing Information is posted Monday through Friday, but it is not posted on Saturday or Sunday. Multiple observations were conducted on (MONTH) 19, (YEAR), of the posted Nurse Staffing Information. The information was dated (MONTH) 19, (YEAR), however, it did not contain the resident census. Review of a facility policy and procedure titled, Staffing, Numbers, Posting revealed It is the policy of this facility to post staffing numbers. The policy did not include that the Nurse Staffing Information was required to be posted on a daily basis, or that the information had to contain the resident census.",2020-09-01
577,SHEA POST ACUTE REHABILITATION CENTER,35105,11150 NORTH 92ND STREET,SCOTTSDALE,AZ,85260,2017-07-19,371,E,0,1,M5YE11,"Based on observations, facility documentation, staff interviews and review of policies and procedures, the facility failed to ensure that kitchen logs were completed accurately, that hair restraints were utilized during food service, that meat was properly covered in the refrigerator and that multiple food items in the refrigerator were labeled and dated. Findings include: An observation of the kitchen was conducted on (MONTH) 16, (YEAR) at 8:10 a.m. At this time, a cook (staff #114) was observed plating food behind a steam table. Staff #114 was not wearing a hair covering over his full beard or on his head. During an interview with staff #114 on (MONTH) 16, (YEAR) at 11:30 a.m., he stated that he was required to wear a hair restraint that covered his beard and head. Review of a facility policy and procedure titled, Food Safety and Sanitation revealed that hair restraints are required and should cover all the hair on the head, and[NAME]nets are required when facial hair is visible. Additional observations in the kitchen at this same time revealed the following food items were stored in the refrigerator: -A 10 lb carton of boiled eggs and a carton of half and half were stored on a shelf. The boiled eggs were not dated and the half and half had been opened, but was not dated. During an interview with staff #114 on (MONTH) 16, (YEAR) at 8:30 a.m., staff #114 stated that he did not know when the carton of half and half had been opened, and that the containers were supposed to be dated when opened. -A large metal pan containing 13 pieces of cooked meat had a lid on the pan, however, the lid did not completely cover the meat, which left a gap. The exposed meat appeared to be dried out. During an interview on (MONTH) 16, (YEAR) at 8:30 a.m., a dietary aide (staff #64) stated that the pan of meat had been cooked the day before and the lid on the pan should have been placed to cover the meat. Review of a facility policy and procedure for refrigerated food storage revealed that All foods should be covered, labeled and dated. All foods will be checked to ensure that foods .will be consumed by their safe use by dates, .or discarded. -On the top shelf of the refrigerator there was a partially eaten burrito wrapped in tin foil, a carry out container with items inside including pizza slices and pieces of chicken, and a partially opened bottle of Gatorade. The items were not labeled or dated and were among other food items. During an interview with staff member #114 on (MONTH) 16, (YEAR) at 8:30 a.m., staff #114 stated that the burrito, the food in the carry out container, and the bottle of Gatorade were not resident food items and were not supposed to be in the refrigerator. A facility policy titled, Food Storage contained the statement that Food is stored .by methods to prevent contamination, or cross contamination. During this same kitchen observation, the kitchen logs were reviewed on (MONTH) 16, (YEAR) at 8:30 a.m., and revealed the following entries: -A kitchen log titled Food Temperature Log for (MONTH) (YEAR) included documentation of recorded food temperatures for breakfast, lunch and dinner on (MONTH) 16, and there were food temperatures for breakfast on tomorrow's date (July 17). -A kitchen log titled Walk-in Freezer and Walk-in Refrigerator temperature log for (MONTH) (YEAR), contained freezer and refrigerator temperatures, which had been recorded for the AM and PM on (MONTH) 16, and for the AM on (MONTH) 17. The entries were initialed. -A kitchen log titled Dishwashing Machine Temperature Log for (MONTH) (YEAR) contained recorded temperatures for the wash, rinse and surface temperatures for the morning and afternoon on (MONTH) 16, and for the morning and afternoon on (MONTH) 17. The entries were initialed. -A kitchen log titled Three Compartment Sink Log for (MONTH) (YEAR) contained written results for the testing of the sanitizer solution concentration used in the three compartment sink for 4:30 a.m. and 3:30 p.m. on (MONTH) 16, and for tomorrow's date (July 17) at 5:30 a.m. During an interview conducted on (MONTH) 16, (YEAR) at 10:30 a.m., the Kitchen Manager (staff #7) did not know why the logs had been filled in ahead of time. The kitchen logs were again reviewed on (MONTH) 17, (YEAR) at 1:40 p.m., and the logs contained the same temperatures which had been filled in ahead of time for (MONTH) 16 and 17. Another interview was conducted with staff #7 on (MONTH) 17, (YEAR) at 1:40 p.m. Staff #7 stated that all food temperatures, dishwasher temperatures and other items that are recorded on the kitchen logs had been checked for the afternoon of (MONTH) 16, (YEAR), and the morning of (MONTH) 17, (YEAR) and that all of the data was exactly the same as the data that had been previously recorded the day before. The manager stated that because the data was exactly the same, there was no deed to update the kitchen logs with the current data. During another interview with staff #114 on (MONTH) 18, (YEAR) at 12:30 p.m., staff #114 stated that he did not record the temperatures listed on the Food Temperature Logs for (MONTH) 16 or (MONTH) 17. He stated that the entries on the logs had been recorded by the Kitchen Manager (staff #7). He was unable to explain how the logs contained entries for future dates and times. During an interview with staff #7 on (MONTH) 18, (YEAR) at 9:45 a.m., staff #7 stated that he had filled in the kitchen logs on the evening of (MONTH) 15, (YEAR), for (MONTH) 16 and 17. A facility policy and procedure titled, Food Temperatures included The temperatures of the food items will be taken and properly recorded for each meal. A facility policy titled, Freezer and Refrigerator Temperatures included to Record both internal and external temperatures of freezers and refrigerators at least twice a day (approximately 6:00 AM and 7:00 PM). Review of a policy titled, Dish Machine Temperature Log revealed Dishwashing staff will monitor and record dish machine temperatures to assure proper sanitizing of dishes. A policy and procedure titled, Cleaning Dishes-Manual Dishwashing included Dishes and cookware will be washed after each meal to assure that all dishes are clean and sanitary and Check sanitation sink often using a test strip to assure the level of sanitizing solution is appropriate. Review of a policy titled, Food Safety and Sanitation revealed that ALL local, state and federal standards and regulations are followed in order to assure a safe and sanitary food service department.",2020-09-01
578,SHEA POST ACUTE REHABILITATION CENTER,35105,11150 NORTH 92ND STREET,SCOTTSDALE,AZ,85260,2017-07-19,493,D,0,1,M5YE11,"Based on review of facility documentation, staff interview and policy and procedures, the facility failed to ensure that the governing body that is legally responsible for establishing and implementing policies regarding the management and operation of the facility, ensured that one dietary staff had a current food handler's permit. Findings include: Review of the dietary records revealed that one dietary aide (staff #34) had a hire date of (MONTH) 4, (YEAR). There was no documentation that staff #34 had a food handler's permit on record. Review of the scheduling records for (MONTH) (YEAR) for staff #34 revealed that staff #34 had worked eight shifts, after the deadline had passed to obtain a food handlers permit (30 days past the date of hire per facility policy). During an interview with the Human Resource manager (staff #133) on (MONTH) 17, (YEAR) at 1:00 p.m., the manager stated that food handler permits were required for dietary staff to work in the kitchen and that dietary staff cannot work in the kitchen, unless they have a valid permit. The manager stated that if staff do not have a valid permit, the staff member is removed from duty until a permit is obtained. The manager stated that she was unable to locate a food handlers card for staff #34. Review of a facility policy and procedure titled, Food Handler's Permit revealed that All dietary employees are required to possess a food handler's permit. The policy included that newly hired (dietary) employees have 30 days from the date of hire to obtain a food handler's permit and that copies of the permits are posted in the employee file and the dietary office, where it is readily visible. The policy further included that the dietary manager is responsible for ensuring all permits are current.",2020-09-01
579,SHEA POST ACUTE REHABILITATION CENTER,35105,11150 NORTH 92ND STREET,SCOTTSDALE,AZ,85260,2018-10-15,607,D,1,1,F7JV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, and policy review, the facility failed to ensure policies and procedures were implemented related to an injury of unknown source for one resident (#284). Findings include: Resident #284 was readmitted to the facility on (MONTH) 2, (YEAR), with [DIAGNOSES REDACTED]. The resident was discharged on (MONTH) 1, (YEAR). Review of the end of therapy Minimum Data Set (MDS) assessment dated (MONTH) 23, (YEAR), revealed the resident scored an 8 on the Brief Interview for Mental Status (BIMS), indicating the resident had moderate cognitive impairment. Per the MDS assessment, the resident required extensive assistance for most activities of daily living. A change of condition note dated (MONTH) 31, (YEAR) at 7:32 a.m. revealed the resident was found on the floor of his room, confused and disoriented to time, place, person, and situation. The note included the resident sustained [REDACTED]. A nursing note dated (MONTH) 1, (YEAR) at 12:19 a.m. revealed the resident had a red area on his right forehead, two skin tears to the right arm, and was restless. Per the documentation, the resident was placed in bed after a.m. change of shift and about one hour later was crawling on the floor. Further review revealed the resident was pulling at his Foley catheter and was confused, asking if he had school tomorrow and was attempting to get out of bed. Review of a nursing note dated (MONTH) 1, (YEAR) at 4:01 a.m. revealed the resident had a second abrasion to the right elbow and a bump with redness to the right side of his forehead. The note included the resident was confused and disoriented. A change of condition note dated (MONTH) 1, (YEAR) at 9:41 p.m. revealed the resident was transported to the hospital for a head scan due to a fall, which left a laceration to his right eyebrow. Review of the hospital computed tomography (CT) scan of the brain dated (MONTH) 1, (YEAR) revealed the resident sustained [REDACTED]. However, no evidence was found that an investigation was conducted or that the results of the investigation were submitted to the State Agency. There was also no evidence that the injury of unknown source was reported to the required agencies. An interview was conducted on (MONTH) 12, (YEAR) at 8:30 a.m. with a registered nurse (RN/staff #56). Staff #56 stated that if a resident sustained [REDACTED]. The RN stated that she would notify the Director of Nursing (DON) as soon as possible and that the DON would conduct an investigation and notify the State Agency and the police. During an interview conducted on (MONTH) 12, (YEAR) at 8:40 a.m. with a RN (staff #27), staff #27 stated that for an injury of unknown source, the nurse would review the clinical record to determine what occurred. The RN stated that the DON or Administrator would be notified immediately and the abuse coordinator would conduct an investigation. An interview was conducted on (MONTH) 12, (YEAR) at 9:47 a.m. with the Administrator (staff #122) and the DON (staff #119). The DON stated that if an injury is truly an injury of unknown origin, the injury would be reported to the state agency. The DON stated that the criteria for an injury of unknown source can include when a resident has an unwitnessed fall resulting in a fracture (injury). She stated that the expectation is that an injury of an unknown source would be investigated. During an interview conducted on (MONTH) 12, (YEAR) at 10:43 a.m. with the Director of Nursing (DON/staff #119), she stated that an investigation was not done related to the resident's injury. Review of the facility's policy titled Abuse Prevention revealed that each resident has the right to be free from abuse and neglect. The policy included identifying events such as but not limited to, suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse. The policy included bruises, skin tears, and injuries of unknown source will be investigated to rule out abuse. Per the policy, all alleged violation or identified events are reported to the Administrator or designee immediately and will be thoroughly investigated. The policy revealed that when an incident or allegation of resident abuse or injury of an unknown source is identified, the administrator/designee will initiate an investigation. The policy also included all alleged violations will be reported within 24 hours to the State Agency, and the follow up results of the investigation will be submitted to the State Agency within the required timeframe per state and federal regulations. However, the regulation requires that all alleged violations involving abuse, neglect and an injury of unknown source be reported to the State Agency within two hours.",2020-09-01
580,SHEA POST ACUTE REHABILITATION CENTER,35105,11150 NORTH 92ND STREET,SCOTTSDALE,AZ,85260,2018-10-15,609,D,1,1,F7JV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews and policy review, the facility failed to ensure an injury of unknown source was reported to the State Agency for one resident (#284). Findings include: Resident #284 was readmitted to the facility on (MONTH) 2, (YEAR), with [DIAGNOSES REDACTED]. The resident was discharged on (MONTH) 1, (YEAR). A change of condition note dated (MONTH) 31, (YEAR) at 7:32 a.m. revealed the resident was found on the floor of his room, confused and disoriented to time, place, person, and situation. The note included the resident sustained [REDACTED]. A nursing note dated (MONTH) 1, (YEAR) at 12:19 a.m. revealed the resident had a red area on his right forehead, two skin tears to the right arm and was restless. Per documentation, the resident was placed in bed after a.m. change of shift and about one hour later was crawling on the floor. Further review revealed the resident was pulling at his Foley catheter and was confused, asking if he had school tomorrow and attempting to get out of bed. Review of a nursing note dated (MONTH) 1, (YEAR) at 4:01 a.m. revealed the resident had a second abrasion to the right elbow and a bump with redness to the right side of his forehead. The note included the resident was confused and disoriented. A change of condition note dated (MONTH) 1, (YEAR) at 9:41 p.m. revealed the resident was transported to the hospital for a head scan due to a fall, which left a laceration to his right eyebrow. Review of the hospital computed tomography (CT) scan of the brain dated (MONTH) 1, (YEAR) revealed the resident sustained [REDACTED]. No evidence was found that the injury of unknown source was reported to the State Agency. An interview was conducted on (MONTH) 12, (YEAR) at 8:30 a.m. with a registered nurse (RN/staff #56). Staff #56 stated that if a resident sustained [REDACTED]. An interview was conducted on (MONTH) 12, (YEAR) at 9:47 a.m. with the Administrator (staff #122) and the DON (staff #119). The DON stated that if an injury is truly an injury of unknown origin, the injury would be reported to the State Agency. The DON stated that the criteria for an injury of unknown source can include when a resident has an unwitnessed fall resulting in a fracture (injury). Review of the facility's policy titled Abuse Prevention revealed that when an incident or allegation of resident abuse or injury of an unknown source is identified, the administrator/designee will initiate an investigation. The policy also included that all alleged violations will be reported within 24 hours to the State Agency. However, the regulation requires that all alleged violations involving abuse, neglect and an injury of unknown source be reported to the State Agency within two hours.",2020-09-01
581,SHEA POST ACUTE REHABILITATION CENTER,35105,11150 NORTH 92ND STREET,SCOTTSDALE,AZ,85260,2018-10-15,610,D,1,1,F7JV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews and policy review, the facility failed to ensure an injury of unknown source was thoroughly investigated and the results of the investigation were reported to the State Agency for one resident (#284). Findings include: Resident #284 was readmitted to the facility on (MONTH) 2, (YEAR), with [DIAGNOSES REDACTED]. The resident was discharged on (MONTH) 1, (YEAR). A change of condition note dated (MONTH) 31, (YEAR) at 7:32 a.m. revealed the resident was found on the floor of his room and was confused and disoriented to time, place, person, and situation. The note included the resident sustained [REDACTED]. A nursing note dated (MONTH) 1, (YEAR) at 12:19 a.m. revealed the resident had a red area on his right forehead, two skin tears to the right arm, and was restless. Per documentation, the resident was placed in bed after a.m. change of shift and about one hour later was crawling on the floor. Further review revealed the resident was pulling at his Foley catheter and was confused, asking if he had school tomorrow and attempting to get out of bed. Review of a nursing note dated (MONTH) 1, (YEAR) at 4:01 a.m. revealed the resident had a second abrasion to the right elbow and a bump with redness to the right side of his forehead. The note included the resident was confused and disoriented. A change of condition note dated (MONTH) 1, (YEAR) at 9:41 p.m. revealed the resident was transported to the hospital for a head scan due to a fall which left a laceration to his right eyebrow. Review of the hospital computed tomography (CT) scan of the brain dated (MONTH) 1, (YEAR) revealed the resident sustained [REDACTED]. However, no evidence was found that an investigation was conducted regarding the injury of unknown source. An interview was conducted on (MONTH) 12, (YEAR) at 8:30 a.m. with a registered nurse (RN/staff #56). Staff #56 stated that if a resident sustained [REDACTED]. An interview was conducted on (MONTH) 12, (YEAR) at 8:40 a.m. with a RN (staff #27), who stated that for an injury of an unknown source, the DON or Administrator would be notified immediately and the abuse coordinator would conduct an investigation. An interview was conducted on (MONTH) 12, (YEAR) at 9:47 a.m. with the Administrator (staff #122) and the DON (staff #119). The DON stated that the criteria for an injury of unknown source can include when a resident has an unwitnessed fall resulting in a fracture (injury). She stated that the expectation is that an injury of an unknown source would be investigated. During an interview conducted on (MONTH) 12, (YEAR) at 10:43 a.m. with the DON, she stated that there was not an investigation related to the resident's injury. Review of the facility's policy titled Abuse Prevention revealed that each resident has the right to be free from abuse and neglect. The policy included identifying events such as but not limited to, suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse. The policy included bruises, skin tears, and injuries of unknown source will be investigated to rule out abuse. Per the policy, all alleged violation or identified events will be thoroughly investigated. The policy revealed that when an incident or allegation of resident abuse or injury of an unknown source is identified, the administrator/designee will initiate an investigation.",2020-09-01
582,SHEA POST ACUTE REHABILITATION CENTER,35105,11150 NORTH 92ND STREET,SCOTTSDALE,AZ,85260,2018-10-15,655,D,0,1,F7JV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy review, the facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident (#6) which included the instructions needed to provide effective and person-centered care, and failed to provide a summary of the baseline care plans to the resident/representative. Findings include: Resident #6 was admitted to the facility on (MONTH) 11, (YEAR), with [DIAGNOSES REDACTED]. Regarding a summary of the baseline care plans: Review of the baseline care plans for the resident revealed there were care plans that addressed Hospice services, utilization of a gerichair for comfort when out of bed, bathing and pressure ulcers. The care plans included goals and interventions for each area. However, there was no documentation that a summary of the baseline care plans were provided to the resident/representative. Regarding developing baseline care plans: Review of the physician's admission orders [REDACTED] Review of the physician's orders [REDACTED].>However, review of the baseline care plans revealed there were no care plans that addressed the use of an indwelling urinary catheter, a mood disorder and the use of narcotic pain medication. During an interview conducted with the Director of Nursing (DON/staff #119) on (MONTH) 15, (YEAR), the DON stated that a baseline care plan is to be completed within 48 hours of admission. She stated that the baseline care process is started on admission by the admission nurse and assistant DON. The DON stated that the social worker schedules care conferences and invites the residents and their families to the conferences and that sometimes care conferences are conducted over the telephone. The DON further stated that a form is signed and scanned into the electronic medical record and the resident is given a copy of the baseline care plan summary. A policy titled, Comprehensive Person-Centered Care Planning revealed that the facility will develop and implement a baseline care plan within 48 hours of admission and that the baseline care plan will include the minimum healthcare information necessary to properly care for a resident which includes, but is not limited to physicians orders. The policy included that the facility will provide a written summary of the care plan to the resident or the resident's representative by the time of the completion of the comprehensive care plan.",2020-09-01
583,SHEA POST ACUTE REHABILITATION CENTER,35105,11150 NORTH 92ND STREET,SCOTTSDALE,AZ,85260,2018-10-15,658,E,1,1,F7JV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff and resident interviews, and policies and procedures, the facility failed to ensure services provided met professional standards of quality for seven residents (#s 13, 34, 40, 46, 69, 284 and 484). Findings include: -Resident #34 was admitted on (MONTH) 29, (YEAR), with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Cetritzine 10 mg (milligrams) po (by mouth) qd (every day) for seasonal allergies [REDACTED].>[MEDICATION NAME] Powder 17 gm (grams) po qd for bowel care; Multivitamin with minerals 1 po qd as a supplement; [MEDICATION NAME] Chloride ER (extended release) 10 mg po qd for urinary incontinence; [MEDICATION NAME] Nebulization 1 unit inhaled via nebulizer bid (twice a day) for congestion and shortness of breath; [MEDICATION NAME] Suspension 1 mg inhaled bid for shortness of breath; Med Pass 2.0 4 oz (ounces) bid as a dietary supplement; [MEDICATION NAME] 2.5 mg po bid for [MEDICAL CONDITION]; [MEDICATION NAME] 50 mg po q 8 hours for pain; and Tylenol 325 mg 2 po tid (three times a day) for pain. A review of the resident's care plan revealed that the resident had [MEDICAL CONDITION] and chronic pain, and that medications were to be administered as ordered. Review of the Medication Administration Record (MAR) for (MONTH) (YEAR) revealed the following: 3 occasions with no documentation that the Cetritzine, [MEDICATION NAME], Multivitamin with minerals, [MEDICATION NAME] was administered; 5 occasions with no documentation that the [MEDICATION NAME] was administered; 6 occasions with no documentation that the Tylenol was administered;16 occasions with no documentation that the Med Pass was administered; and 20 occasions with no documentation that the [MEDICATION NAME] was administered. Review of the MAR for (MONTH) (YEAR) revealed the following: 3 occasions with no documentation that the [MEDICATION NAME] was administered; 5 occasions with no documentation that the Med Pass was administered; and 8 occasions with no documentation that the [MEDICATION NAME] was administered. Review of the MAR for (MONTH) (YEAR) revealed the following: 9 occasions with no documentation that the Med Pass was administered; 12 occasions with no documentation that the [MEDICATION NAME] was administered. -Resident #40 was admitted (MONTH) 8, (YEAR) and readmitted on (MONTH) 6, (YEAR), with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Multivitamin with minerals 1 po qd as a supplement; Nuplazid 17 mg 2 po qd for [MEDICAL CONDITIONS]; [MEDICATION NAME] 25 mg po qd for depression; Vitamin B1 100 gm po qd as a dietary supplement; [MEDICATION NAME] 2 mg po bid for muscle spasms; [MEDICATION NAME]-Salmeterol Aerosol 250/50 mcg (micrograms) 1 puff inhaled bid for wheezing; Med Pass 2 oz po bid as a dietary supplement; [MEDICATION NAME] Sodium DR (delayed release) 500 mg po tid for mood disorder; Pregabalin 50 mg po q 8 hours for [MEDICAL CONDITION]; [MEDICATION NAME]-[MEDICATION NAME] 25/100 mg 1 po q 6 hours for [MEDICAL CONDITION]; and [MEDICATION NAME] Nebulization 3 ml (milliliters) inhaled via nebulizer every 2 hours for shortness of breath and wheezing. A review of the resident's clinical record revealed care plans for chronic pain and [MEDICAL CONDITION] and related symptoms. The care plans included the medications were to be administered per orders. Review of the MAR for (MONTH) (YEAR) revealed the following: 1 occasion with no documentation that the Multivitamin with minerals, Nuplazid, [MEDICATION NAME], Vitamin B1, [MEDICATION NAME], and [MEDICATION NAME]-Salmeterol was administered; 3 occasions with no documentation that the Med Pass was administered; 5 occasions with no documentation that the [MEDICATION NAME]-[MEDICATION NAME] was administered; 17 occasions with no documentation that the Pregabalin and [MEDICATION NAME] was administered; and 19 occasions with no documentation that the [MEDICATION NAME] was administered. Review of the MAR for (MONTH) (YEAR) revealed the following: 2 occasions with no documentation that the Med Pass was administered; 4 occasions with no documentation that the [MEDICATION NAME]-[MEDICATION NAME] was administered; 11 occasions with no documentation that the [MEDICATION NAME] was administered; 12 occasions with no documentation that the [MEDICATION NAME] was administered; and 13 occasions with no documentation that the Pregabalin was administered. Review of the MAR for (MONTH) (YEAR) revealed the following: one occasion with no documentation that the [MEDICATION NAME]-[MEDICATION NAME] was administered; 4 occasions with no documentation that the Med Pass was administered; and 7 occasions with no documentation that the [MEDICATION NAME], and Pregabalin was administered. An interview was conducted with a LPN (Licensed Practical Nurse/staff #31) on (MONTH) 14, (YEAR) at 12:00 p.m. Staff #31 stated that the nurse is to document administrations of medications in the EMAR (Electronic Medication Administration Record). Staff #31 stated the undocumented medications will flag the nurse for documentation, but does not freeze up the EMAR and that the nurses can leave at the end of their shift without completing the documentation. Staff #31 stated that the nurses are to sign a sheet of paper at the end of their shift to state their documentation was complete at the end of the shift. The LPN stated the sheet is given to the DON (Director of Nursing) for review. Staff #31 further stated the on-coming nurse is to audit the previous shifts MAR for documentation and remind the previous shift nurse to complete the documentation before leaving. The LPN stated that this does not always happen. An interview was conducted with the DON (staff #119) on (MONTH) 15, (YEAR) at 12:14 p.m. Staff #119 stated that nurses are to sign off at the end of their shift that they have completed their documentation on the MAR and TAR (Treatment Administration Record). After reviewing the (MONTH) (YEAR) MAR for resident #34, staff #119 stated that obviously it was not being done. Staff #119 further stated that no nursing administrative staff were auditing the MARs and TARS. The DON stated that she had delegated the auditing to the nurses. -Resident #13 was admitted on (MONTH) 9, (YEAR) with [DIAGNOSES REDACTED]. A review of the annual Minimum Data Set assessment dated (MONTH) 23, (YEAR) revealed the resident had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. The MDS assessment also revealed the resident received scheduled and as needed (PRN) pain medication and that she reported she had occasional pain at a level 4 which did not limit her day to day activities or sleep. A review of the resident's care plan revealed that the resident had pain related to generalized pain and muscle spasms with interventions that included to administer pain medications as ordered. A review of the physician's orders [REDACTED]. [MEDICATION NAME] Tablet 10 mg 1 tablet by mouth every 8 hours for muscle spasms ordered (MONTH) 26, (YEAR). [MEDICATION NAME] Capsule 300 milligrams (mg) 1 capsule by mouth every 8 hours for muscle spasms ordered (MONTH) 26, (YEAR) and discontinued on (MONTH) 10, (YEAR). [MEDICATION NAME] Capsule 300 mg 1 capsule by mouth two times a day for muscle spasms ordered (MONTH) 10, (YEAR). A review of the Medication Administration Record (MAR) for (MONTH) (YEAR) revealed 17 occasions with no documentation that [MEDICATION NAME] and [MEDICATION NAME] was administered; A review of the MAR for (MONTH) (YEAR) revealed 19 occasions with no documentation that [MEDICATION NAME] and [MEDICATION NAME] was administered. A review of the MAR for (MONTH) (YEAR) revealed 17 occasions with no documentation that [MEDICATION NAME] and [MEDICATION NAME] was administered. A review of the MAR for (MONTH) (YEAR) revealed 8 occasions with no documentation that [MEDICATION NAME] was administered and 6 occasions with no documentation that [MEDICATION NAME] was administered. Review of the Progress Notes from (MONTH) 1, (YEAR) through (MONTH) 14, (YEAR) revealed no documentation regarding the [MEDICATION NAME] or [MEDICATION NAME] administration. During an interview conducted on (MONTH) 11, (YEAR) at 9:45 a.m., resident #13 stated that occasionally she does not receive her regularly scheduled medications; however, she was unable to state a specific instance of which medication she did not receive or a specific date or time. An interview was conducted on (MONTH) 15, (YEAR) at 12:03 PM with a Licensed Practical Nurse (LPN/staff #31). The LPN stated that the nurses are not supposed to leave blanks on the MAR and that it is possible to close the MAR without documenting. She also stated that the nurses are supposed to audit their documentation at the change of shift and sign a sheet every day that states that they have completed all MAR documentation for their shift. In an interview on (MONTH) 15, (YEAR) at 1:34 p.m., staff #119 stated that the nurses are not supposed to leave blanks on the MAR. She stated that the nurses are responsible for auditing their documentation at the change of shift and that they are to sign a sheet every day that states that they have completed all MAR documentation for their shift. -Resident #69 was admitted on (MONTH) 12, (YEAR), with [DIAGNOSES REDACTED]. A quarterly MDS assessment dated (MONTH) 24, (YEAR) revealed the resident had a BIMS score of 14, which indicated the resident was cognitively intact. The MDS assessment also indicated the resident had frequent pain, received scheduled pain medication, and received antidepressant and narcotic medications. Review of the care plans revealed the resident has chronic pain related to [MEDICAL CONDITION] and chronic wounds. An intervention was to administer medication as ordered. Review of the physician's orders [REDACTED]. Review of the Medication Administration Record (MAR) for (MONTH) (YEAR) revealed the following: 5 occasions with no documentation that the [MEDICATION NAME] was administered; 5 occasions with no documentation that the Baclophen was administered; and 12 occasions with no documentation that the [MEDICATION NAME] was administered. Review of the (MONTH) (YEAR) MAR revealed there were 4 occasions with no documentation that the [MEDICATION NAME] was administered. A review of the (MONTH) (YEAR) MAR revealed the following: 3 occasions with no documentation that the [MEDICATION NAME] was administered; 3 occasions with no documentation that the Baclophen was administered; and 3 occasions with no documentation that the [MEDICATION NAME] was administered. Regarding the antidepressant medication: Review of the (MONTH) (YEAR) physician orders [REDACTED]. A care plan included the resident received an antidepressant medication related to depression, as evidenced by self isolation, sadness and inability to sleep. An approach included to give the antidepressant medication as ordered by the physician. Review of the (MONTH) (YEAR) MAR revealed the resident was not administered [MEDICATION NAME] from (MONTH) 19, through 29, (YEAR). The documentation included that the medication was unavailable, pending refill. In addition, there was no clinical record documentation that the physician was notified. An interview was conducted on (MONTH) 12, (YEAR) at 2:26 p.m., with a Registered Nurse (staff #60). Staff #60 stated if a medication is missing the nurse reorder it on the pharmacy website. Staff #60 said that one the website it will show if the medication has been reordered or if the order is pending. Staff #60 stated that if the medication does not come in a few days, then the pharmacy should be called to see what is going on. Staff #60 said that if a medication is not given, the reason should be written in the notes on the MAR. An interview was conducted on (MONTH) 12, (YEAR) at 2:45 p.m. with the Director of Nursing (DON/staff #119). The DON stated that according to their policy, if a medication hasn't come within 24 hours, the nurse is expected to notify her. Staff #119 said then an investigation is done to find out why the medication is not here. She stated the physician should be notified if a significant medication is missed. -Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Regarding the Medication Administration Record (MAR): Review of the recapitulation of physicians orders dated (MONTH) (YEAR), revealed an order for [REDACTED]. A review of the (MONTH) (YEAR) MAR revealed no documentation that the [MEDICATION NAME] was administered on (MONTH) 2, 5, 17, and 30, (YEAR). An interview was conducted on 10/11/2018 at 10:47 AM with a Licensed Practical Nurse (LPN/staff #56). She stated that after the resident has taken the medication, it is documented in the electronic MAR. The LPN stated that if it is not documented, this indicates that either the nurse forgot to document or that the medication was not given for some reason. She stated that if the medication is not administered, the nurse should document why. She also stated that if it is not documented, then it was not done. The LPN stated that each nurse is responsible to audit her own documentation. During an interview conducted on 10/11/18 at 13:01 p.m., staff #119 stated that her expectation is that all medications administered are to be documented. She also stated that she was unable to state why [MEDICATION NAME] was not given on the 4 days in August. The facility's policy titled Administration of Drugs revealed that only licensed nurses or other lawfully authorized staff members may prepare, administer, and record the administration of medications. The policy also included that all current drugs and dosage schedules must be recorded on the electronic medication administration record and that if a medication is withheld, refused, or given at other than the scheduled time, the documentation will be reflected in the clinical record, and if a medication is unavailable and is not administered at the scheduled time, the documentation will be reflected in the clinical record. The policy also lists the 7 rights of medication administration which includes the right documentation: document the administration or refusal of the medication after the administration or attempt and note any concerns. The policy included physician notification and other information regarding unavailable medication will be documented accordingly. A review of the facility's policy titled Pain Management revealed medications received, refused, and the response to the medication will be documented on the MAR. Regarding the skin assessments: Review of the recapitulation of physician's orders [REDACTED]. A review of the Treatment Administration Review (TAR) from (MONTH) 13, (YEAR) through the first week of (MONTH) (YEAR) revealed the skin assessments were initialed as being done every Monday. However, further review of the clinical record revealed there was no documentation that weekly skin assessments were completed from (MONTH) 18, (YEAR) through (MONTH) 8, (YEAR). A weekly skin assessment was completed on [DATE], (YEAR), after the missing assessments were brought to the nurses' attention. An interview was conducted on 10/11/18 at 10:47 a.m., with a LPN (staff #56). The LPN stated that the weekly skin evaluations are documented in the electronic record under assessments. She stated that she did not know why there were no weekly skin evaluations in the electronic record from late (MONTH) to early (MONTH) (YEAR). During an interview conducted with the wound nurse (staff #68) on 10/11/18 at 11:31 a.m., she stated that the weekly skin evaluations are under assessments in the electronic record. The wound nurse stated that the TAR is initialed to indicate that the skin evaluations are completed. She agreed that there was no documentation that the skin evaluations had been completed from late (MONTH) through the first week of (MONTH) (YEAR). An interview was conducted with the Assistant Director of Nursing (ADON/staff#12) on 10/12/18 at 2:10 p.m. She stated that the procedure for the weekly skin assessments is for the wound nurse to remind each nurse daily of the individual residents that have a weekly skin assessment due on that day. She stated that the nurse is to complete the assessment and initial it on the TAR. The ADON stated that the information from the skin assessment is to be documented in the electronic record under assessments and that the TAR is to be initialed. The ADON also stated that there may have been a miscommunication over the past months that the nurses believed the skin assessments were already completed. She stated that it was an oversight that the documentation was not caught on review. The facility's policy regarding wound management included that the purpose of the policy is to prevent the residents from developing skin ulcers or other skin issues. The policy included to complete a weekly head to toe assessment with follow up as applicable. The policy also included that all skin assessments and treatments should to be documented in the clinical record at the time they are administered. -Resident #284 was readmitted to the facility on (MONTH) 2, (YEAR), with [DIAGNOSES REDACTED]. The resident was discharged (MONTH) 1, (YEAR). Review of the physician's orders [REDACTED]. A nurse practitioner progress note dated (MONTH) 30, (YEAR) revealed the resident was awake, pleasantly confused, pupils were equal, round, reactive to light, and accommodation. A change of condition note dated (MONTH) 31, (YEAR) at 7:32 a.m. revealed the resident was found on the floor of his room, confused, and disoriented to time, place, person, and situation. The note included the resident sustained [REDACTED]. The note further included vital signs were taken and neuro checks were initiated. A nursing note dated (MONTH) 1, (YEAR) at 12:19 a.m. revealed the resident had a red area on his right forehead, two skin tears to the right arm, and was restless. Per documentation, the resident was placed in bed after a.m. change of shift and about one hour later was crawling on the floor. Further review revealed the resident was pulling at his Foley catheter, confused, asking if he had school tomorrow, and attempting to get out of bed. The note included the neuro checks were within normal limits. Review of a nursing note dated (MONTH) 1, (YEAR) at 4:01 a.m. revealed the resident had a second abrasion to the right elbow and a bump with redness to the right side of his forehead. The note included the resident was confused and disoriented. A review of the resident's neurological observation sheet dated (MONTH) 31, (YEAR) at 4:15 a.m. through (MONTH) 1, (YEAR) to 4:15 a.m. revealed the resident's vital signs were taken 12 times. Further review of the neurological observation sheet revealed no documentation the resident's level of consciousness, hand grasps, and pupillary reactions were assessed and no documentation whether or not the physician was notified. Review of the physician's orders [REDACTED]. A change of condition note dated (MONTH) 1, (YEAR) at 9:41 p.m. revealed the resident was transported to the hospital for a head scan due to a fall which left a laceration to the resident's right eyebrow. An interview was conducted on (MONTH) 11, (YEAR) at 9:27 a.m. with a registered nurse (staff #27/RN). The RN stated that if a resident is found on the floor or crawling on the floor it is a fall. Staff #27 stated that once a fall has occurred, the resident is assessed for injuries, asked what happened, vital signs are taken, the physician is notified, and an incident report is initiated. Staff #27 stated that if the resident is unable to communicate what happened, neuro checks would be initiated. The RN stated the resident would be monitored every 15 minutes for one hour, every 30 minutes for one hour, and then every hour for 4 hours. Staff #27 stated that if a resident is on blood thinners, the resident would be sent out to the emergency room immediately because the resident could have a bleed. An interview was conducted on (MONTH) 11, (YEAR) at 9:45 a.m. with a licensed practical nurse (LPN/staff #31). Staff #31 stated that if a resident was found on the floor, the nurse would immediately assess the resident, take vital signs, and that if the fall was unwitnessed, neuro checks including pupils equal, round, reactive to light, and accommodation (PERRLA) would be assessed every 15 minutes for 1 hour. Staff #31 further stated that the physician and the family would be notified immediately. The LPN stated that for a resident being administered blood thinners, there could be a potential for the resident to bleed out. During an interview conducted on (MONTH) 11, (YEAR) at 12:36 p.m. with a RN (staff #79), the RN stated that if a resident had a fall and was unable to verbalize what happened, neuro checks would be assessed every 15 minutes, every 30 minutes, and then every 1 hour. Staff #79 stated that if the resident is receiving anticoagulants, the resident is at risk for developing a bleed. The RN stated the physician would be notified. An interview was conducted on (MONTH) 11, (YEAR) at 12:40 p.m. with staff #119. She stated that if a resident sustained [REDACTED]. She further stated that if the resident is on anticoagulants, the physician is notified and the physician's orders [REDACTED]. She stated that the fall occurred at 4 a.m. and that the physician and the DON were notified at 7:30 a.m. The DON stated that the neuro check sheet corresponded to the fall on (MONTH) 31, (YEAR) at approximately 4 a.m. and that the vital signs were taken at regular intervals, but that the neuro checks were not completed. The facility's policy titled Neurological Evaluation revealed it is the policy of the facility to gather accurate nursing data necessary for a comprehensive neurological evaluation. The policy included that any resident having a injury involving the head or an unobserved fall will have neuro checks and vital sign taken. The policy also included all incidents involving trauma to the head will result in a comprehensive neurological evaluation for a minimum of forty-eight hours. -Resident #484 was admitted on [DATE] on hospice services, with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. A review of the Medication Administration Record (MAR) revealed that the resident received the medication on 10/9/18 and 10/10/18. The dosage on the MAR was 10 mg. During an observation conducted on (MONTH) 10, (YEAR) at 9:00 a.m. of the medication cart on the resident's hall, a bottle of rivaroxaban was observed with a pharmacy label with the resident's name on it. However, the bottle contained 15 mg tablets, instead of 10 mg tablets. An interview was conducted with a Registered Nurse (RN/staff# 27) on (MONTH) 10, (YEAR) at 9:15 AM. The nurse stated that the medication was delivered by hospice two days ago and that it was a home medication used by the resident. The nurse said that this is the only rivaroxaban medication in the facility for this resident and that he had given the resident this medication today and on (MONTH) 9. He said that he should have checked the medication for the correct dose prior to administering it as the dosage in the bottle is different than the physician's orders [REDACTED]. A second interview was conducted with staff #27 on (MONTH) 11, (YEAR) at 11:37 AM. He stated that it is the nurse's responsibility to check that the right dose of medication is being administered to the resident. An interview was conducted with staff #119 on (MONTH) 12, (YEAR) at 11:30 a.m The DON said that the staff are expected to check for all rights of medication administration including that it is the right dose prior to administration the medication. The facility's policy regarding administration of medication included that medications must be administered in accordance with the written orders of the attending physician. The policy also included that orders will be accurately implemented and that the seven rights of medication administration are followed in order to ensure safety and accuracy of administration. This includes that medications are administered according to the dose prescribed.",2020-09-01
584,SHEA POST ACUTE REHABILITATION CENTER,35105,11150 NORTH 92ND STREET,SCOTTSDALE,AZ,85260,2018-10-15,686,G,0,1,F7JV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#6) received the necessary care and services to prevent and promote the healing of an unstageable pressure ulcer, and failed to complete a timely assessment of a pressure ulcer for one resident (#13). Findings include: -Resident #6 was admitted on (MONTH) 11, (YEAR), with [DIAGNOSES REDACTED]. Review of the admission orders [REDACTED]. An admission Minimum Data Set (MDS) assessment dated (MONTH) 18, (YEAR), revealed the resident had a Brief Interview for Mental Status (BIMS) score of 6, which indicated severe cognitive impairment. The MDS included the resident required extensive assistance with bed mobility and transfers. The MDS also included that the resident was at risk for pressure ulcers and had two pressure ulcers which were present on admission and was not on a turning and repositioning program. A care plan identified that the resident had two stage 2 pressure ulcers on the buttocks. Interventions included to administer treatments as ordered, assess/record/monitor wound healing, measure length, width, and depth where possible, assess and document status of wound perimeter, wound bed and healing progress, report improvements and declines to the MD, float heels, notify nurse immediately of any new areas of skin breakdown, weekly head to toe skin assessments and for wound care team to follow. A Braden Scale for Predicting Pressure Ulcer Risk dated (MONTH) 3, (YEAR) included the resident was at high risk for developing pressure ulcers. Review of the clinical record including the weekly skin assessments revealed there was no documentation that the resident had a pressure ulcer to the right foot from admission through (MONTH) 16, (YEAR). There was also no documentation that the resident's heels were floated as care planned from admission through (MONTH) 16, (YEAR). Review of the CNA (Certified Nursing Assistant) ADL (activities of daily living) documentation regarding turning and repositioning revealed there were several notations that it was not applicable to turn and reposition the resident every two hours, and there were multiple shifts with no documentation that the resident was turned and repositioned every 2 hours from admission through (MONTH) 16, (YEAR). Review of a wound care physician's note dated (MONTH) 17, (YEAR), revealed the resident's right lateral dorsal foot had a superficial ulceration which exposed the dermis and had thin slough, with a scant amount of serous drainage. The note did not include any measurements of the wound. This was the first documentation of the right lateral dorsal foot wound. The plan included for Xeroform and a bordered gauze to the right lateral foot daily. However, review of the physician orders [REDACTED]. In addition, there was no documentation that any wound treatments were provided from (MONTH) 17 through 25, (YEAR). The next assessment of the right lateral dorsal foot wound was completed on (MONTH) 26, (YEAR), which was nine days after the previous assessment (on (MONTH) 17). Per the physician's note dated (MONTH) 26, (YEAR), the right foot had a superficial ulceration which exposed the dermis and had thin slough, with a scant amount of serous drainage. The assessment did not include any measurements of the wound. The plan was to monitor closely, as the resident can not turn himself. The note also included for Xeroform and bordered gauze to the right lateral foot daily. A physician's orders [REDACTED]. The order included to cleanse the right lateral dorsal foot with normal saline, cover with [MEDICATION NAME] and bordered gauze every Tuesday, Thursday and Saturday. The next assessment of the right foot pressure ulcer was not completed until 12 days later on (MONTH) 8, (YEAR), by the physician. The physician note included that the right plantar forefoot ulcer began as a bulla and was unstageable. There were no measurements and there was no description of the unstageable pressure ulcer. The plan was to apply [MEDICATION NAME] and gauze to the right plantar forefoot ulcer. Review of a Weekly Skin Evaluation dated (MONTH) 8, (YEAR) revealed the resident had a right plantar forefoot bulla, which measured 4 cm x 3 cm. This is the first documentation of any measurements of the pressure ulcer to the right foot. A Weekly Skin Evaluation dated (MONTH) 10, (YEAR) included the right plantar foot pressure ulcer measured 0.9 cm x 1.3 cm, with black eschar and was unstageable. Review of the Pressure Ulcer Weekly documentation which was completed by the wound nurse dated (MONTH) 13, (YEAR), revealed the right medial foot wound was unstageable with slough and black/brown eschar. The pressure ulcer measured 2.0 cm by 3.0 cm with a no exudate, no odor, wound edges were attached and the surrounding tissue was normal. The documentation included the pressure ulcer was dressed with [MEDICATION NAME] soaked gauze and covered with [MEDICATION NAME], and wrapped in Kerlix. The documentation further noted that the pressure ulcer was not present on admission. This was the first documentation by the wound nurse regarding the right foot wound, which was more than three weeks after the pressure ulcer was discovered. A wound care physician note dated (MONTH) 15, (YEAR) included the right plantar forefoot ulcer began as a bulla and was unstageable. The plan was to apply [MEDICATION NAME] and gauze to the right foot ulcer. A review of the clinical record for the period of (MONTH) 15, (YEAR) through (MONTH) 23, (YEAR) revealed weekly wound care physicians notes, which addressed the right foot wound and frequent modifications of the treatment orders. The wound care physician's note dated (MONTH) 28, (YEAR) indicated the non-healing right plantar forefoot ulceration was debrided at the bedside, which exposed peiosteum on the wound bed. The plan was to continue iodosorb gel and gauze to the right plantar forefoot ulceration, turn every two hours, and continue to mobilize patient out of bed as tolerated. A review of the Licensed Nurse Pressure Ulcer Weekly documentation dated (MONTH) 30, (YEAR), indicated that the right foot wound had slough, was unstageable and measured 1.1 by 1.2 cm with no depth. The wound also had a small amount of serosanguinous exudate and the wound edges were fibrotic and calloused, and the tissue surrounding the wound was normal. Further review of the clinical record revealed the right foot wound continued to be assessed weekly and treatments were provided through (MONTH) (YEAR). A quarterly MDS assessment dated (MONTH) 1, (YEAR) revealed a BIMS score of 7, which indicated severe cognitive impairment. The MDS included the resident required extensive assistance with bed mobility and transfers, and that he had one stage 4 pressure ulcer that was not present on admission. The MDS noted that the resident was not on a turning and positioning program. A review of the (MONTH) 4, (YEAR) Pressure Ulcer Weekly assessment revealed the right foot pressure ulcer was a stage 4 and measured 0.3 cm by 0.3 cm with a depth of 0.3 cm, with no undermining. The wound bed had granulation tissue, and had a small amount of serosanguinous exudate, no odor, and the wound edges were fibrotic and calloused, and the surrounding tissue was normal. A wound care observation was conducted with the wound nurse (Registered Nurse/staff #68) on (MONTH) 10, (YEAR) at 2:00 p.m. The resident was lying on his back with his heals floated, by a foam bridge across the foot of the bed. Staff #68 performed the dressing change in accordance with the current physician's orders [REDACTED]. Staff #68 stated that the wound presented as a stage 4 pressure ulcer with red granulation tissue. During an interview with staff #68 on (MONTH) 10, (YEAR) at 2:05 p.m., the RN stated that this wound began when the resident was in a shorter bed, and his foot would rest against the footboard. The RN stated that the wound started as a small black eschar covered area. Staff #68 said that she had been on leave around the time that this wound developed and that she had been following it weekly since her return. An interview was conducted with the Director of Nursing (DON/staff #119) on (MONTH) 15, (YEAR) at 1:34 p.m. The DON stated that she expects that who ever discovers a new wound would notify the wound nurse and the charge nurse, and the wound nurse would assess the wound and put orders in place. She stated that any nurse can notify the physician. The DON stated that documentation should include describing the wound bed and measuring the wound, and that the physician should be notified of any new wounds. -Resident 13 was admitted on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. A review of the annual MDS assessment dated (MONTH) 23, (YEAR), revealed the resident had a BIMS score of 8, which indicated moderate cognitive impairment. The MDS included that the resident required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene, and was frequently incontinent of urine and bowel. The MDS further revealed the resident was at risk for pressure sores, and had no pressure sores currently. A pressure reducing device was in place for the bed, but no pressure reducing device for the chair, and was not on a turning or positioning schedule. Review of a care plan revealed the resident was at risk for developing pressure ulcers related to incontinence of bowel and bladder and decreased functional mobility. A goal included the resident would be free from injury. Interventions included assist with toileting and/or offer incontinent care on rounds and as needed, keep skin clean and dry, monitor/document location, size, and treatment of [REDACTED]. The care plan further noted that the resident had refused placement of a low air loss mattress. physician's orders [REDACTED]. According to the corresponding MARs, the barrier cream was applied. A review of the clinical record and the Weekly Skin Evaluations from (MONTH) 24, (YEAR) through (MONTH) 7, (YEAR), revealed the resident did not have any skin breakdown or pressure sores. A physician's orders [REDACTED]. Despite having a physician's orders [REDACTED]. There was no documentation of any measurements of the sacral area pressure ulcer, no description of the wound bed and surrounding skin, or if there was any drainage or odor. There was also no staging of the pressure ulcer. In an interview on (MONTH) 9, (YEAR) at 4:41 p.m., resident #13 stated that she had a sore on her tailbone, which developed since she was admitted to the facility. She stated that the nursing assistants had been putting a salve on it but it hurt, so they changed the salve. Review of the Licensed Nurse Weekly Skin Evaluation dated (MONTH) 10, (YEAR), revealed documentation of a stage II pressure ulcer on the sacrum which measured 0.5 cm by 0.3 cm with 0 cm depth, with a pink wound bed and no peri wound skin issues. Wound care provided per MD orders. This was the first assessment of the pressure ulcer on the sacrum, which was completed two days after the physician ordered treatment. A wound treatment observation was conducted with the wound nurse (staff #68) and a Certified Nursing Assistant (CNA/staff #1) on (MONTH) 11, (YEAR) at 10:00 a.m. Staff #68 stated the wound measured 0.3 by 0.3 cm with no measurable depth, and described the wound bed as pink, with healing tissue. Staff #68 stated that the pressure ulcer was a stage II. A review of the Licensed Nurse Skin Pressure Ulcer Weekly Review dated (MONTH) 11, (YEAR) revealed it was the initial evaluation of a stage II pressure ulcer on the sacrum that was not present on admission. The wound measured 0.3 cm by 0.3 cm with no depth, and had a pink wound bed with defined edges and normal surrounding skin. The treatment included for [MEDICATION NAME] covered with foam. In an interview conducted with staff #1 on (MONTH) 15, (YEAR) at 11:13 a.m., staff #1 stated that to prevent pressure ulcers for resident #13, she changed her brief often and applied barrier cream to protect the skin. She stated that she helps the resident turn and change position and that the resident is able to use the bar to pull herself to her side. Staff #1 also stated that the resident developed the pressure sore about a week ago and that she was the CNA who discovered it and reported it to the nurse and the wound nurse. Another interview was conducted with staff #68 on (MONTH) 15, (YEAR) at 12:09 p.m. Staff #68 stated the unit nurses are responsible to document the wound appearance and initiate the standing orders for wound care and they may describe the wound. She said that the wound nurses are the only ones who may stage a wound. Staff #68 stated the wound nurse is responsible to assess the wound, to follow standing orders for wound care, add the resident to the wound rounds list, and update the care plan. She stated every wound should receive an assessment, care orders, and is added to the rounding list by the next day. A review of a policy titled, Wound Management revealed a resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the individual's clinical condition or other factors demonstrate that a developed pressure ulcer was unavoidable and a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable sores from developing. The policy included to provide care and services to promote the prevention of pressure ulcers, promote the healing of pressure ulcers that are present and prevent the development of additional pressure ulcers. The policy further stated that nursing staff are responsible to implement approaches as appropriate and consistent with the resident's care plan, which include stabilizing, reducing or removing any existing underlying risks, reposition the resident, and use pressure relieving/reducing and redistributing devices (including, but not limited to, low air loss mattresses, wedges, pillows, etc.), monitor the impact of interventions and modify interventions as appropriate based on any identified changes in condition.",2020-09-01
585,SHEA POST ACUTE REHABILITATION CENTER,35105,11150 NORTH 92ND STREET,SCOTTSDALE,AZ,85260,2018-10-15,688,E,0,1,F7JV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, review of clinical records, facility records, and policy, the facility failed to ensure two residents (#182 and #26) with limited range of motion received appropriate treatment and services to increase their range of motion and/or prevent further decrease in their range of motion. Findings include: -Resident #182 was admitted on (MONTH) 10, (YEAR) with [DIAGNOSES REDACTED]. An Initial Admission Record dated (MONTH) 10, (YEAR) revealed the resident's bilateral hand grips were equal and that there were no contractures present. The record included there were no limitations in range of motion in the resident's hands and no loss in the resident's ability to move his hands voluntarily. A physician's orders [REDACTED]. An OT (Occupational Therapy) evaluation dated (MONTH) 11, (YEAR) included short-term goals that the resident was to have a splint wearing schedule established to avoid further contracture of the left hand and wrist. The evaluation included an RNA program will be established for the left upper extremity to avoid further contracture. An admission MDS (Minimum Data Set) assessment dated (MONTH) 17, (YEAR) revealed the resident had a BIMS (Brief Interview for Mental Status) score of 10, which indicated the resident had moderately impaired cognition. The MDS assessment also included that the resident had impaired functional limitation in range of motion on one side and was receiving OT services. Review of the daily skilled documentation dated (MONTH) 29 through (MONTH) 31, (YEAR) revealed the resident had decreased grasp and movement of the upper left extremity and was receiving OT services. An OT discharge summary dated (MONTH) 24, (YEAR) revealed the resident had completed OT services. The summary included the therapy goals had been met which included establishment of a splint wearing schedule to avoid further contracture of the left hand and wrist. The summary also included the resident was independent with range of motion for the left hand in a resting hand splint and that the goals had been met for donning and doffing the left hand splint. The discharge summary further included recommendations to establish a restorative splint and brace program and for the resident to be able to tolerate splinting daily. Further review of the clinical record revealed no documentation that RNA services were provided to the resident as recommended by OT. An interview was conducted on (MONTH) 9, (YEAR) at 2:56 p.m. with the resident. During the interview, the resident demonstrated that he was unable to fully open his left hand; the fingers of the hand remained slightly bent when he attempted to open his hand. The resident was not observed to have a splint on the left hand. The resident stated that the splint was in a drawer in his room and that the staff only sometimes applied the splint. During an interview conducted with a LPN (Licensed Practical Nurse/staff #56) on (MONTH) 11, (YEAR) at 12:53 p.m., the nurse stated that the resident was unable to use his left hand and that his fingers were not contracted. The nurse stated that the resident had received RNA (Restorative Nursing Assistant) services who she believed had placed splints on the resident's hands, but that the resident no longer used the splints. During an interview conducted with the RNA (staff #13) on (MONTH) 11, (YEAR) at 1:00 p.m., the RNA stated that the resident was not currently receiving RNA services and had not received RNA services in the past. The RNA stated that there had been a discussion with the therapy staff regarding RNA services for the resident but that he had not heard any more about it. An interview was conducted on (MONTH) 11, (YEAR) at 1:15 p.m. with the Director of Rehab Services (staff #21). The Director stated that the resident completed OT services and that the resident had functional ROM (Range of Motion) of the left hand. The Director stated that OT services included the use of a resting hand splint and that at the time the resident was discharged from therapy services, RNA was recommended. The Director stated that he did not know why the resident had not received the RNA services that had been recommended. The Director also stated that when RNA services are recommended by the therapy staff, a form is completed for the recommended services and provided to the RNA staff, who then initiates the services. An interview was conducted on (MONTH) 11, (YEAR) at 1:51 p.m. with staff #13. Staff #13 stated that he never received a referral for this resident to receive RNA services, and that the splint for the resident's left hand was in the resident's drawer in his room. An interview was conducted on (MONTH) 11, (YEAR) at 2:40 p.m. with the Director of Nursing (DON/staff #119). The DON stated that when RNA services are recommended for a resident by the therapist, a referral form is completed and provided to the RN[NAME] The DON stated the RNA then initiates an RNA schedule for the resident based on the therapist's recommendation. Staff #119 stated that the RNA staff are responsible for applying and removing hand splints. The DON agreed that the recommendation for RNA services had not been communicated to the RNA staff. -Resident #26 was admitted to the facility on (MONTH) 30, (YEAR), with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 13, (YEAR), revealed the resident was moderately cognitively impaired and required extensive assistance from staff for his activities of daily living. Review of the physician's orders [REDACTED]. arm to aid in contracture reduction. The order also included for the resident to receive restorative range of motion to the right upper and lower extremities. The care plan regarding activities of daily living revealed the resident had right upper extremity and right lower extremity contractures. The care plan goal was that the resident would demonstrate the appropriate use of adaptive devices to increase ability. The intervention included nursing rehabilitation would apply rolled towels and perform range of motion to the right upper and lower extremities daily. Review of the Restorative Nursing Assistant (RNA) documentation from (MONTH) 1, (YEAR) through (MONTH) 31, (YEAR), revealed no documentation for 35 days that range of motion was provided or that rolled towels were used daily and no documentation from (MONTH) 1, (YEAR) through (MONTH) 10, (YEAR) for 49 days. Observations of the resident were conducted on (MONTH) 9, (YEAR) at 2:19 PM and (MONTH) 10, (YEAR) at 8:25 AM. The resident was observed seated in his wheelchair with no rolled towels present in his right hand or under his right arm. Review of an Occupational Therapy (OT) evaluation dated (MONTH) 10, (YEAR), revealed the resident was referred to OT from RNA due to decreased right upper extremity range of motion. An interview was conducted on (MONTH) 11, (YEAR) at 12:08 PM with the RNA (staff #13). He stated the RNA is responsible for providing and documenting the range of motion and rolled towel treatments. He stated that if the resident refused, he would document the refusal. He further stated that the rolled towel should be used in the resident's right hand at all times. The RNA stated the larger rolled towel under the resident's right arm was only supposed to be used when the resident was lying down in bed. An observation was conducted on (MONTH) 11, (YEAR) at 1:26 PM of the resident lying in his bed. No rolled towel was observed in the resident's right hand or under his right arm. Observations were conducted on (MONTH) 12, (YEAR) at 10:07 AM and at 1:52 PM. Both times the resident was observed seated in his wheelchair with no rolled towels present in his right hand or under his right arm. During an interview conducted on (MONTH) 12, (YEAR) at 11:05 AM with an Occupational Therapist (staff #21), he stated that the resident's range of motion was evaluated on (MONTH) 10, (YEAR). He stated that the degree of the resident's extension in his right arm and right hand was greater than the range that would be needed to fit a rolled towel in his hand or under his arm. He stated that based on the evaluation, the resident's contractures had not worsened beyond the range of what a rolled towel would provide. An interview was conducted on (MONTH) 12, (YEAR) at 11:38 AM with the Director of Nursing (DON/staff #119). She stated that she is responsible for adding restorative interventions to the resident's care plan. The DON stated that interventions in the care plan automatically transfer to the RNA to view, perform, and document in the electronic record. She stated that the RNA is the one that would provide the restorative nursing treatments and document the treatment. The DON stated that she was not aware the RNA services were not being provided daily, and that currently no one is auditing the RNA documentation to ensure that treatments are provided as ordered. The facility's restorative care policy revealed a policy statement that restorative care will be provided to each resident according to his/her individual needs. The policy also included that residents will receive services to attain and maintain the highest possible mental/physical functional status and psychosocial well-being defined by the comprehensive assessment and plan of care. The policy further included that a resident's restorative care requires close intervention and follow-through by a licensed nursing staff or designee.",2020-09-01
586,SHEA POST ACUTE REHABILITATION CENTER,35105,11150 NORTH 92ND STREET,SCOTTSDALE,AZ,85260,2018-10-15,695,D,0,1,F7JV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, and policy and procedures, the facility failed to ensure that one resident (#44) received oxygen as ordered by the physician. Findings include: Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a physicians order dated 5/15/2018 revealed the resident was to receive oxygen at 2 liters via nasal cannula as needed for shortness of breath, respiratory distress, cyanosis, or labored breathing. Review of the current respiratory care plan initiated 5/15/2018 revealed that the resident had [MEDICAL CONDITION] and [MEDICAL CONDITION] related to smoking and uses oxygen therapy related to [MEDICAL CONDITIONS] and ineffective gas exchange. The goal for the care plan was that the resident will display optimal breathing patterns daily. One of the interventions was to give oxygen therapy as ordered by the physician. A quarterly Minimum Data Set (MDS) assessment dated [DATE] included that the resident had a Brief Interview for Mental Status (BIMS) score of 5, which indicated severe cognitive impairment. The MDS assessment also included that the resident was receiving oxygen therapy. Review of physician progress notes [REDACTED]. During multiple observations of the resident conducted on 10/9/2018 at 2:15 p.m., 10/10/2018 at 9:15 a.m. and 2:15 p.m. and 10/11/2018 at 8:29 a.m., the resident had a nasal cannula on and the oxygen was running at 3 liters, instead of 2 liters as ordered. An interview was conducted on 10/11/2018 at 8:48 AM with a Licensed Practical Nurse (LPN/staff# 31). The nurse stated that when she has a resident in her section who is on oxygen she would check to see that the oxygen is being administered as per the physician's orders [REDACTED]. During an interview with a Registered Nurse (RN/staff#47) on 10/11/2018 at 3:15 p.m., she checked the resident's oxygen concentrator and said that the resident was on 3 liters of oxygen. She then checked the physician's orders [REDACTED]. She stated that the resident should not be on 3 liters of oxygen and that the resident was getting the incorrect amount of oxygen. An interview was conducted on 10/12/2018 at 11:30 a.m. with the Director of Nursing (DON/staff #119). She stated that she expects that the nurses will administer oxygen at the rate that is ordered by the physician. According to facility policy, oxygen therapy is administered by licensed nurses as ordered by the physician.",2020-09-01
587,SHEA POST ACUTE REHABILITATION CENTER,35105,11150 NORTH 92ND STREET,SCOTTSDALE,AZ,85260,2018-10-15,697,D,0,1,F7JV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record reviews, resident and staff interviews and policy review, the facility failed to ensure pain management was provided to one resident (#13) consistent with professional standards of practice and the resident's goals and preferences. Findings include: Resident #13 was admitted on (MONTH) 9, (YEAR) and readmitted on (MONTH) 26, (YEAR), with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment dated (MONTH) 23, (YEAR) revealed a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderate cognitive impairment. The assessment included the resident received scheduled pain medication and as needed pain medication and that she occasionally reported her pain level at a 4 which did not interfere with day to day activities or sleep. The assessment also included that the resident had not received non-medication interventions for pain. A review of the care plan revealed the resident had generalized pain and muscle spasms. The goals were the resident would voice level of comfort and would have no discomfort related to side effects. Interventions included pain medications as ordered, pain assessment every shift, and activities of choice for distraction. A review of the physician's orders [REDACTED]. -[MEDICATION NAME] 10 milligrams (mg) by mouth every 8 hours for muscle spasms ordered on (MONTH) 26, (YEAR). -[MEDICATION NAME] 300 mg by mouth every 8 hours for muscle spasms ordered on (MONTH) 26, (YEAR) and discontinued on (MONTH) 10, (YEAR). -[MEDICATION NAME] 300 mg by mouth twice daily for muscle spasms ordered on (MONTH) 10, (YEAR). -[MEDICATION NAME] 325 mg 2 tablet by mouth every 6 hours as needed for a pain level of 1-3 ordered on (MONTH) 1, (YEAR). -[MEDICATION NAME] 15 mg by mouth every 6 hours as needed for a pain level of 4-10 ordered on (MONTH) 1, (YEAR). Review of the Medication Administration Records (MAR) and progress notes from (MONTH) (YEAR) until (MONTH) (YEAR) revealed there were multiple times with no documentation that the [MEDICATION NAME] and [MEDICATION NAME] were administered or that the resident had refused. Further review of the clinical record revealed the resident rated her pain at a level of 4 on multiple occasions, however, there was no documentation that non pharmalogical interventions were offered or that pain medication was administered. During an observation conducted on (MONTH) 9, (YEAR) at 4:20 p.m., the resident asked a Licensed Practical Nurse (LPN/staff #78) for pain medication for a pain level of 12. The resident told the nurse that she had requested [MEDICATION NAME] at 1:30 p.m. and had not received it. Staff #78 stated that she was unaware of the request from the previous shift, but she would get the pain medication right away. Staff #78 was observed to administer [MEDICATION NAME] at 4:26 p.m. to the resident. A review of the MAR and progress notes for (MONTH) 9, (YEAR) revealed the only time [MEDICATION NAME] was documented as administered was at 4:26 p.m. An interview was conducted with the resident on (MONTH) 9, (YEAR) at 4:40 p.m. The resident stated that she has waited for hours to receive pain medication. During another interview with the resident on (MONTH) 11, (YEAR) at 9:45 a.m., the resident stated that occasionally she does not receive her regularly scheduled medications; however, she was unable to state a specific instance of which medication she did not receive or a specific date or time. A follow up interview was conducted with the resident on (MONTH) 12, (YEAR) at 1:01 p.m. The resident stated that often she has waited 2 hours for pain medication after requesting it. She said the pain medication relieves her pain, but that sometimes it can take up to an hour for relief. She stated that she may have to request the pain medication sooner, because of the wait. During an interview conducted with the resident on (MONTH) 15, (YEAR) at 9:45 a.m., the resident stated that she continues to wait up to 3-4 hours for pain medication. An interview was conducted with a Certified Nursing Assistant (staff #1) on (MONTH) 15, (YEAR) at 11:13 a.m. The CNA stated that when the resident complains of pain, she reports it to the nurse. During an interview conducted with the Director of Nursing (DON/staff #119) on (MONTH) 15, (YEAR) at 1:34 p.m., the DON stated that she expects the nurses to follow the physician's orders [REDACTED]. The facility's policy titled Pain Management revealed the resident's pain is assessed and managed by an interdisciplinary team who work together to achieve the highest practicable outcome. The policy included the facility will assist each resident with pain by developing and implementing a plan, using pharmacologic and/or non-pharmacologic interventions to manage the pain and/or try to prevent the pain consistent with the resident's goals. The policy also included medications received, refused, and response to medication will be documented on the Medication Administration Record (MAR). The policy further revealed to monitor pain status and treatment effects on a regular basis, e.g., during routine medication passes.",2020-09-01
588,SHEA POST ACUTE REHABILITATION CENTER,35105,11150 NORTH 92ND STREET,SCOTTSDALE,AZ,85260,2018-10-15,757,D,0,1,F7JV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure one resident's (38) drug regimen was free of unnecessary drugs, by failing to ensure that pain medication was administered as physician ordered. Findings include: Resident #38 was admitted to the facility on (MONTH) 17, (YEAR) with [DIAGNOSES REDACTED]. Review of a pain care plan dated (MONTH) 8, (YEAR), revealed the resident had acute and chronic pain related to depression, an abdominal surgical site and back pain. Interventions included to administer pain medications as ordered and monitor and document for side effects and effectiveness. The admission Minimum Data Assessment (MDS) dated (MONTH) 27, (YEAR) revealed that the resident scored 14 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. The assessment also noted that the resident had received opioids during all days of the 7-day look-back period and he indicated that he had occasional pain. Review of the (MONTH) (YEAR) recapitulation of physician orders [REDACTED]. -[MEDICATION NAME] (a pain medication) 650 milligrams (mg) every 6 hours as needed for pain levels of 1 through 3. -[MEDICATION NAME] (an opioid pain medication) 4 mg every 4 hours as needed for pain levels of 4 through 10. A review of the Medication Administration Record [REDACTED]. Review of the nursing notes for (MONTH) 1 through 11, (YEAR) revealed no documentation as to why the [MEDICATION NAME] was administered for pain levels of 3 instead of the [MEDICATION NAME]. An interview was conducted with a Licensed Practical Nurse (LPN/staff# 44) on (MONTH) 12, (YEAR) at 11:15 AM. The nurse stated that when a resident complains of pain, she would asses the resident by asking what level the pain is and then check the physician's orders [REDACTED]. She said that she would administer the medication that corresponds to the resident's pain level as per the physician's orders [REDACTED]. In an interview with the Director of Nursing (DON/staff#119) on (MONTH) 12, (YEAR) at 11:30 AM, she stated that she expects that the nurses will follow the physician orders [REDACTED]. She said they should not administer medications outside of these orders. Review of facility policy for administration of drugs revealed that medications must be administered in accordance with the written orders of the attending physician. The policy further noted that when as needed medications are administered, the nurse must record the justification or reason the medication is given.",2020-09-01
589,SHEA POST ACUTE REHABILITATION CENTER,35105,11150 NORTH 92ND STREET,SCOTTSDALE,AZ,85260,2018-10-15,761,D,0,1,F7JV11,"Based on observations, staff interviews and policy review, the facility failed to ensure that expired medications were discarded and that one insulin vial was dated when opened. Findings include: A medication storage observation was conducted on (MONTH) 10, (YEAR) at 9:00 a.m., on the skilled unit. The following items were observed in medication cart #1: one anoro ellipta aerosol powder breath inhaler 62.5-25 mcg/Inh with an expiration date of 10/2017; one bottle of Xarelto (anticoagulant) 15 mg which included pharmacy labeled directions to discard by 5/17/2016 and one vial of Humalog insulin was opened but was not dated. An interview was conducted with a registered nurse (RN/staff #27) on (MONTH) 10, (YEAR) at 9:15 a.m. The RN stated that these were the resident's home medications which were delivered by hospice 2 days ago. When asked if they had Xarelto and the inhaler medication to use for this resident that were not expired, staff #27 replied they did not. He stated that he will follow up with hospice to get more medication. Staff #27 said that he gave the resident the two medications yesterday and today from the expired bottles. Regarding the undated insulin vial, staff #27 stated that he did not know when the vial was opened. He stated the open date should be written on it. He said insulin is good for 28 days after it is opened, but there is no way to tell if 28 days have passed, since there was no open date on the vial. An interview was conducted with a licensed practical nurse (LPN/staff #31) on (MONTH) 11, (YEAR) at 8:48 a.m. Staff #31 stated that the nurse who is administering medications needs to be checking for expiration dates. Another interview was conducted with staff #27 on (MONTH) 11, (YEAR) at 11:37 a.m. Staff #27 stated that the nurse administering medications is the one responsible to ensure that medications are not expired. An interview was conducted with a pharmacy consultant (staff #126) on (MONTH) 12, (YEAR) at 11:00 a.m. He stated that medications loose about 60-70% of their potency after the expiration date. He stated that expired medications should not be administered. An interview was conducted on (MONTH) 12, (YEAR) at 11:30 a.m., with the Director of nursing (DON/staff #119), the Administrator (staff #122) and a RN consultant (staff #124). The DON stated that she expects the nurses to check for expiration dates, prior to administering medications. She also stated that when a multi use vial like insulin is opened, it has to be dated. The DON said it is the responsibility of the nurse to check the med cart for expired medications. A policy titled, Medication Access and storage included that any outdated, contaminated or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock, and disposed of according to procedures for medication destruction. The policy also included that any opened vial without an open date will be discarded immediately and replaced with a new vial.",2020-09-01
590,SHEA POST ACUTE REHABILITATION CENTER,35105,11150 NORTH 92ND STREET,SCOTTSDALE,AZ,85260,2018-10-15,867,E,0,1,F7JV11,"Based on concerns identified during the survey, staff interview and policy and procedures, the Quality Assessment and Assurance (QAA) committee failed too develop and implement appropriate plans of action to correct identified quality deficiencies regarding clinical record documentation. Findings include: During the survey, concerns were identified regarding multiple occasions when there was no documentation on the Medication Administration Records (MARs) that medications were administered to several residents in July, August, (MONTH) and (MONTH) (YEAR). During an interview conducted on (MONTH) 15, (YEAR) at 3:45 p.m. with the Administrator (staff #122) and the Director of Nursing (staff #119), both stated that the committee identifies concerns brought forth by facility staff, residents, and families, as well as concerns from on-going monitoring of pressure ulcers, falls, and infections. Regarding the pervasive lack of nursing documentation for the administration of medications, staff #119 stated she was aware of the issue and had attempted to implement interventions such as, nursing staff signing sheets at the end of their shift to state that their documentation was complete and by having the on-coming nurses audit the previous shift's documentation on the MARs for completeness. Staff #119 stated this was just an informal intervention with no actual goal or tracking to ensure the interventions were successful. Staff #119 said that it had not become a formal QAA plan of action. Review of the facility's policy regarding QAA and QAPI (Quality Assurance and Performance Improvement) revealed that QAA and QAPI are data-driven and are a proactive approach to quality improvement. All staff and residents are involved in continuously identifying opportunities for improvement. Gaps in systems are addressed through planned interventions with a goal of improving the overall quality of the life and quality of care and services delivered to nursing home residents.",2020-09-01
591,SHEA POST ACUTE REHABILITATION CENTER,35105,11150 NORTH 92ND STREET,SCOTTSDALE,AZ,85260,2019-12-05,600,D,1,1,MMS711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, resident and staff interviews, facility documentation and policy review, the facility failed to ensure that one resident (#45) was free from physical abuse by one resident (#89), and that one resident (#5) was free from physical abuse by another resident (#88). The deficient practice could result in the potential for further resident to resident abuse. Findings include: Regarding the incident between resident #45 and resident #89: -Resident #45 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a score of 10 on the Brief Interview for Mental Status (BIMS), which indicated the resident had moderate cognitive impairment. The care plan initiated on May 9, 2019 revealed that [MEDICAL CONDITION] medications were being used related to [MEDICAL CONDITION], as evidenced by angry outbursts. The goal was that the resident would have fewer episodes of angry outbursts. Interventions included monitoring and recording occurrences of angry outbursts and documenting them. A nursing progress note dated July 22, 2019 revealed that as resident #45 was walking past resident #89, resident #89 stated to resident #45 that he had bad body odor and to take a shower. Per the note, resident #45 told resident #89 to mind his f business. Resident #89 then pushed resident #45 down. Resident #45 complained of hip pain and was taken to the hospital. According to the hospital discharge summary dated July 28, 2019, resident #45 sustained a [MEDICAL CONDITION] end of the right femur. -Resident #89 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] revealed a score of 15 on the BIMS, which indicated the resident had intact cognition. A nursing progress note dated July 26, 2019 included a late entry for July 24, 2019. The note included the Director of Nursing (DON/staff #123) and the Executive Director (ED) met with resident #89 to discuss the altercation. The note included that resident #89 was presented with a 30-day notice of discharge. A care plan initiated on July 26, 2019 revealed the resident had the potential to demonstrate physical behaviors related to a resident to resident altercation. One of the goals was that the resident would demonstrate effective coping skills. An intervention included a psych evaluation was ordered. Review of the facility's investigation report dated July 26, 2019 revealed that on July 22, 2019, resident #45 walked up to the nursing station when resident #89 stated to resident #45 that he had body odor and to take a shower. Resident #45 told resident #89 to mind his f business. Resident #89 then pushed resident #45 away from him and resident #45 fell to the floor. The residents were separated immediately. The report included that resident #45 reported having right hip/leg pain and was transported to the hospital and was admitted with a femur fracture. An interview was conducted on December 2, 2019 at 1:48 p.m. with resident #45, who stated that resident #89 told him that he smelled and needed to take a shower. He said that he told resident #89 to shut the f .up. Resident #45 stated that resident #89 struck him and he fell down and broke his hip. An interview was conducted with a Registered Nurse (RN/staff #94) on December 5, 2019 at 9:52 a.m. She stated that resident #45 could be passive aggressive and would say things that were not appropriate to other people. Staff #94 said both residents were known for not getting along with others. She stated that knowing their history/behaviors, she would have gotten in-between the two residents as soon as resident #89 said, You smell and need to shower. During an interview conducted with the Director of Nursing (staff #123) on December 5, 2019 at 12 p.m., staff #123 stated they try to do everything possible to prevent abuse from occurring. Staff #123 said that resident #89 did not have a history of physical aggression/abuse and that the residents were separated as soon as possible. Regarding an incident between resident #5 and resident #88: -Resident #5 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the annual MDS assessment dated [DATE] revealed a score of 9 on the BIMS, which indicated the resident had moderate cognitive impairment. Review of the progress notes for July 2019 revealed no information regarding an altercation between resident #5 and resident #88. -Resident #88 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the annual MDS assessment dated [DATE] revealed the resident had moderate cognitive impairment, with daily decision making skills. Review of the progress notes for July 2019 did not reveal any information regarding an altercation between resident #5 and resident #88. Review of the facility's investigation report dated July 30, 2019 revealed that on July 25, 2019, yelling was heard coming from a room. When staff entered the room, they observed resident #88 slapping resident #5. Per the report, resident #5 made racial slurs to resident #88 and resident #88 attacked her. Resident #5 sustained a small skin tear to her left hand, which was treated. The report included that resident #88's room was changed and a 30-day notice of discharge was issued. A care plan initiated on July 30, 2019 revealed that resident #88 had the potential for a behavior problem of physical aggression. The goal was that the resident would not have evidence of behavior problems. Interventions included anticipating and meeting the resident's needs. An interview was conducted on December 5, 2019 at 9:52 a.m. with a Registered Nurse (staff #94), who stated that resident #5 can be loud and opinionated, but usually quiet. Staff #94 stated that resident #5's dementia has worsened and that may be the reason for the inappropriate comments. An interview was conducted on December 5, 2019 at 12:00 p.m. with the Director of Nursing (staff #123), who stated neither resident had a history of [REDACTED]. Review of the facility's Abuse policy revised on September 14, 2019, revealed that each resident has the right to be free from abuse. The policy included oversight and monitoring will be provided to ensure the staff deliver care and services that promotes the residents' rights to be free from abuse. The policy also included action will be taken to prevent abuse from occurring by identifying, correcting, and intervening in situations in which abuse is more likely to occur.",2020-09-01
592,SHEA POST ACUTE REHABILITATION CENTER,35105,11150 NORTH 92ND STREET,SCOTTSDALE,AZ,85260,2019-12-05,655,D,0,1,MMS712,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record reviews, staff interviews, facility documentation and policies and procedures, the facility failed to ensure that baseline care plans were in place for two residents (#12 and #78) related to hearing. The deficient practice could result in care not being provided to residents. Findings include: At the beginning of the revisit survey, the facility provided a list of residents with hearing aids. Resident #12 and #78 were on this list. As a result, the closed clinical record for resident #12 and resident #78 were reviewed. -Resident #12 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. The 5 day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. The assessment also included that the resident's hearing was adequate, and that he utilized hearing aids. Review of the Certified Nursing Assistant (CNA) Point of Care documentation from January 19, 2020 through February 13, 2020, revealed there was no documentation of any CNA monitoring for hearing aid placement or rejection of use, as outlined in the facility's plan of correction. Review of the resident's care plans revealed there was no baseline care plan that addressed a hearing deficit or the use of hearing aids. On February 14, 2020 at 11:45 a.m., an interview was conducted with the Director of Social Services (staff #47). She stated that since January 19, 2020, she had been assigned to monitor the placement of hearing aids for residents in the facility that wear them. She said she was not aware that resident #12 had hearing aids. She said she did not check on him every day, because he was not on her list. -Resident #78 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission MDS assessment dated [DATE] revealed the resident scored 15 on the BIMS, indicating intact cognition. The MDS included the resident had adequate hearing and did not use hearing aids. Review of the CNA Point of Care documentation dated January 19, 2020 through January 31, 2020 revealed there was no CNA monitoring of hearing aid placement or rejection of use, as outline in the facility's plan of correction. However, review of the Hearing Aid Review sheet completed by the Director of Social Services indicated the resident's hearing aids were in place daily from January 20, 2020 through January 31, 2020. Review of the resident's care plans revealed there was no baseline care plan that addressed a hearing deficit or the use of hearing aids. On February 14, 2020 at 11:45 a.m., an interview was conducted with staff #47. She stated that beginning January 19, 2020, which was their allegation of correction date, she checked each resident with hearing aids daily. She stated that if the resident did not want to wear their hearing aids, she would document why in the resident's clinical record. She stated that if the hearing aids were broken, she would send an email to the mobile hearing aid unit to come fix them. She said if there was a need for a new battery, she would tell the nurse. She stated that after January 31, 2020, she began monitoring every 3 days. She said she still does the checks every 3 days. She stated the CNA's also started monitoring the hearing aids in mid-January. She said that every resident in the facility with hearing aids has CNA monitoring, which is documented in Point of Care four times per day. Staff #47 displayed the hearing aid documentation for resident #78 dated January 20 through January 31, 2020. She said that she remembered the resident wearing her hearing aids every day. However, she acknowledged that the CNA monitoring task had not been added to the CNA Point of Care task list. An interview was conducted with the Assistant Director of Nursing (ADON/staff #62) and the Director of Nursing (DON/staff #2) on February 14, 2020 at 12:10 p.m. The ADON stated she added a hearing aid care area to each resident's care plan who wore them. She stated that she also added the task to the task bar in Point of Care CNA documentation. The DON and ADON reviewed resident #12 and resident #78's care plans, and stated they did not see care areas that addressed hearing aids. They also looked at the Point of Care task bar and stated they did not see that the hearing aid task had been added for either resident. The facility policy titled Hearing Aid, Care of stated it is the policy of the facility to maintain the resident's hearing aid in good order, including placement of the hearing aid, checking the batteries, and caring of the hearing aid. A facility policy titled Activities of Daily Living, Services to Carry out included it is the policy of the facility that residents are given the appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care.",2020-09-01
593,SHEA POST ACUTE REHABILITATION CENTER,35105,11150 NORTH 92ND STREET,SCOTTSDALE,AZ,85260,2019-12-05,658,D,0,1,MMS712,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy review, the facility failed to ensure that professional standards of quality were maintained, by failing to ensure a licensed nurse donned gloves prior to administering an injection, and by failing to accurately document medication administration for one resident (#29). The deficient practice could result in further professional standards not being followed regarding resident care. Findings include: Resident #29 was readmitted on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. An observation of medication administration was conducted on February 14, 2020 at 7:55 a.m., with a Licensed Practical Nurse (LPN/staff #13). Staff #13 was observed to place the [MEDICATION NAME] sodium in a medicine cup and also retrieved the [MEDICATION NAME] syringe. She then documented in the resident's electronic record that both medications had been administered. Staff #13 then took the medications into resident #29's room. She handed the resident the medication cup. The resident stated that he did not want to take the [MEDICATION NAME] sodium, because he didn't need it. The nurse took the medication cup with the [MEDICATION NAME] sodium and set it aside and prepared to administer the [MEDICATION NAME] injection. Staff #13 did not don gloves and then cleaned the right side of the resident's abdomen with an alcohol wipe. She let the alcohol dry and then gave the injection, without wearing any gloves. On February 14, 2020 at 8:09 a.m., an interview was conducted with staff #13. She said that she usually wears gloves when administering an injection. She stated that she forgot to put them on. Review of the resident's February 2020 MAR was reviewed at 12:00 p.m. on February 14, 2020. The MAR showed that the resident had received [MEDICATION NAME] sodium at 8:00 a.m. An interview was conducted with the Assistant Director of Nursing (ADON/staff #62) and the Director of Nursing (DON/staff #2) on February 14, 2020 at 12:21 p.m. Staff #62 stated that her expectation regarding administering injections were to don gloves. She stated that giving an injection without gloves did not meet her expectation. Additionally, staff #62 stated that if a resident refused a medication, she would expect nursing to choose the option in the electronic health record to indicate that the resident had not received it. She reviewed the MAR and stated that the nurse's documentation did not meet her expectation. At 2:38 p.m. on February 14, 2020, the DON stated that the facility does not have a policy on injectable medication administration. Review of a policy titled, Administration of Drugs revealed it is the policy of the facility that medications shall be administered as prescribed by the attending physician. The policy included that if a medication is withheld, refused, or given other than at the scheduled time, the documentation will be reflected in the clinical record.",2020-09-01
594,SHEA POST ACUTE REHABILITATION CENTER,35105,11150 NORTH 92ND STREET,SCOTTSDALE,AZ,85260,2019-12-05,676,E,0,1,MMS711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, and resident and staff interviews, the facility failed to provide the appropriate care and services for one resident (#41), in order to maintain or improve their hearing abilities. The deficient practice could result in residents not maintaining their communication abilities. Findings include: Resident #41 was admitted [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of an audiology record dated January 22, 2019, revealed recommendations that the resident should wear hearing aids daily and that the batteries should be changed every Monday. The annual Minimum Data Set assessment dated [DATE], revealed a score of 9 on the Brief Interview for Mental Status, which indicated the resident had moderate cognitive impairment. The assessment included the resident had minimal difficulty with hearing and that hearing aids were not used to complete the assessment. Review of the care plan initiated on November 15, 2019, revealed the resident was at risk for a communication problem related to a hearing deficit. The goal was that the resident would be able to make basic needs known on a daily basis. Interventions included using eye contact, speaking slowly and using short direct phrases. The interventions did not include the use of hearing aids. During an interview conducted with the resident on December 2, 2019 at 3:53 p.m., the resident was having difficulty hearing. The resident stated that he has hearing aids in the drawer and that staff are to put in new batteries, but they never do. On December 5, 2019 at 12:39 p.m., an interview was conducted with a Certified Nursing Assistant (CNA/staff #108), who stated she was not aware that resident #41 had hearing aids. She stated that she talks very loud and faces the resident, so he can see her mouth to understand what she is saying. At this time, an interview with the resident was conducted. The resident stated that his hearing aids were in the drawer in a bag. Staff #108 found two gold colored boxes, one for each hearing aid and two batteries. A yellow post was observed on one of the boxes that contained the documentation Change batteries every Monday. At the request of the resident, the CNA paced the hearing aids in the resident's ears. During the interview, the CNA was observed talking loud to the resident, close to resident's face. An interview was conducted on December 5, 2019 at 12:52 p.m. with a Licensed Practical Nurse (LPN/staff #43), who stated that she did not know that the resident had hearing aids. She stated when a resident is having trouble hearing; she would contact the physician to see if the physician wants to order a hearing evaluation. However, the LPN was unable to locate a progress notes that the physician had been contacted regarding the resident's hearing deficit. An interview was conducted on December 5, 2019 at 1:36 p.m. with the Director of Social Services (staff #55). Staff #55 said she believed the resident was admitted with hearing aids. She said the resident refuses to wear the hearing aids, but was unable to find documentation that the resident refused to wear the hearing aids. During the interview, staff #55 went to the resident and asked the resident how the hearing aids felt. The resident stated good and that he wants to wear his hearing aids. Staff #55 stated that resident #41 does not have the ability to open his drawer independently and would be unable to retrieve his hearing aids. During an interview conducted on December 5, 2019 at 2:23 p.m. with the Director of Nursing (DON/staff #123), the DON stated she would look for documentation regarding the resident refusing to wear his hearing aids, however, was unable to provide the documentation. Later that day at 4:50 p.m., the DON stated they did not have a policy regarding hearing devices, hearing assessments or hearing maintenance.",2020-09-01
595,SHEA POST ACUTE REHABILITATION CENTER,35105,11150 NORTH 92ND STREET,SCOTTSDALE,AZ,85260,2019-12-05,687,G,0,1,MMS711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review and resident and staff interviews, the facility failed to ensure that one of two sampled residents (#11) received proper care and treatment to maintain good foot health. The deficient practice resulted in a lack of podiatry care resulting in foot complications. Findings include: Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a care plan initiated May 6, 2019, revealed the resident had a self-care performance deficit, with a goal that the resident would maintain his current level of functioning with bed mobility, dressing, grooming, toilet use and personal hygiene through the review date. Interventions included to explain procedures before starting, promote dignity by ensuring privacy, and encourage the resident to participate to the fullest extent possible with each interaction. Review of the admission physician's orders [REDACTED]. A care plan initiated on May 15, 2019 for impairment to skin integrity related to [MEDICAL CONDITION], immobility and history of pressure ulcers included the goal that the resident would be free from injury through the review date. Interventions included to administer wound care per physician orders, a low air loss mattress, and to use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surface. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident did not have short term memory problems and had the cognitive skills to independently make decisions regarding tasks of daily living. The assessment also included that the resident required extensive assistance with bed mobility, dressing and personal hygiene, and the resident had functional limitations in range of motion to both lower extremities. A provider progress note dated May 31, 2019 revealed the resident had requested to be seen by podiatry to clip his toenails and that a podiatry consult had been ordered. A physician's orders [REDACTED]. Patient has to be on stretcher lying down or have podiatrist come see him here at the facility. A podiatry progress note dated June 3, 2019 included that the resident's toenails had not received care in over a year. The nails were thick and long on both feet. There was blood on the left and right great toes from subungual hematoma (bleeding and bruising under the nail). All left and right foot toenails were cut, filed and thinned using a mechanical grinder. [MEDICATION NAME] (antibiotic ointment) was applied to the left and right great toes and they were covered with adhesive bandages. The wound nurse was instructed to apply [MEDICATION NAME] and monitor the toes for one week. The note included there was an initial concern that the resident might develop [MEDICAL CONDITION], but the resident was already receiving intravenous antibiotics for another condition, so further antibiotics were not needed. Review of a provider progress note dated July 24, 2019, revealed the resident was not seen that day, due to the resident being out of the building for podiatry. Review of the clinical record revealed no evidence that the resident was seen by the podiatrists in July 2019. A podiatry progress note dated August 7, 2019 revealed the resident was not seen by podiatry, because the resident was out of the building at the dentist. There was no clinical record documentation that the resident was seen by the podiatrist in August 2019. A physician's orders [REDACTED]. However, there was no evidence that the resident was seen by the podiatrist in September 2019. A physician's orders [REDACTED]. Review of the clinical record revealed there was no documentation that the resident was seen by the podiatrist from October 1 through 9, 2019. A nursing note dated October 10, 2019 included the resident complained of an ingrown toenail (did not specify if on the left or right) and the provider was notified and no new orders were received. A provider progress note dated October 10, 2019 revealed the resident was sent to the hospital related to a new onset of fevers and the decline of a wound, which was not on the resident's feet. A podiatry progress note dated October 14, 2019 included that the resident was not seen by podiatry, because the resident was out of the building at the hospital. According to the clinical record documentation, the resident was readmitted to the facility on [DATE]. There was no clinical record documentation that the resident received podiatry services from October 15 through November 19, 2019. A provider progress note dated November 20, 2019, included the podiatrist was to evaluate and trim the resident's toenails, per the resident's request. Further review of the clinical record revealed there was no evidence that the resident was provided podiatry services from November 20 through December 2, 2019. An interview was conducted with the resident on December 2, 2019 at 10:08 a.m. He stated he had been waiting for more than six months for his toenails to be trimmed. He said staff kept telling him he was on the list for podiatry, but that was all they did. He said he believed his toenails were starting to curl. An interview was conducted with a Licensed Practical Nurse (LPN/staff #98) on December 3, 2019 at 11:24 a.m. She stated the podiatrist comes to the facility every three months to treat residents. She said a list of residents is kept for the podiatrist, but the podiatrist would be willing to see additional residents not on the list, during routine visits to the facility. She said some residents were also sent out of the facility to see a podiatrist if needed. An observation of the resident's feet was conducted on December 3, 2019 at 2:21 p.m., with a Certified Nursing Assistant (CNA/staff #15). The resident's right great toe had yellow-green discharge which was partially dried and was attached to and pulling from the inside of the resident's sock, as it was removed. Once the resident's socks were removed, yellow-green discharge was observed on the surface and under the medial nail fold of the right great toe. The resident's right and left great toes appeared reddened. Both the right and the left great toenails were long, extending approximately one centimeter beyond the nail bed. The resident's other toenails were also long. The resident's left great toenail appeared to be partially detached from the nail bed. There was also a dark accumulation of debris which was approximately one centimeter in diameter that was underneath and protruding from the end of the right and left great toenails. Another observation of the resident's feet was conducted on December 3, 2019 at 2:51 p.m., with a Registered Nurse (staff #67). Staff #67 stated she was the wound nurse. She said the resident's right great toe appeared to have an ingrown toenail, and she described the drainage from the right great toe as purulent and greenish. At this time, staff #67 took a sample of the drainage for a culture test. The nail bed of the right great toe began bleeding once the drainage was cleansed and removed. Staff #67 said the resident's toenails were very, very long. She said the resident's left great toenail looked like it was going to come off. She said the accumulation under the right and left great toenails appeared fungal. She said the resident definitely needed a podiatry consultation. She said she would obtain treatment orders from the physician. A follow-up interview was conducted on December 3, 2019 at 3:46 p.m. with staff #67. She said the reason the resident did not receive podiatry care in August and October 2019 was because the resident was out of the facility when the podiatrist was onsite. She said podiatry normally trimmed toenails, but the nurses could initiate and provide other treatments to the resident's feet. She said residents could also be sent out to see a podiatrist if needed. She said it was not necessary to wait for podiatry, in order for a resident's feet to be treated. She said now that a problem has been identified for the resident, it would be treated. Review of a wound nurse progress note dated December 3, 2019, revealed documentation that purulent blood-tinged drainage was noted from the right great toe. Triple antibiotic ointment and a band-aid were applied to the right great toe. A culture from the drainage of the right great toe was sent to the lab. The left foot and toenails were also assessed. A weekly skin assessment dated [DATE] included that the resident's right great toe had some serous drainage noted, with topical treatments applied as ordered. An interview was conducted with a corporate resource nurse (staff #121) on December 4, 2019 at 7:44 a.m. She stated the facility did not have a policy for podiatry care. She said if a resident needed a referral for podiatry, the facility would obtain a referral. An interview was conducted on December 5, 2019 at 1:54 p.m., with the Director of Nursing (DON/staff #123), a corporate resource nurse (staff #121), the Administrator (staff #122) and the resident's physician (staff #125). The DON stated the wound nurse had mistakenly noted that the drainage had been coming from the resident's right great toe, when in fact it was the left great toe that had drainage (however, it was explained that the yellow-green discharge was observed from the resident's right great toe on December 3, not the left toe). She said the resident's left foot had previously been receiving treatments for wound care, and if additional issues had been identified at that time, the appropriate treatments would have been initiated. The DON further stated that very thick toenails must be trimmed by the podiatrist and that in addition to podiatry services, the doctors were present almost daily in the facility and wound rounds were conducted weekly. She said that residents could be sent out of the facility to receive podiatry care, if needed. Staff #121 stated when the nurse aides provide care to the feet, they would notify the nurses of any changes they observed. A follow up observation of the resident's feet was conducted on December 5, 2019 at 2:00 p.m., with staff #121 and #125. The tip of the left great toe was reddened. There appeared to be ointment on the left great toe, but not on the right great toe. Neither the left nor the right great toe had visible drainage above or below the surface of the skin. Staff #125 pointed to the reddened area on the tip of the left great toe and stated that this was where the drainage had been. A physician's progress note dated December 5, 2019 included there was a report of greenish-blood tinged drainage from the left great toe for the past two days. The note included the resident had long nails without evidence of an ingrowing toe nail of the left great toe, and that the culture of the drainage was only growing a few white blood cells.",2020-09-01
596,SHEA POST ACUTE REHABILITATION CENTER,35105,11150 NORTH 92ND STREET,SCOTTSDALE,AZ,85260,2019-12-05,690,G,1,1,MMS711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff and resident interviews, hospital documentation and policy and procedures, the facility failed to ensure that one out of two sampled residents (#11) received care and services related to an indwelling urinary catheter, in accordance with professional standards of practice. The deficient practice resulted in the resident being sent to the hospital for an invasive procedure, with the potential to result in further complications. Findings include: Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was readmitted to the facility on [DATE]. Review of the clinical record revealed the resident was admitted with an indwelling urinary Foley catheter (a catheter which drains urine from the bladder and is inserted through the urethra opening). However, a care plan initiated on May 6, 2019 included the resident had an indwelling supra pubic catheter (a catheter which drains urine from the bladder and is inserted through a small hole in the lower abdomen). The care plan included goals and interventions. Despite this, there was no clinical record documentation that the resident had a supra pubic catheter, only documentation that the resident had an indwelling urinary Foley catheter in place. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The assessment also included that the resident had an indwelling urinary catheter. According to a physician progress notes [REDACTED]. Review of a late entry nursing note dated November 13, 2019 revealed that on November 12, 2019 at 5:35 p.m., nursing staff attempted to change the resident's Foley catheter with some difficulty and that a new catheter was inserted by the charge nurse at 6:00 p.m. (The size of the catheter used was not documented). Per the note, the catheter drainage bag was checked at 7:30 p.m. with no urine noticed in the bag. The catheter was rechecked and the catheter balloon would not deflate. The resident's bladder was palpated for fullness, and the bladder was lightly extended. The resident was sent out due to a catheter malfunction and the Director of Nursing (DON) and physician were notified. Review of the hospital records dated November 12 and 13, 2019, revealed that the resident was initially seen by the physician in the Emergency Department at 11:14 p.m. on November 12. The note included the resident had a history of [REDACTED]. The resident presents with a malfunctioning Foley catheter. The resident reported that nursing staff attempted to replace the catheter, however, the balloon was inflated prior to obtaining return of urine. Staff were not able to withdraw the catheter and unable to obtain any drainage. Staff then cut the catheter in an attempt to deflate the balloon, without success. Per the note, the resident was complaining of fullness to his abdomen and feeling sweaty, which happens to him when his bladder gets too full. The resident had a Foley catheter extending about 4.5 centimeters past the end of his penis, and the catheter tubing had been cut. The resident had a palpable distended bladder. At 11:40 p.m., hospital nursing staff attempted to deflate the catheter balloon without success. A bedside ultrasound was performed which was unable to locate the catheter balloon within the resident's bladder. The ultrasound also indicated the resident had a very full bladder. At 12:15 a.m., there was an attempt to deflate the catheter balloon with a guidewire without success. The results of a Computed Tomography (CT) scan at 12:50 a.m., revealed the catheter balloon was inflated within the proximal portion of the resident's urethra, and the resident's bladder had prominent distention with a calculated volume of approximately 1.6 liters. At 2:30 a.m., the resident was taken to [MEDICATION NAME] radiology where a CT-guided technique was used to puncture the catheter balloon, removed the Foley catheter, and a new Foley catheter was placed. The hospital records included that the resident did not have sensation in the lower extremities and he did not feel pain in this area, however he stated that he experienced shakiness and diaphoresis (sweating) instead of pain. Review of the clinical record revealed the resident was readmitted to the facility on [DATE], with an indwelling urinary Foley catheter in place. Review of the physician orders [REDACTED]. Review of a nurse practitioner progress note dated November 20, 2019 revealed the resident reports that the Foley is leaking and wants it changed. Evaluated today and no signs of leaking. An interview was conducted with the resident on December 2, 2019 at 10:05 a.m. He stated that staff in the facility had put his catheter in wrong and he had to go to the hospital and have a procedure to take it out. He said he had a lot of swelling and bleeding afterward. He said that the swelling had since gone down, but the catheter in now was too small and has started to leak. He said he had recently asked to have his catheter changed because it was leaking, but no one would change it. An observation of catheter care was conducted on December 3, 2019 at 2:21 p.m., with a Certified Nursing Assistant (CNA/staff #15). The resident had a Foley urinary catheter in place. During the observation, the resident again stated that his catheter had been leaking, because it was too small. At this time, there was no leaking observed and the size of the catheter was a 14 French (which is smaller than a 16 French catheter, which is the size that was ordered by the physician). An interview was conducted with a Registered Nurse (RN/staff #112) on December 4, 2019 at 2:32 p.m. He stated that he remembered the incident involving difficulty in changing the resident's catheter. He said he was working as the charge nurse, when the resident's nurse (staff #11) came to him and said that the resident's catheter would not flush. He said he went to help remove the catheter, and then he inserted a new catheter. He said the catheter returned urine during the insertion, and he instructed the nurse to monitor the catheter for urine output. He said his shift ended and he went home. He said he later learned that the resident had been sent to the hospital. He said he did not participate in cutting the resident's catheter tubing, as that occurred after his shift ended. An interview was conducted with a RN (staff #11) on December 4, 2019 at 2:43 p.m. She said she was the nurse caring for the resident during the incident when there had been difficulty changing his catheter. She said that she and two nurses (staff #112 and staff #76) tried to remove the catheter, but the balloon would not deflate. She said a new catheter was inserted, and that there was a little urine draining into the bag, but within one hour of insertion she noticed no additional urine was draining. She said that she knew something was wrong, so she and two other nurses tried to cut the catheter tubing as a last resort to see if it would drain urine from the bladder. She said cutting the tubing would not be a normal procedure. She said it did not work and they could not remove the catheter, so they had to send the resident to the hospital. An interview was conducted with a Licensed Practical Nurse (LPN/staff #76) on December 5, 2019 at 2:29 p.m. He said staff #11 had called him over because she could not remove the resident's catheter. He said he attempted to draw fluid out of the catheter balloon, but it did not work. He said they got the charge nurse (staff #112), who was able to deflate the balloon, remove the catheter and insert a new one. He said later in the evening, staff #11 said the resident's new catheter was not draining urine. He said he and the night nurse (RN/staff #24) assisted staff #11 to try to remove the resident's catheter. He said it appeared like the catheter might have been kinked inside the resident's urethra. He said he and staff #24 tried to un-kink the catheter, with no success. He said he had never seen anything like it, as the catheter balloon would not deflate. He said he suggested to staff #24 that maybe if they cut the catheter it would help to remove the kink and release fluid. He said he and staff #24 cut the catheter, but it did not work. He said then the resident was sent to the hospital. An interview was conducted with a RN (staff #24) on December 5, 2019 at 2:41 p.m. He stated that staff #76 came to him because he was trying to flush the resident's catheter. He said the catheter was twisted and they could not get it untangled. He said staff #76 had an idea to cut the catheter to help it unravel. He said they cut it, but it did not help so they called 911. He said he did not cut the catheter, it was the other nurse. An interview was conducted with the DON (staff #123) on December 5, 2019 at 3:12 p.m. She stated her expectation is if a nurse was troubleshooting a resident's catheter, they should attempt several times to inflate, deflate, insert or remove the catheter, according to the situation. She said if the attempts were unsuccessful, the nurse should call the physician and send the resident to the emergency room . She said she would not expect staff to cut the resident's catheter. Review of the facility's policy regarding indwelling catheter insertion revealed that the insertion of a Foley catheter is completed to maintain drainage of urine from the bladder. The procedure should be done by qualified personnel. Instructions included to not force the catheter into the urethra, to insert the catheter until urine begins to flow, and to advance the catheter 1.5 inches beyond the point of urine flow. Hold the catheter in place with one hand and attached a pre-filled syringe to the balloon part of the catheter. Slowly inject sterile water, do not force, if the water does not inject easily or if the resident complains of pain, deflate completely and advance the catheter farther, then re-inflate. Gently pull on the catheter until resistance is felt. This positions the balloon correctly. Check urinary flow frequently and document information.",2020-09-01
597,SHEA POST ACUTE REHABILITATION CENTER,35105,11150 NORTH 92ND STREET,SCOTTSDALE,AZ,85260,2019-12-05,756,D,0,1,MMS711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy and procedures, the facility failed to ensure that recommendations from the pharmacist were acted upon for one of six sampled residents (#41). The deficient practice could result in failure to identify adverse consequences of medication use and residents receiving unnecessary medications. Findings include: Resident #41 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. A pharmacy review dated January 20, 2019 included the following: Please consider DECREASING [MEDICATION NAME] to 15 mg at bedtime for depression once current supply is depleted. If dose reduction is contraindicated, please provide reason(s) for contraindication. CMS does not recognize 'patient stable' or general comment such as 'Benefit v. risk. Further review revealed a space for the provider to respond. There was a x placed in front of the box to disagree, with a handwritten note, Pt has behaviors. The provider response section was signed and dated February 18, 2019. Physician orders [REDACTED]. A psychiatric progress note dated April 9, 2019, included the resident was receiving [MEDICATION NAME] 30 mg and [MEDICATION NAME] 0.5 mg at bedtime. The note included that the resident was stable and had required less re-direction. The note further included to continue current medications, and that a gradual dose reduction (GDR) was not indicated and to follow up in one month. A pharmacy review dated April 29, 2019 included the following: The resident has received [MEDICATION NAME] 30 mg at bedtime for depression since at least December 2017. Most recent MDS and nursing notes indicated no signs or symptoms of depression. CMS requires routine reassessment of antidepressant therapy .Please consider DECREASING [MEDICATION NAME] to 15 mg at bedtime for depression. Further review revealed a space for the provider to respond. There was a x placed in front of the box to disagree, and the form was signed and dated May 22, 2019. There was no documentation on the pharmacy review or any clinical record documentation by the physician/prescriber of the rationale for disagreeing with the pharmacy recommendation. A psychiatric progress note dated May 4, 2019 included the resident's memory was significantly impaired. Staff reported no new behavioral concerns. The note included the resident was receiving [MEDICATION NAME] 0.5 mg and [MEDICATION NAME] 30 mg at bedtime, and the resident was clinically stable on current medications, with no gradual dose reduction or increase indicated. Follow up in one month. A psychiatric progress note dated June 9, 2019, included the resident denied depression or anxiety symptoms. Staff reported the resident had been behaviorally at his baseline. [MEDICATION NAME] 0.5 mg and [MEDICATION NAME] 30 mg at bedtime were listed as current medications. The note included the resident was clinically stable on current medications, with no gradual dose reduction or increase indicated and to follow up in one month. A pharmacy review dated June 26, 2019 included the following: Resident #41 has received [MEDICATION NAME] 30 mg at bedtime for depression since at least December 2017. The resident also receives [MEDICATION NAME] 0.5 mg twice daily for [MEDICAL CONDITION] Disorder. Most recent MDS and nursing notes indicate no signs or symptoms of depression. CMS requires routine reassessment of antidepressant therapy .Please consider DECREASING [MEDICATION NAME] to 15 mg at bedtime for depression. However, there was no evidence of a response by the physician/prescriber regarding the pharmacy recommendation from June 26. A psychiatric progress note dated July 5, 2019, included that staff reported the resident's level of symptoms were at baseline with no acute episodes of agitation. The note included the resident was alert and oriented to self with disorganized thought processes, poor insight and/or judgement, impaired memory and decreased concentration and/or attention. Current medications included [MEDICATION NAME] 0.5 mg at bedtime and [MEDICATION NAME] 30 mg at bedtime. The note also included the resident was clinically stable on current medications, no gradual dose reduction or increase was indicated, and the goal of treatment was to minimize dementia behaviors and provide safety with behavioral interventions and the lowest effective dose of medications. Follow up in one month. A psychiatric progress note dated August 5, 2019, included the resident presented for ongoing management with no changes in mood or behaviors, and staff reported the level of symptoms were at baseline. Current medications were not listed. The note included the resident was clinically stable on current medications, no gradual dose reduction or increase was indicated, and the goal of treatment was to minimize dementia behaviors and provide safety with behavioral interventions and the lowest effective dose of medications. Instructions were to follow up as needed. Review of the clinical record revealed the resident was discharged from the facility on August 7, 2019 and readmitted to the facility on [DATE]. The admission physician's orders [REDACTED]. A pharmacy review dated August 30, 2019, included the resident had a [DIAGNOSES REDACTED]. The review included that upon review of the July 2019 psychiatric notes, the resident had a [DIAGNOSES REDACTED]. The review further included to please clarify the [DIAGNOSES REDACTED]. However, review of the clinical record revealed no evidence of a response from the physician/prescriber regarding the pharmacy recommendation from August 30. A pharmacy review dated September 30, 2019, included the resident had a [DIAGNOSES REDACTED]. The review included that upon review of the July 2019 psychiatric notes, the resident had a [DIAGNOSES REDACTED]. The review also included to please clarify the [DIAGNOSES REDACTED]. There was a handwritten note on the review which read, message sent to look X 2. Review of the clinical record revealed no evidence of a response from the physician/prescriber regarding the pharmacy recommendation from September 30. An interview was conducted with the Director of Nursing (DON/staff #123) on December 5, 2019 at 11:11 a.m. She said all residents received medication reviews monthly by the pharmacist. She said if the pharmacist had recommendations, a form with the recommendation would be provided to the physician, and the physician would decide to agree or disagree with the recommendations. She said the estimated turn around time for receiving a pharmacy recommendation, presenting it to the provider, and documenting the provider's response would hopefully be within a couple of weeks. She said the facility depends on the pharmacist to initiate a GDR for residents taking [MEDICAL CONDITION] medications. She said the facility would follow the lead of pharmacist, and if pharmacist had not recommended a GDR, that is why it had not been done yet. Regarding the missing physician's responses to pharmacy recommendations, she said she would try to locate those response forms. A follow-up interview was conducted with staff #123 on December 5, 2019 at 2:37 p.m. She said she was not able to locate the requested physician responses to the pharmacy recommendations. Review of the facility's Medication Regimen Review policy revealed the drug regimen of each resident would be reviewed at least monthly by the pharmacist. Identified irregularities, medication errors, adverse consequences, and the use of unnecessary drugs would be documented on a written report that is sent to the attending physician, the facility's Medical Director, and the Director of Nursing. The report would list the resident's name, the relevant drug, and the irregularity identified. These reports would be acted upon. The attending physician would document in the resident's medical record that the identified irregularity had been reviewed and what, if any, action had been taken to address it. If there was no change in the medication, the attending physician would document the rationale in the resident's medical record. In performing the drug regimen review, the pharmacist utilizes federally-mandated standards of care, in addition to other applicable standards.",2020-09-01
598,SHEA POST ACUTE REHABILITATION CENTER,35105,11150 NORTH 92ND STREET,SCOTTSDALE,AZ,85260,2019-12-05,758,D,0,1,MMS711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interviews and policy and procedure, the facility failed to ensure that gradual dose reductions (GDR) were attempted or that there was documentation by the physician/prescriber as to why GDR's were contraindicated for one (#41) out of six sampled residents receiving [MEDICAL CONDITION] medications. The deficient practice could result in residents receiving [MEDICAL CONDITION] medications without medical necessity. Findings include: Resident #41 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. The assessment also included the resident required extensive assistance with bed mobility and toileting, and that the resident had received an antidepressant for seven days during the look back period. Review of the physician's orders [REDACTED]. A care plan included the resident was taking antidepressant medication with a goal that the resident would be free from discomfort or adverse reactions. Interventions included to give medications as ordered, monitor and document for side effects, and provide non-pharmacological interventions. A pharmacy review dated January 20, 2019 included the following: Please consider DECREASING [MEDICATION NAME] to 15 mg at bedtime for depression once current supply is depleted. If dose reduction is contraindicated, please provide reason(s) for contraindication. CMS does not recognize 'patient stable' or general comment such as 'Benefit v. risk. The review included a space for the provider to respond. There was a x placed in front of the box to disagree, with a handwritten note, Pt has behaviors. The provider response section was signed and dated February 18, 2019. Review of the clinical record revealed there was no specific documentation by the physician/prescriber as to why a GDR was contraindicated. Review of the physician's orders [REDACTED]. Another order dated March 8, 2019 included for [MEDICATION NAME] (antipsychotic ) 0.5 mg at bedtime related to other specified depressive episodes. Review of the Medication Administration Record [REDACTED]. A psychiatric progress note dated April 9, 2019, included the resident was receiving [MEDICATION NAME] 30 mg and [MEDICATION NAME] 0.5 mg at bedtime. The note included that the resident was stable and had required less re-direction. The note further included to continue current medications, that a GDR was not indicated, and to follow up in one month. A pharmacy review dated April 29, 2019 included the following: Resident #41 has received [MEDICATION NAME] 30 mg at bedtime for depression since at least December 2017. Most recent MDS and nursing notes indicated no signs or symptoms of depression. CMS requires routine reassessment of antidepressant therapy .Please consider DECREASING [MEDICATION NAME] to 15 mg at bedtime for depression. The review included a space for the provider to respond. There was a x placed in front of the box to disagree, and the form was signed and dated May 22, 2019. The provider response did not include a rationale as to why a gradual dose reduction was contraindicated. Review of the MAR for April and May 2019, revealed the resident continued to receive [MEDICATION NAME] 30 mg and [MEDICATION NAME] 0.5 mg at bedtime. The MAR indicated [REDACTED]. A psychiatric progress note dated May 4, 2019, included the resident's memory was significantly impaired. Staff reported no new behavioral concerns. The note included the resident was receiving [MEDICATION NAME] 0.5 mg and [MEDICATION NAME] 30 mg at bedtime, and the resident was clinically stable on current medications with no gradual dose reduction or increase indicated. Follow up in one month. A psychiatric progress note dated June 9, 2019, included the resident denied depression or anxiety symptoms. Staff reported the resident had been behaviorally at his baseline. [MEDICATION NAME] 0.5 mg and [MEDICATION NAME] 30 mg at bedtime were listed as current medications. The note included the resident was clinically stable on current medications with no gradual dose reduction or increase indicated, and to follow up in one month. A pharmacy review dated June 26, 2019 included the following: Resident #41 has received [MEDICATION NAME] 30 mg at bedtime for depression since at least December 2017. The resident also receives [MEDICATION NAME] 0.5 mg twice daily for [MEDICAL CONDITION] Disorder. Most recent MDS and nursing notes indicate no signs or symptoms of depression. CMS requires routine reassessment of antidepressant therapy .Please consider DECREASING [MEDICATION NAME] to 15 mg at bedtime for depression. Review of the clinical record revealed no evidence of a response by the physician/prescriber regarding the pharmacy recommendation from June 26. There was also no documentation by the physician/prescriber as to why a GDR was contraindicated. Review of the MAR for June 2019 revealed the resident received [MEDICATION NAME] 30 mg and [MEDICATION NAME] 0.5 mg at bedtime. The MAR indicated [REDACTED]. A psychiatric progress note dated July 5, 2019, included that staff reported the resident's level of symptoms at baseline with no acute episodes of agitation. The note included the resident was alert and oriented to self with disorganized thought processes, poor insight and/or judgement, impaired memory and decreased concentration and/or attention. Current medications included [MEDICATION NAME] 0.5 mg at bedtime and [MEDICATION NAME] 30 mg at bedtime. The note also included the resident was clinically stable on current medications, no gradual dose reduction or increase was indicated, and the goal of treatment was to minimize dementia behaviors and provide safety with behavioral interventions and the lowest effective dose of medications. Follow up in one month. Review of the MAR for July 2019, revealed the resident received [MEDICATION NAME] 30 mg and [MEDICATION NAME] 0.5 mg at bedtime. The MAR indicated [REDACTED]. A psychiatric progress note dated August 5, 2019, included the resident presented for ongoing management with no changes in mood or behaviors, and staff reported the level of symptoms was at baseline. Current medications were not listed. The note included the resident was clinically stable on current medications, no gradual dose reduction or increase was indicated, and the goal of treatment was to minimize dementia behaviors and provide safety with behavioral interventions and the lowest effective dose of medications. Instructions were to follow up as needed. Review of the MAR for August 2019 revealed the resident continued to receive [MEDICATION NAME] 30 mg and [MEDICATION NAME] 0.5 mg at bedtime from August 1 through 6, 2019. The MAR indicated [REDACTED]. Continued review of the clinical record revealed that from January 2019 through August 7, 2019, there was no evidence that a gradual dose reduction for the [MEDICATION NAME] had been attempted, nor was there documentation by the physician/prescriber that it was clinically contraindicated. Clinical record documentation showed that the resident was discharged from the facility on August 7, 2019 and readmitted to the facility on [DATE]. Review of the admission physician's orders [REDACTED]. A psychoactive medication evaluation dated August 13, 2019, included that the resident was currently receiving [MEDICATION NAME] 30 mg and [MEDICATION NAME] (antipsychotic) 0.5 mg. However, per the physician orders, the resident was receiving [MEDICATION NAME], and not [MEDICATION NAME]. The [DIAGNOSES REDACTED]. The only behavior problem included in the evaluation was recurrent outbursts of anger. Review of the MAR for August 2019 revealed the resident received [MEDICATION NAME] 30 mg and [MEDICATION NAME] 0.5 mg at bedtime from August 13 through 31, 2019. The MAR indicated [REDACTED]. A pharmacy review dated August 30, 2019, included the resident had a [DIAGNOSES REDACTED]. The review further included to please clarify the [DIAGNOSES REDACTED]. Review of the clinical record revealed no evidence of a response from the physician/prescriber regarding the pharmacy review dated August 30. Review of the September 2019 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A pharmacy review dated September 30, 2019, included the resident had a [DIAGNOSES REDACTED]. The review further included to please clarify the [DIAGNOSES REDACTED]. There was a handwritten note on the review which read, message sent to look X 2. However, review of the clinical record revealed no evidence of a response from the physician/prescriber regarding the pharmacy recommendation from September 30. A care plan initiated on October 15, 2019, included the resident was receiving [MEDICAL CONDITION] medications related to major [MEDICAL CONDITION] as evidenced by yelling out. A goal was that the resident would be free from drug related complications. Interventions included to administer medications as ordered, monitor for side effects and provide non-pharmacological interventions. Review of the MAR for October 2019 revealed the resident continued to receive [MEDICATION NAME] 30 mg at bedtime, with zero depression episodes documented and [MEDICATION NAME] 0.5 mg at bedtime, with twenty four episodes of yelling outbursts documented. The annual MDS assessment dated [DATE] included a BIMS score of 9, which indicated the resident had moderate cognitive impairment. The assessment included that the resident had received an antidepressant and an antipsychotic for seven days of the look back period. The assessment also included that a GDR for antipsychotic medication had not been documented by the provider as clinically contraindicated. Review of the MAR for November 2019 revealed the resident continued to receive [MEDICATION NAME] 30 mg at bedtime, with zero depression episodes documented and [MEDICATION NAME] 0.5 mg at bedtime, with fifty six episodes of yelling outbursts documented. Review of the MAR for December 1 through 4, 2019 revealed the resident continued to receive [MEDICATION NAME] 30 mg at bedtime, with zero depression episodes documented and [MEDICATION NAME] 0.5 mg at bedtime, with zero episodes of yelling outbursts documented. Review of the clinical record from August 13, 2019 through December 4, 2019, revealed no evidence that a gradual dose reduction had been attempted or that a gradual dose reduction was contraindicated for [MEDICATION NAME] and [MEDICATION NAME]. An observation was conducted of the resident on December 5, 2019 at 9:54 a.m. The resident was sitting in bed with the head of the bed raised about forty-five degrees. The resident was leaning significantly to his left side. No behaviors were observed at this time. An interview was conducted with the Director of Nursing (DON/staff #123) on December 5, 2019 at 11:11 a.m. She said for [MEDICAL CONDITION] medications, she would expect nurses to monitor and document targeted behaviors related to medication use. She said all residents receive medication reviews monthly by the pharmacist. She said if the pharmacist had recommendations, a form with the recommendation would be provided to the physician, and the physician would decide to agree or disagree with the recommendations. She said the estimated turnaround time for receiving a pharmacy recommendation, presenting it to the provider and documenting the provider's response would hopefully be within a couple of weeks. She said the facility depends on the pharmacist to initiate a GDR for residents taking [MEDICAL CONDITION] medications. She said the facility would follow the lead of the pharmacist, and if the pharmacist had not recommended a GDR, that would be why it had not been done yet. Regarding the missing physician's responses to pharmacy recommendations, she said she would try to locate those response forms. She said social services would know more about coordinating evaluations and care with the psychiatric providers. Interviews were conducted with the social services supervisor (staff #55) on December 5, 2019 at 12:11 p.m. and at 12:58 p.m. She said residents would receive psychiatric evaluations and care based on the results of social services assessments or a referral from the provider. She said the psychiatric provider comes to the facility to see residents every other week. She said for resident #41, there was a point where he was screaming and yelling out, but it had subsided. She said the resident had been followed by the psychiatric provider, but then he was pretty stable and was discharged by the psychiatric provider on August 5, 2019. A follow-up interview was conducted with staff #123 on December 5, 2019 at 2:37 p.m. She said she was not able to locate the requested physician responses to pharmacy recommendations. Review of the facility's policy for Psychoactive Medications revealed that each resident requiring psychoactive medications would have ongoing assessments and care plan reviews. The goal would be to reduce the duration and/or dose of the medication. Pharmacists would act as sources of information to define the criteria for monitoring medication use, which may include cautions, warnings and identified adverse consequences. The facility would perform a GDR to find an optimal dose or determine if continued use of the medication benefited the resident. A GDR may be indicated when the resident's clinical condition had stabilized. A GDR would be considered contraindicated if the physician had documented a clinical rationale for why any attempted dose reduction would be likely to impair the resident's function or cause psychiatric instability, or if the resident's targeted symptoms returned or worsened after the most recent attempt at a GDR, and the physician had documented a clinical rationale for why any additional attempted dose reductions would be likely to impair the resident's function or cause psychiatric instability.",2020-09-01
599,SHEA POST ACUTE REHABILITATION CENTER,35105,11150 NORTH 92ND STREET,SCOTTSDALE,AZ,85260,2019-12-05,759,D,0,1,MMS711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and policy and procedure, the facility failed to ensure that the medication error rate was not greater than 5%, by failing to administer medications as ordered to one resident (#287). The medication error rate was 6.45%. Findings include: Resident #287 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the admission physician's orders [REDACTED]. A medication administration observation was conducted on December 4, 2019 at 8:12 a.m., with a Licensed Practical Nurse (LPN/staff #43). At this time, staff #43 was observed to prepare medications for resident #287, including retrieving the [MEDICATION NAME] Diskus inhaler. Staff #43 was not observed to prepare the [MEDICATION NAME] powder in liquid. Prior to approaching resident #287, staff #43 placed the [MEDICATION NAME] Diskus inhaler back in the medication cart. Staff #43 was then observed administering other medications to resident #287. Staff #43 was not observed offering or administering the [MEDICATION NAME] Diskus inhaler or the [MEDICATION NAME] to the resident. However, review of the Medication Administration Record [REDACTED]. An interview was conducted with staff #43 on December 4, 2019 at 1:34 p.m. She said that she had not offered the [MEDICATION NAME] to the the resident or provided the resident a chance to refuse. She said the resident had a tendency to always refuse the [MEDICATION NAME], and she had been meaning to ask the physician if the order could be discontinued. She said she did not realized that she had placed the [MEDICATION NAME] Diskus inhaler back in the cart, prior to administration. She said she had not administered the [MEDICATION NAME] to the resident, and it had been a mistake to document the medication as administered. An interview was conducted with the Director of Nursing (DON/staff #123) on December 5, 2019 at 11:11 a.m. She stated her expectation is that medications should be offered to residents, even if the residents had a tendency to refuse. She said after three days of documented medication refusals, the physician should be notified. She said the physician would decide whether or not to continue the medication. She said the facility should continue to offer the medication or the order should be discontinued, according to the physician's direction. Review of the facility's Medication Administration policy revealed that all medications should be administered as prescribed by the attending physician, and that scheduled medications must be administered within the facility time frame. If medication was withheld, refused or given other than at the scheduled time, documentation would be reflected in the clinical record.",2020-09-01
600,SHEA POST ACUTE REHABILITATION CENTER,35105,11150 NORTH 92ND STREET,SCOTTSDALE,AZ,85260,2019-12-05,867,E,0,1,MMS712,"Based on concerns identified during the revisit survey and staff interviews, the facility failed to ensure that the Quality Assessment and Assurance (QAA) committee implemented plans of action which corrected the deficient practices. The deficient practice resulted in concerns which were identified on the recertification survey not being corrected and the deficient practices continuing to exist. Findings include: During a revisit survey conducted on February 13 and 14, 2020, the following concerns were identified: -Two residents with hearing deficits and who utilized hearing aids did not have the CNA monitoring documentation in place as per their plan of correction. Also, they did not have care plans to address the hearing deficit or the use of hearing aids. -Four residents with urinary catheters and/or had no orders for the size of the catheter; no orders when to change the catheters; when catheters were changed there was no documentation of confirmation of placement and no documentation of any urine return after catheter was inserted; one catheter was inserted with no orders for the size that was inserted, one resident had documentation of 25 straight catherizations with no supportive documentation of why it was necessary, no assessment pre and post catherization and no urine output amounts were documented; and a lack of catheter care being provided; failed to act upon a pharmacy recommendation; and failed to ensure a gradual dose reduction was attempted or that there was documentation by the physician as to why the gradual dose reduction was contraindicated. These concerns were also identified on the recertification survey and the facility had developed a plan of correction to address these issues and addressed the issues in their QAA program. However, these concerns were again identified during the revisit survey. On February 14, 2020 at 2:43 p.m., an interview was conducted with the Administrator (staff #22) and the Director of Nursing (DON/staff #2). Staff #22 stated that the QAA/Quality Assurance and Performance Improvement (QAPI) committees have monitored the areas of concern listed in the Plan of Correction, by discussing the areas daily in the first meeting of the morning. He stated that QAPI meets once per month to discuss system failures, and that meeting includes the physician and the leadership team. He stated the plan of correction was taken to QAPI and the team addressed the issues. He stated the team ensures that the corrective actions had been implemented and maintained by putting timelines on the corrective actions and identifying a staff member to be responsible for it. He said the issues will be addressed again and again, utilizing new interventions, until the issues are resolved. Staff #2 stated that she ensured that all staff completed the catheter in-services by conducting directed in-services for the CNA's and for the nurses. She stated that it was part of QAPI. Staff #22 said that there have been no further problems with catheters. He stated the audits give him feedback. Staff #22 stated that the QAA committee will monitor an issue that has been corrected until the committee feels like the issue has been resolved. Staff #2 stated that she ensured that all staff from different shifts received the in-service education by holding meetings at different times. Regarding the in-service for catheters, staff #2 stated that she really couldn't answer whether all the staff had either attended the in-service or reviewed the Power Point presentation.",2020-09-01
601,TEMPE POST ACUTE,35106,6100 SOUTH RURAL ROAD,TEMPE,AZ,85283,2017-04-20,241,E,0,1,UZSR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident, family and staff interviews, facility documentation and policy and procedures, the facility failed to ensure that call lights in five resident's rooms (#'s 39, 44, 55, 61 and 63) were answered in a timely manner. Findings include: -Resident #63 was admitted to the facility on (MONTH) 15, (YEAR), with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 26, (YEAR), revealed a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. During an interview conducted at 1:08 p.m. on (MONTH) 17, (YEAR), the resident stated she had to wait forever when she pushed the call light. She stated that sometimes she has waited up to one hour for staff to respond. A review of the call light log for this resident's room revealed that between (MONTH) 1-19, (YEAR), the call light was on for 20 minutes to 2 hrs and 42 minutes, on 17 occasions. -Resident #39 was admitted to the facility on (MONTH) 16, (YEAR), with [DIAGNOSES REDACTED]. A review of the admission MDS assessment dated (MONTH) 23, (YEAR), revealed a BIMS score of 15, indicating the resident was cognitively intact. During an interview conducted at 1:17 p.m. on (MONTH) 17, (YEAR), the resident stated he had to wait an hour for staff assistance. Review of the call light log for this resident's room revealed that between (MONTH) 1-19 (YEAR), the call light was on for 20 minutes to 2 hours and 5 minutes, on 13 occasions. -Resident #55 was admitted to the facility on (MONTH) 18, (YEAR), with [DIAGNOSES REDACTED]. A review of the annual MDS assessment dated (MONTH) 11, (YEAR), revealed a BIMS score of 15. During an interview conducted at 1:22 p.m. on (MONTH) 17, (YEAR), the resident stated that staff take a long time to answer the call light and it could be over an hour before the call light was answered. A review of the call light log for this resident's room revealed that between (MONTH) 1-19 (YEAR), the call light was on for 20 minutes to 2 hours and 37 minutes, on 35 occasions. -Resident #44 was admitted to the facility on (MONTH) 11, (YEAR), with [DIAGNOSES REDACTED]. A review of the admission MDS assessment dated (MONTH) 6, (YEAR), revealed a BIMS score of 15. During an interview conducted at 1:29 p.m. on (MONTH) 17, (YEAR), the resident stated he felt the facility was understaffed. A review of the call light log for this resident's room revealed that between (MONTH) 1-19, (YEAR), the call light was on for 20 minutes to 4 hours and 53 minutes, on approximately 46 occasions. -Resident #61 was admitted to the facility on (MONTH) 28, (YEAR), with [DIAGNOSES REDACTED]. A review of the admission MDS assessment dated (MONTH) 7, (YEAR), revealed the resident's speech was unclear and was sometimes understood, however, the resident's decision making ability was severely impaired. Observations of the resident conducted on all days of the survey revealed the resident could not turn on the call light, without assistance. During an interview conducted at 8:28 a.m. on (MONTH) 18, (YEAR), a resident's family member stated that sometimes it takes a long time to get help from staff. The family member stated that on one occasion it took over 2 hours to get a staff member to respond to the call light and provide incontinence care to the resident. A review of the call light log for this resident's room revealed that between (MONTH) 1-19, (YEAR), the call light was on for 51 minutes to 2 hours and 29 minutes, on five occasions. -During a telephone interview conducted with another resident's family member at 3:00 p.m. on (MONTH) 19, (YEAR), the family member stated that the resident in room [ROOM NUMBER] was often heard yelling for help and staff were extremely slow in answering the resident's call light. A review of the call light log for room [ROOM NUMBER] revealed that between (MONTH) 1-19, (YEAR), the call light was on for 20 minutes to 2 hours and 48 minutes, over 40 occasions. During an interview conducted at 2:36 p.m. on (MONTH) 20, (YEAR), a certified nursing assistant (CNA/staff #14) stated she answers call lights within two to five minutes. She said she carries a pager that notifies her if a resident turns on the call light. She stated that if she is in another room and is unavailable, after 5 minutes she uses her walkie talkie to notify another staff member to answer the call light. During an interview conducted at 2:39 p.m. on (MONTH) 20, (YEAR), a Licensed Practical Nurse (LPN/staff #50) stated that call lights should be answered within 5 minutes, except during an emergency. During an interview conducted at 2:42 p.m. on (MONTH) 20, (YEAR), a LPN (staff #101) stated that after five minutes if the call light has not been answered, the nurse should respond to the call light. During an interview conducted at 2:45 p.m. on (MONTH) 20, (YEAR), the Executive Director (staff #102) stated this problem was identified in QA (Quality Assurance) and staff were provided an in-service on (MONTH) 14, (YEAR), regarding answering call lights. She said the call light system is an electronic system that notifies the CNA's when a call light is turned on. She stated the call lights should be answered within five minutes, but if not answered in 8 minutes, the electronic call light system sends a message to the nurse manager's pager. The Executer Director further stated that if the call light is not answered within 10 minutes, a message is sent to the Director of Nursing's pager. An interview was conducted at 2:50 p.m. on (MONTH) 20, (YEAR) with the Director of Nursing (DON/staff #42) in a hallway outside of the chapel annex. The DON stated the use of the pagers and walkie talkies was recently instigated. She stated that if the call lights are not answered within 10 minutes, a message is sent to her pager. However, the DON further stated that her pager was in her office and was not on her at this time. The Executive Director provided QA documentation regarding call lights. The documentation was dated (MONTH) 29, (YEAR) and included that Social Services had reported and discussed that in (MONTH) there were two complaints about call light response times. The documentation also included all have been resolved, call lights were addressed with staff members. The team action plan included that the Executive Director . has ordered pagers that alert room call lights for the CNAs. Although the facility did identify a concern regarding call light response times and implemented an action plan, there were still ongoing concerns identified in (MONTH) (YEAR) regarding call lights not being answered in a timely manner. Review of the Use of Call Light policy and procedure revealed All facility personnel must be aware of the call lights at all times and Answer ALL call lights promptly whether or not you are assigned to the resident. The policy also included to Answer call lights in a prompt, calm, courteous manner; turn off the call light as soon as you enter the room.",2020-09-01
602,TEMPE POST ACUTE,35106,6100 SOUTH RURAL ROAD,TEMPE,AZ,85283,2017-04-20,280,E,0,1,UZSR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff and resident interviews, and a review of policies and procedures, the facility failed to ensure that pressure ulcer care plans were revised for two residents (#50 and 27) and failed to ensure that one resident (#63) was provided an opportunity to attend care plan conferences. Findings include: -Resident #50 was admitted on (MONTH) 22, (YEAR), with [DIAGNOSES REDACTED]. The resident discharged on (MONTH) 7, (YEAR) to the hospital. A review of the clinical record revealed documentation that the resident had developed two stage two pressure ulcers in (MONTH) (YEAR), which then healed in (MONTH) (YEAR). The clinical record documentation further included that in (MONTH) (YEAR), the resident developed a pressure ulcer to the coccyx and one on the right gluteal fold. By (MONTH) 7, both pressure ulcers were identified as unstageable. In addition, the documentation included the resident had developed a pressure ulcer to the left buttocks on (MONTH) 2. Review of the resident's care plans, including one for at risk for skin integrity revealed that the care plans were not revised in (MONTH) (YEAR) or in (MONTH) or (MONTH) (YEAR), to reflect the development of multiple pressure ulcers. The care plans did include any additional interventions which were implemented to prevent further skin breakdown. An interview was conducted on (MONTH) 18, (YEAR) at 11:05 a.m., with the Director of Nursing (staff #42). She stated that the skin integrity care plan should have been revised and the wound nurse would have been responsible for the revision. An interview was conducted on (MONTH) 18, (YEAR) at 2:30 p.m. with the Assistant Director of Nursing (wound nurse/staff #35) who stated at that time, she was not aware that the resident had developed multiple pressure ulcers and therefore, she had not revised the skin integrity care plan to include the resident had actual pressure ulcers. -Resident #63 was admitted on (MONTH) 15, (YEAR), with [DIAGNOSES REDACTED]. During a resident interview conducted on (MONTH) 17, (YEAR) at 11:01 a.m., the resident stated that she was not able to attend the care plan conference meetings, because they were always scheduled at lunch time. A review of the MDS (Minimum Data Set) assessment schedule revealed that a significant change MDS was completed on (MONTH) 23, (YEAR), and that a quarterly MDS assessment was completed on (MONTH) 24, (YEAR) and on (MONTH) 26, (YEAR). A care plan conference invitational letter regarding the (MONTH) (YEAR), meeting was unable to be located in the clinical record. Review of a care plan conference invitational letter dated (MONTH) 12, (YEAR) which was sent to the resident and her family revealed the resident's care plan conference was scheduled for (MONTH) 26, (YEAR) at 12:00 p.m. Another care plan conference invitational letter which was sent to the resident and her family was dated (MONTH) 22, (YEAR). The letter included that the resident's care plan conference was scheduled for (MONTH) 6, (YEAR) at 11:30 a.m. An interview was conducted on (MONTH) 20, (YEAR) at 10:30 a.m., with the Social Service Director (staff #74), who stated that the MDS staff determine which residents will be reviewed at the care plan conference meeting. According to staff #74, the MDS staff then provide the receptionist with the list of residents who are scheduled for a care plan conference, so that the invitational care plan conference letters can be sent to the resident and their family. Staff #74 also stated that the invitational care conference letters include the date and time of the care plan conference. An interview was conducted on (MONTH) 20, (YEAR) at 10:45 a.m., with the MDS staff (staff#13), who stated that the receptionist determines the time of the care plan conference. Staff #13 stated that care plan conferences usually start at 10:00 a.m., and could last until 12:45 p.m., depending on the number of residents scheduled for a care plan meeting. Following a review of the (MONTH) and (MONTH) (YEAR) care plan invitational letters, she stated that she had not realized the resident might have chosen not to attend the care plan conference meeting, because it was during her lunch time. Staff #13 further stated that the care plan conference meetings could easily be changed to accommodate residents' meal time, by scheduling morning and afternoon care plan conference meeting, with a scheduled break for lunch. A facility policy titled, Care Plan Policy and Procedure included the following: 15. Residents have the right to participate in the development and implementation of person-centered plan of care. The facility must inform the resident of the right to participate in his/her treatment which includes established goals, type and frequency of care, and seeing the care plan. 16. The IDT (Interdisciplinary Team) will involve the resident/resident representative in the development of their care plan in order to promote autonomy, dignity, self-determination and participation and individual care. -Resident #27 was admitted on (MONTH) 15, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident was admitted with a stage II pressure ulcer to the coccyx and a left hip pressure ulcer. Review of the skin care plan initiated on (MONTH) 16, (YEAR) and revised on (MONTH) 18, (YEAR), revealed the resident was at increased risk for skin breakdown due to loss of mobility, nutritional compromise and incontinence. The care plan also included that the resident had a stage II pressure ulcer to the coccyx and a pressure ulcer to the left hip. Interventions were as follows: inspect skin daily with cares and nursing assistant to report any problems to the nurse; position the resident's body with pillows/support devices to protect bony prominences, turn and reposition resident every 2 hours, air mattress, and treatments as ordered. Regarding the coccyx pressure ulcer: A wound note dated (MONTH) 16, (YEAR) described the coccyx stage II pressure ulcer as having a pink wound bed with 100% [MEDICATION NAME] tissue and no tunneling or undermining was present. A wound note dated (MONTH) 6, (YEAR) included that the coccyx pressure ulcer was now unstageable. On (MONTH) 18, (YEAR), a wound note documented that the coccyx pressure ulcer was a stage IV, with undermining present from 12 o'clock to 3 o'clock and the wound bed had 100% pink [MEDICATION NAME] tissue. Further review of the resident's care plans including the skin care plan revealed they were not revised to reflect that the coccyx wound had deteriorated to an unstageable pressure ulcer, nor were there additional interventions included on the care plan to prevent further skin breakdown. Regarding the left trochanter pressure ulcer: According to the wound documentation, the resident was admitted with a pressure ulcer to the left trochanter and the wound bed was described as having 80% slough. On (MONTH) 30, and (MONTH) 6, the wound documentation included that the pressure ulcer had 100% [MEDICATION NAME] tissue. The wound documentation dated (MONTH) 12, (YEAR) revealed the left trochanter hip was now unstageable and the wound bed had 100% slough, with no tunneling or undermining. Another wound note dated (MONTH) 19, (YEAR), included the left trochanter pressure ulcer was unstageable, as the wound bed was obscured with 100% slough, with no tunneling or undermining. Further review of the resident's care plans including the skin care plan revealed they were not revised to reflect the presence of an unstageable pressure ulcer to the left trochanter, nor were there additional interventions included on the care plan to prevent further skin breakdown. Regarding the right gluteal fold pressure ulcer: Review of the nursing bath skin check dated (MONTH) 24, (YEAR) revealed the resident had two new wounds. The wounds were described as a right gluteal fold abrasion with a scab, which was directly under the edge of the brief. The second wound was described as a maroon colored area to the right gluteal fold, which was directly under where the edge of the brief meets the skin. Review of a wound note dated (MONTH) 24, (YEAR) revealed a new shearing wound was present on the right gluteal fold. The wound was described as having 20% [MEDICATION NAME] tissue and 80% was covered with a scab, and the wound edges were macerated from moisture. A wound note dated (MONTH) 12, (YEAR) included documentation that the distal right gluteal fold wound was now a stage II pressure ulcer, with 100 % granulation tissue. This note also included the resident had another open wound on the right gluteal fold, which was more proximal and was an unstageable pressure ulcer. The wound bed was described as having 100% slough, with no tunneling or undermining. Further review of the resident's care plans including the skin care plan revealed they were not revised to reflect the presence of any right gluteal fold pressure ulcers, nor were there additional interventions included on the care plan to prevent further skin breakdown. Regarding the upper mid vertebral wound: Review of the clinical record revealed there were no wounds to the resident's upper mid vertebral area from the time of admission through (MONTH) 31, (YEAR). Review of a wound note dated (MONTH) 6, (YEAR) revealed the new onset of a mid upper vertebral shearing wound. The wound bed was described as having 100% [MEDICATION NAME] tissue. Review of a wound note dated (MONTH) 12, (YEAR) revealed the upper mid vertebral shearing wound had deteriorated to an unstageable pressure ulcer and the wound bed was 98% slough and 2% granulation tissue. A wound note dated (MONTH) 19, (YEAR) included documentation that the upper mid vertebral wound was a shearing wound, with a 100% [MEDICATION NAME] tissue and no undermining or tunneling was present. Further review of the resident's care plans including the skin care plan revealed they were not revised to reflect that the resident had a wound to the upper mid vertebral, nor were there additional interventions included on the care plan to prevent further skin breakdown. An interview was conducted with the wound nurse (staff #35) on (MONTH) 20, (YEAR) at 11:58 a.m. Staff #35 stated that the care plan should be updated for newly identified wounds and should reflect progression of the wounds. She stated that generally MDS staff or herself updates the care plans. An interview with the Director of Nursing (DON/staff #42) was conducted on (MONTH) 20, (YEAR) at 12:40 p.m. She stated that each wound should be included on the care plan. She stated this resident's care plans were more generalized, and with so many wounds this shouldn't occur. A facility policy titled, Resident Change of Condition included to update the resident's Care Plans with new additional problems, goals, approaches and new orders. Another facility policy titled, Prevention and treatment of [REDACTED]. The policy further included that if a resident is admitted with or there is a new development of a pressure ulcer, the care plan should be updated and the plan of care should be re-evaluated as appropriate.",2020-09-01
603,TEMPE POST ACUTE,35106,6100 SOUTH RURAL ROAD,TEMPE,AZ,85283,2017-04-20,314,G,0,1,UZSR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, observations, staff interviews and policy and procedures, the facility failed to ensure the necessary care and treatments were provided for two residents (#50 and #27), with pressure ulcers. Findings include: -Resident #50 was admitted on (MONTH) 22, (YEAR), with [DIAGNOSES REDACTED]. The resident was discharged to the hospital on (MONTH) 7, (YEAR). A facility form titled nursing bath check dated (MONTH) 11, (YEAR) included that no skin issues were present. Regarding the coccyx: A nursing note dated (MONTH) 18, (YEAR) included the resident had a skin abrasion on the coccyx and that an order for [REDACTED]. A nurse practitioner (NP) order dated (MONTH) 18, (YEAR) included to cleanse the open area on the coccyx with normal saline, pat dry and apply the Duoderm every three days and PRN (as needed). A Braden risk assessment dated (MONTH) 19, (YEAR) identified that the resident was at mild risk for the development of pressure ulcers. According to a nursing skin bath check form dated (MONTH) 19, (YEAR), the resident had a pressure ulcer on the coccyx. This form included a section to identify the site, type and stage of the pressure ulcer, the measurements and an area to write a narrative nursing note regarding the assessment. However, the documentation only included that the coccyx continued with redness and that there was an opened area, which was covered with Duoderm. A quarterly MDS (Minimum Data Set) assessment dated (MONTH) 30, (YEAR), assessed the resident to have moderate cognitive impairment, was non-ambulatory, and required extensive assistance with bed mobility and personal hygiene. The MDS also included that a stage 2 pressure ulcer was present. A care plan identified that the resident was at risk for skin breakdown related to fragile skin, incontinent of bowel, and due to requiring assistance with transfers. The goal was that the resident would not show any complications with skin integrity. Interventions included the following: inspect skin daily with cares and for nursing assistant to report any concerns to the nurse, moisturize dry skin as needed, position body with pillow/support devices and to protect bony prominences. Further review of the clinical record revealed there was no order for the Duoderm to the coccyx. There was also no documentation that the coccyx wound had been thoroughly assessed which included measurements, a description of the wound bed and surrounding tissue, if any drainage was present, or any staging of the pressure ulcer, from (MONTH) 18-31. Review of the (MONTH) (YEAR) Treatment Administration Record (TAR) revealed there was no documentation that Duoderm was being applied to the coccyx. Review of a nursing skin bath check form dated (MONTH) 2, (YEAR) revealed a pressure ulcer was present on the resident's coccyx. Again, the documentation did not include the site, stage, measurements or a description of the wound bed. Five days later, on (MONTH) 7, (YEAR), a NP progress note included that an unstageable pressure ulcer was present on the coccyx and that eschar covered the wound bed. A nursing assessment was completed on (MONTH) 7, (YEAR) and included the following; -Unstageable pressure ulcer which measured 10.5 by 5 cm. -Eschar and slough obscured the wound bed (no percent of each was documented). -The edges were slightly macerated and the skin was beginning to lift in several areas. -Strong odor present. -Moderate amount of serosanguineous drainage was present. -The site was painful. Review of the pressure ulcer treatment orders for the coccyx dated (MONTH) 7, (YEAR) included the following: -Cleanse with normal saline. -Pat dry. -Apply Santyl to the wound bed. -Cover with barrier island dressing. -Administer the treatment every three days and PRN. -Low air loss mattress. -Turn and reposition every three hours. Per the clinical record documentation, the resident was discharged to the hospital on (MONTH) 7, (YEAR). Regarding the right gluteal fold: A nursing note dated (MONTH) 13, (YEAR), included the resident had a skin abrasion on the right gluteal fold and that Duoderm was applied. However, review of the clinical record revealed there was no physician's order for Duoderm for the right gluteal fold. In addition, the (MONTH) (YEAR) TAR did not include that Duoderm was being applied to the right gluteal fold. There was no further clinical record documentation of a thorough assessment of the right gluteal fold from (MONTH) 13 through (MONTH) 6. There was also no documentation that the physician/NP was notified of the wound during this time frame. A NP note dated (MONTH) 7, (YEAR), now included the resident had a right gluteal fold pressure ulcer, which had eschar covering the wound bed. A nursing assessment dated (MONTH) 7, (YEAR) described the right gluteal fold pressure ulcer as follows: -Unstageable pressure ulcer which measured 4.5 by 5 cm (centimeters). -The site was covered in approximately 80% eschar and 20% slough. -The edges were red and macerated. -A small amount of serosanguineous drainage was present. -A slight foul odor was present. -The site was painful. Review of the right gluteal fold pressure ulcer treatment orders dated (MONTH) 7, (YEAR) included the following: -Cleanse with normal saline. -Pat dry. -Apply Santyl to the wound bed. -Cover with barrier island dressing. -Administer the treatment every three days and PRN. -Low air loss mattress. -Turn and reposition every three hours. Regarding the left buttocks: Review of the clinical record revealed no documentation that the resident had a pressure ulcer to the left buttocks in (MONTH) (YEAR). Review of the (MONTH) 2, (YEAR) nursing skin bath check form revealed the resident now had a pressure ulcer to the left buttocks. However, the documentation did not include a thorough assessment of the pressure ulcer, which included measurements, a description of the wound bed and surrounding tissue, if any drainage was present and the stage of the pressure ulcer. There was no further clinical record documentation regarding the left buttocks pressure ulcer from (MONTH) 2 through 6. There was also no documentation that the physician/NP had been notified during this time frame and there were no treatment orders obtained. Further review of the resident's care plans including one for at risk for skin integrity revealed that the care plans were not revised to reflect the development of multiple pressure ulcers and there were no additional interventions which were implemented to prevent further skin breakdown. An interview was conducted on (MONTH) 18, (YEAR) at 11:05 a.m. with the Director of Nursing (staff #42). She stated licensed staff who had completed the nursing bath check forms, should have provided a complete and thorough assessment of the pressure ulcer. She stated that she was unable to provide any documentation that the pressure ulcer on the resident's coccyx and had been thoroughly assessed. In regards to the (MONTH) 2, (YEAR) nursing bath check form which identified that another pressure ulcer was present on the resident's left buttocks, staff #42 stated that she was unable to locate any documentation that the pressure ulcer had been assessed. Staff #42 further stated that complete and thorough pressure ulcer assessments should have been provided which included the stage, measurements and a description of the pressure ulcers. An interview was conducted on (MONTH) 18, (YEAR) at 10:00 a.m., with the resident's physician (staff #96). She stated that she was able to recall this resident, however, the NP primarily cared for the resident and that she would see the resident every few months. Staff #96 stated that she became aware of the pressure ulcer issues when the NP reported to her that two unstageable pressure ulcers were discovered on (MONTH) 7. An interview was conducted on (MONTH) 18, (YEAR) at 2:20 p.m., with the Assistant Director of Nursing (wound nurse/registered nurse/staff #35). She stated that she was not aware of the (MONTH) 19 or (MONTH) 2, assessments which had identified that pressure ulcers were present. She stated the licensed staff should have notified her of the change in the resident's skin and should have notified the NP/physician and obtained treatment orders. Staff #35 stated that she was first made aware of the pressure ulcers on (MONTH) 7. On (MONTH) 19, (YEAR) at 9:00 a.m. a follow up interview was conducted with the staff #42. She stated that the facility did not have standing treatment orders, and that pressure ulcer treatment orders should have been obtained from the NP or physician and then documented on the TARs. On (MONTH) 19, (YEAR) at 2:20 p.m., an interview was conducted with the NP (staff #97). Staff #97 stated that she had been called regarding a change in the resident's condition on (MONTH) 6, and ordered multiple laboratory test and diagnostic studies to be done. She stated she then saw the resident on (MONTH) 7, (YEAR), and observed two unstageable pressure ulcers on the resident's coccyx and buttocks. She stated that she had not previously been notified of the two unstageable pressure ulcers. -Resident #27 was admitted on (MONTH) 15, (YEAR) with [DIAGNOSES REDACTED]. Regarding the coccyx pressure ulcer: Review of the nursing day 1 admission assessment dated (MONTH) 15, (YEAR) revealed the resident had one stage II sacral/coccyx pressure ulcer, which measured 1 x 1 x 0 cm and another stage II sacral/coccyx pressure ulcer, which measured 3 x 3 x 0 cm. There was no description of the wound beds. Review of the nursing day 2 post admission assessment dated (MONTH) 16, (YEAR) revealed the two coccyx pressure ulcers had connected together. Review of the nurses weekly wound note dated (MONTH) 16, (YEAR) revealed the coccyx stage II pressure ulcer was present on admission, and measured 3 x 3 x 0 cm. The wound was described as having a a pink wound bed with 100% [MEDICATION NAME] tissue, no odor, no tunneling or undermining was present, and had dry/intact wound edges. The note included the wound was stable and covered with an allevyn dressing. According to a skin care plan dated (MONTH) 16, (YEAR), the resident was at increased risk for skin breakdown related to a loss of mobility, nutritional compromise and incontinence. The care plan included that the resident was admitted with a stage II pressure ulcer to the coccyx. Interventions were as follows: inspect skin daily with cares and nursing assistant to report any problems to the nurse; air mattress; position the resident's body with pillows/support devices; protect bony prominences and treatments as ordered. Despite documentation of the resident having a stage II pressure ulcer to the coccyx, there were no physician ordered treatment for [REDACTED]. Wound treatment orders were obtained two days after admission on (MONTH) 17, (YEAR). A physician's order included to cleanse the coccyx wound with normal saline, pat dry, apply skin prep around the wound edges, apply hydrogel to the wound bed, cover with a barrier island dressing every Monday, Wednesday and Friday and as needed for soilage/dislodgement. Review of the Braden Risk assessment dated (MONTH) 21, (YEAR) revealed the resident was at moderate risk for developing pressure sores. This assessment included the resident had very limited sensory perception, was always incontinent, had very limited mobility and had a potential problem with friction and shear. Also the following risk factors were listed: head of bed elevated most of the day, required assistance with ADL's and had fragile skin. Review of the admission MDS assessment dated (MONTH) 22, (YEAR) revealed the resident was assessed to have severe cognitive impairment and required extensive assistance of two persons with bed mobility and hygiene. The MDS also included the resident was at risk for pressure ulcer development and had two stage 2 pressure ulcers upon admission. The coccyx pressure ulcer was assessed eight days after the last assessment. According to the nurses weekly wound document dated (MONTH) 24, (YEAR), the stage II coccyx pressure ulcer measured 3 x 2 x 0 cm, with no tunneling or undermining, had a scant amount of serous drainage, no odor, and the surrounding tissue had normal firmness. The wound bed was described as follows: loose dark purple skin obscuring parts of the wound bed, edges are purple, rolled and macerated from moisture exposure, wound bed also has dark, pink [MEDICATION NAME] tissue (30% [MEDICATION NAME] tissue and 70% loose purple skin). The wound was documented as being stable. Review of the nurses weekly wound document dated (MONTH) 30, (YEAR) revealed the stage II coccyx pressure ulcer measured 3 x 3 x 0 cm with a 100 % [MEDICATION NAME] tissue, wound edges were intact but exposed to moisture from stool, the wound edges were no longer rolled, and the dark purple skin was receding from the wound bed. The wound bed was described as being completely smooth, with no tunneling and no undermining and the wound was stable. A physician's order dated (MONTH) 5, (YEAR) included to discontinue the previous treatment and to cleanse the coccyx wound with normal saline, pat dry, apply a nickel-thick layer of Santyl to the wound bed, apply skin prep around the wound perimeter, and cover with a barrier island dressing twice a day and as needed, and to initial and date the dressing. Review of the nurses weekly wound document dated (MONTH) 6, (YEAR) revealed the coccyx pressure ulcer measured 2.4 x 2 x 0 cm and the wound bed had 100% slough, due to constant exposure to moisture, the edges were flat with dark discoloration, and no tunneling or undermining was present. The pressure ulcer was identified as a stage II, despite having 100% slough covering the wound bed. The note further included the wound had declined and the physician was notified on (MONTH) 5. Review of the (MONTH) (YEAR) TAR revealed that the Santyl treatment to the coccyx was not performed as ordered on (MONTH) 7 and 8, during the 6 a.m. - 2 p.m. shift, and was not performed on (MONTH) 10, 11, and 12, during the 2 p.m. - 10 p.m. shift. Review of the nurses weekly wound document dated (MONTH) 12, (YEAR) revealed the coccyx wound was unstageable with 100% slough and measured 3 x 2 x 0 cm, with a small amount of serosanguineous drainage, no tunneling or undermining, and had intact wound edges. The note included to continue with treatment and the wound was stable. Review of the (MONTH) (YEAR) TAR revealed that the Santyl treatment to the coccyx was not performed as ordered on (MONTH) 15 during the 6 a.m. - 2 p.m. shift, and was not performed on (MONTH) 17 during the 2 p.m. - 10 p.m. shift. A physician's telephone order dated (MONTH) 17, (YEAR) included to discontinue the previous treatment and to cleanse the coccyx wound with normal saline, pat dry, apply skin prep to the wound edges, loosely pack the wound bed with Dakins 0.25% soaked 2 x 2 gauze, and to cover with a barrier island dressing twice a day. Further review of the resident's care plans, including the skin care plan revealed they were not revised to reflect that the coccyx wound had deteriorated to an unstageable pressure ulcer, nor were there additional interventions to prevent further skin breakdown. An observation of pressure ulcer care was conducted with the wound nurse (staff #35) at 11:15 a.m. on (MONTH) 18, (YEAR). She stated the coccyx wound started as one open area, not two as documented in the admission assessment. Staff #35 stated she had measured the wounds yesterday and was going to use those measurements (however, there was no clinical record documentation of any measurements on (MONTH) 17). Staff #35 stated that the coccyx wound was all slough and now that the slough cap had come off, it has depth and has deteriorated. She stated the wound had undermining from 12 o'clock to 3 o'clock. At this time, the coccyx wound was observed to be approximately the size of a quarter, and had a red/white center, surrounding tissue was pink and there was a dark area on the outer aspect of the wound. Review of the nurses weekly wound document dated (MONTH) 18, (YEAR) revealed the coccyx pressure ulcer was now a stage IV and measured 3.5 x 3.3 x 1.3 cm, with undermining present from 12 o'clock to 3 o'clock (with a distance of 1.3 cm), the wound bed had 100% pink [MEDICATION NAME] tissue, no tunneling was present, and the surrounding skin was not boggy. The note included that the wound had declined and the physician was notified on (MONTH) 17. Review of the (MONTH) (YEAR) TAR revealed the Dakins treatment to the coccyx wound was not performed as ordered on (MONTH) 18, during the 2 p.m. - 10 p.m. shift. An interview was conducted with the wound nurse (staff #35) at 11:15 a.m. on (MONTH) 18, (YEAR). She stated that the resident is turned every 2 hours and as needed, and is on a low air loss mattress. She stated the coccyx wound was not stable. Another interview was conducted with staff #35 on (MONTH) 20, (YEAR) at 11:58 a.m. She stated that if the wound measurements are increasing, it means the wound has gotten worse. She stated the coccyx wound started as two spots with an island of skin between them and then the areas connected into one pressure ulcer. Regarding the left trochanter pressure ulcer: Review of the nursing day 1 admission assessment dated (MONTH) 15, (YEAR), revealed the resident had a left trochanter stage II pressure ulcer, which measured 3 x 2 x 0 centimeters (cm). Review of the nursing day 2 post admission assessment dated (MONTH) 16, (YEAR), revealed the left trochanter was described as having a pink peri wound bed and the center of the wound was scabbed over. Review of the nurses weekly wound document dated (MONTH) 16, (YEAR) revealed the resident had pressure ulcer on the left trochanter, which was present upon admission and measured 2 x 1 x 0 cm. The wound bed was described as having 20% pink granulation tissue, 80% slough, with no tunneling or undermining, intact wound edges, and the wound was covered with an allevyn dressing (although there was no physician's order for this). Despite documentation the wound bed had 80% slough, the pressure ulcer was identified as a stage II. A physician's order for wound treatment was not obtained until two days after admission. A physician's order dated (MONTH) 17, (YEAR) included to cleanse the left trochanter with normal saline, pat dry, apply skin prep around the wound edges, apply hydrogel to the wound bed, and cover with a barrier island dressing, every Monday, Wednesday and Friday during the day shift and as needed for soilage/dislodgement. Further review of the skin care plan revised on (MONTH) 18, (YEAR) revealed the resident was admitted with a stage II pressure ulcer on the left hip. An additional intervention included to turn and reposition the resident every 2 hours. The next assessment of the left trochanter pressure ulcer was completed eight days after the previous assessment. Per the nurses weekly wound document dated (MONTH) 24, (YEAR), the left trochanter pressure ulcer measured 2 x 1 x 0 cm, the wound bed had 60% slough and 40% [MEDICATION NAME] tissue with pink wound edges, and no tunneling or undermining were present. The note included the surrounding tissue was firm and similar to scar tissue. Again, the pressure ulcer was identified as a stage II, despite the wound bed being covered with 60% slough. The wound was documented as stable. Review of the nurses weekly wound document dated (MONTH) 30, (YEAR) revealed the left trochanter hip stage II pressure ulcer had improved and was 2 x 1 x 0 cm, the wound bed was described as having 100% [MEDICATION NAME] tissue, with no tunneling or undermining, no drainage and had intact wound edges. Review of the (MONTH) (YEAR) TAR revealed the hydrogel wound treatment was completed on Monday (MONTH) 3, however, the treatment was not performed on Wednesday, (MONTH) 5. Review of the nurses weekly wound document dated (MONTH) 6, (YEAR) revealed the left trochanter stage II ulcer measured 2 x 1 x 0 cm, the wound bed had 100% [MEDICATION NAME] tissue, with no tunneling or undermining, no drainage, and intact wound edges. The note included to continue with the current treatment of [REDACTED]. Further review of the (MONTH) (YEAR) TAR revealed that the hydrogel wound treatment was not performed as ordered on Friday, (MONTH) 7 and on Monday, (MONTH) 10. As the last wound treatment was documented as being done on (MONTH) 3, and the next wound treatment was documented as being done until Wednesday (MONTH) 12, the documentation showed that the wound treatment was not done for a period of eight days. Review of the nurses weekly wound document dated (MONTH) 12, (YEAR) revealed the left trochanter hip ulcer was now unstageable and measured 1 x 1 x 0 cm, the wound bed had 100% slough, with no tunneling or undermining, had dry wound edges, and a scant amount of serosanguineous drainage was present. The note included the wound was stable, however, the wound had deteriorated from having 100% [MEDICATION NAME] tissue on (MONTH) 6, to having 100% slough. Further review of the clinical record revealed there was no documentation that the physician was notified of the deterioration of the wound. Further review of the resident's care plans, including the skin care plan revealed they were not revised to reflect that the left hip wound had deteriorated to an unstageable pressure ulcer, nor were there additional interventions to prevent further skin breakdown. An observation of pressure ulcer care was conducted with staff #35 at 11:15 a.m. on (MONTH) 18, (YEAR). Staff #35 stated that she had measured the left trochanter wound yesterday and was going to use those measurements (however, there was no clinical record documentation of any wound measurements for the left trochanter on (MONTH) 17). At this time, the left hip wound was observed to be dime size with a whitish area in the center of the wound, and the surrounding tissue was pink. The hip area also had a new abrasion from the previous dressing being removed. Staff #35 stated the wound bed had possible scar tissue or slough, as it was difficult to determine. Review of the nurses weekly wound document dated (MONTH) 19, (YEAR) revealed the left trochanter pressure ulcer was unstageable and measured 1.9 x 1.6 x 0 cm. The note further included the wound bed was obscured with 100% slough, with no tunneling or undermining, had a scant amount of bloody drainage, wound edges were pink and intact, and surrounding tissue was firm with normal color. The wound was documented as being stable, despite increasing in size (from the last assessment on (MONTH) 12). An interview was conducted with staff #35 on (MONTH) 20, (YEAR) at 11:58 a.m. She stated that in terms of wound documentation, stable means that the treatment seems to be effective and the wound is not getting worse. She stated that if the wound measurements are increasing and there is slough instead of [MEDICATION NAME] tissue, the wound has gotten worse. She stated that the week of (MONTH) 12, (YEAR) she was out of town and if the wound went from a stage II to unstageable, this is deterioration and the wound should not have been documented as stable. Regarding the bilateral heels: Review of the nursing day 1 admission assessment dated (MONTH) 15, (YEAR) revealed the resident's right and left heels were boggy. Review of the nurses weekly wound documentation dated (MONTH) 17, (YEAR) revealed the resident's left heel went from boggy (per the admission assessment) to a suspected deep tissue injury (SDTI), measuring 2.5 x 1 x 0 cm. The left heel was described as having a faint discoloration, with intact skin. There was no mention of the condition of the right heel. A physician's order dated (MONTH) 17, (YEAR) included to apply heel protectors to both heels every shift and to float the heels every shift while in bed. Review of a skin care plan revised on (MONTH) 18, (YEAR) revealed the resident was admitted with right and left heels, which were slightly discolored. Further review revealed that the care plan was not revised to reflect the need to apply heel protectors to both heels every shift and to float the heels every shift while in bed. Review of the nurses weekly wound document dated (MONTH) 24, (YEAR) revealed the left heel had a SDTI which had improved. The wound measured 2 x 0.5 x 0 cm and was light maroon in color, skin was intact, and surrounding skin was dry and mildly calloused with no bogginess. The note also included that the discoloration of the left heel was shrinking, due to heels being floated while in bed. Review of the nurses weekly wound document dated (MONTH) 30, (YEAR) revealed the left heel was identified as a SDTI, with a faint maroon area which measured 2 x 0.5 x 0 cm and the skin was dry and intact, with no bogginess. The note included the surrounding tissue and heel had firmed, due to heels being floated and that the wound had improved. A change of condition MDS assessment dated (MONTH) 1, (YEAR) revealed the resident was rarely or never understood and had severe cognitive impairment. Per the MDS, the resident required extensive assistance with bed mobility and hygiene. The MDS also included the resident had a SDTI. According to the (MONTH) (YEAR) TAR, the order to apply the heel protectors to both heels was included, however, there was no documentation that the treatment had been done during the 6 a.m. - 2 p.m. shift on (MONTH) 2. Review of the nurses weekly wound document dated (MONTH) 6, (YEAR) revealed the left heel was a SDTI which was improving and measured 1.8 x 0.5 x 0 cm, with a faint red discoloration, no bogginess, and the skin was dry and intact. The note included that the heels were floated and heel protectors were being used. Review of the (MONTH) (YEAR) TAR revealed no documentation that the heel protectors to both heels were applied as ordered during the 6 a.m. - 2 p.m. shift on (MONTH) 7, 8, and 10, and during the 2 p.m. - 10 p.m. shift on (MONTH) 9 and 10. The (MONTH) TAR also included the order to float both heels every shift while in bed. However, there was no documentation that the heels were floated as ordered during the 6 a.m. - 2 p.m. shift on (MONTH) 7, 8, and 10, and during the 2 p.m. - 10 p.m. shift on (MONTH) 9, 10, and 11. Review of the nurses weekly wound document dated (MONTH) 12, (YEAR) revealed the left heel SDTI measured 1.5 x 3.5 x 0 cm and the skin was dry and intact. The note did not describe the color of the SDTI area on the left heel. The note included the wound was stable, however, the wound measurements had increased from the previous assessment. The documentation also included that the physician was last notified on (MONTH) 5, (YEAR). Review of the nurses bath skin check dated (MONTH) 18, (YEAR) revealed the resident had the following wounds: right and left heel discoloration, however, the documentation did not include measurements or a description of the discolorated areas. An observation of pressure ulcer care to the bilateral heels was conducted with the wound nurse, staff #35 at 11:15 a.m. on (MONTH) 18, (YEAR). She stated that she had measured the wounds yesterday and was going to use those measurements (however, there was no clinical record documentation of any measurements of the heels on (MONTH) 17). At this time, the resident was observed to have a dime sized maroon colored area on the left heel. Staff #35 stated this wound had improved. The right heel was observed to have a maroon discoloration which was approximately 2 x 2 cm on the heel, and [MEDICAL CONDITION] was present in both feet. Review of the nurses weekly wound document dated (MONTH) 19, (YEAR) revealed the left heel suspected deep tissue injury measured 1.6 x 0.5 x 0 cm, with maroon discoloration and skin was dry and intact, with no bogginess and 3 plus [MEDICAL CONDITION] was present. The wound was described as stable. Further review of the nurses weekly wound document dated (MONTH) 19, (YEAR) revealed there was a new onset of a discoloration on the right heel, which previously had no suspected SDTI. The right heel was described as having a maroon discoloration which measured 1.5 x 1.5 x 0 cm, skin was dry and intact with no bogginess and had 3 plus [MEDICAL CONDITION] was present. The wound was described as stable. However, this wound was not present the previous week. The documentation also included that the physician was notified on (MONTH) 18, (YEAR). An interview was conducted with the staff #35 on (MONTH) 20, (YEAR) at 11:58 a.m. She stated that if the heels are boggy, this is looked at as a SDTI. Regarding the right heel, she stated there was a change in color to the right heel this week and it should not have been documented as stable. She stated the right heel had no SDTI until yesterday, and that's why nothing was documented before. She further stated that if a new wound is identified, it should be measured on the same day. Regarding the right gluteal fold pressure ulcer: Review of the nursing bath skin check dated (MONTH) 24, (YEAR) revealed the resident had two new wounds. The wounds were described as a right gluteal fold abrasion which measured 1 x 1 x 0 cm with a scab, which was directly under the edge of the brief. The second wound was described as a maroon colored area to the right gluteal fold which was directly under where the edge of the brief meets the skin. The wound measured 2 x 1.5 x 0 cm, with no bogginess, with swelling and warmth present. Review of the nurses weekly wound document dated (MONTH) 24, (YEAR) revealed a new shearing wound was present on the right gluteal fold which measured 1 x 1 x 0 cm, and had 20% [MEDICATION NAME] tissue and 80% was covered with a scab. There was no drainage and the wound edges were macerated from moisture. The wound was documented as being a partial thickness wound with no tunneling or undermining, and was stable. This assessment did not include the second wound which was described as a maroon colored area in the above assessment. A physician's order dated (MONTH) 24, (YEAR) included to cleanse the right gluteal fold with normal saline, pat dry, and cover with barrier island dressing every evening shift and as needed for soilage/dislodgement. Review of the nurses weekly wound document dated (MONTH) 30, (YEAR) revealed a shearing wound was present to the right gluteal fold which measured 1 x 1 x 0 cm and the wound bed was 100 % pink [MEDICATION NAME] tissue with macerated edges that are frequently exposed to moisture, no drainage, partial thickness and no tunneling or undermining were present. The note included that [MEDICATION NAME] should be applied with each incontinent episode, and that the wound had improved. However, there was no physician's order to apply [MEDICATION NAME]. In addition, there was no documentation regarding the second wound which had been previously identified as a maroon colored area. Review of the (MONTH) (YEAR) TAR revealed there was no documentation that the treatment to the right gluteal fold was completed as ordered on (MONTH) 1. A physician's order dated (MONTH) 5, (YEAR) included to discontinue the previous order and to cleanse the right gluteal fold open areas with normal saline, pat dry, apply skin prep around the wound perimeter, cut Duoderm to fit the wound sites, and to apply the Duoderm on the skin every other day on the day shift and as needed for soilage/dislodgement. Review of the nurses weekly wound document dated (MONTH) 6, (YEAR) revealed the right gluteal fold wound was still a shearing wound which measured 1 x 1 x 0 cm, and was moisture denuded, and the surrounding skin was presenting signs of moisture breakdown. The wound was described as having a mixture of dark pigmented skin, light pink skin, and very pale skin, representing moisture exp",2020-09-01
604,TEMPE POST ACUTE,35106,6100 SOUTH RURAL ROAD,TEMPE,AZ,85283,2017-04-20,315,D,0,1,UZSR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and facility documentation, the facility failed to ensure that catheter care and intake/output monitoring were consistently completed as ordered for one resident (#27), with an indwelling urinary catheter. Findings include: Resident #27 was admitted to the facility on (MONTH) 15, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident was admitted with a Foley catheter. Review of the nursing day 1 admission/readmission note dated (MONTH) 15, (YEAR), revealed the resident was admitted with a UTI and had very dark, concentrated urine. The note also included the resident was totally dependent on staff for transfers and required two person assistance. The nursing day 2 admission/readmission note dated (MONTH) 16, (YEAR) included the resident had a Foley catheter and had bloody urine. The documentation included for staff to monitor urine output and make sure the catheter is patent/unkinked. A physician's order dated (MONTH) 16, (YEAR) included for urinalysis, with culture and sensitivity. Review of the nursing day 4 post admission/readmission note dated (MONTH) 17, (YEAR) revealed the resident's urine was clear and the resident had [MEDICAL CONDITION]. A nurse's note dated (MONTH) 17, (YEAR) included the physician was notified of the urinalysis results and orders were received to start the resident on an antibiotic. A physician's telephone order was obtained on (MONTH) 17, (YEAR) for Bactrim DS tablet 800/160 milligrams (mg) give 1 tablet via PE[DEVICE] two times a day for UTI. Further review of the clinical record revealed there was no physician's order for the urinary catheter until (MONTH) 17, (YEAR). A physician's order dated (MONTH) 17, (YEAR) included the following: 16 French (Fr) 10 milliliter (ml/cc) balloon catheter; flush the catheter with 30 ml of normal saline every shift and as needed, and repeat as necessary; change the catheter every 30 days during evening shift; change the drainage bag every Monday on evening shift and date and initial the bag when changed; check catheter tubing for proper positioning; provide catheter care every shift; and to monitor intake and output every shift. Per the physician's orders, the antibiotic was changed to [MEDICATION NAME] 100 mg twice daily for 7 days on (MONTH) 21, (YEAR). Review of the admission Minimum Data Set assessment dated (MONTH) 22, (YEAR) revealed the resident was rarely or never understood, and required extensive assistance with bed mobility. The MDS also noted that the resident was admitted with a urinary catheter. Review of the (MONTH) (YEAR) Medication and Treatment Administration Records (MAR/TAR), revealed that catheter care and checking the catheter tubing for proper positioning was not documented as having been performed on (MONTH) 23. Review of a comprehensive care plan initiated on (MONTH) 25, (YEAR) revealed the resident had a Foley catheter for [MEDICAL CONDITION]. The goal included that the resident would remain free from symptoms of UTI. Interventions included the following: keep catheter tubing free of kinks; keep drainage bag below bladder level; monitor patency of catheter and to monitor/record output every shift. A physician's telephone order dated (MONTH) 31, (YEAR) included to administer [MEDICATION NAME] 100 mg give one capsule via PE[DEVICE] two times a day for continued UTI for 14 days. The (MONTH) (YEAR) MAR/TARs also included the following: Catheter: 16 Fr 10 cc balloon, monitor intake and output amounts every shift. Further review revealed that the intake/output amounts were not recorded on the following days: (MONTH) 17 for the 10-6 shift, (MONTH) 18, 19, 27 and 29 during the 6-2 shift, and (MONTH) 20 and 23 during the 2-10 shift. Review of the (MONTH) (YEAR) MAR/TAR revealed that catheter care and/or checking for proper positioning of the catheter tubing was not documented as being done on the following days: (MONTH) 2, 7, 8 and 10 during the 6-2 shift and during the 2-10 shift on (MONTH) 9, 10, and 11. In addition, there were multiple occasions when the intake/output amounts were not documented on various shifts. An observation was conducted on (MONTH) 18, (YEAR) of the resident in bed, with a Foley catheter in place. An interview was conducted with the Director of Nursing (DON/staff #42) on (MONTH) 20, (YEAR) at 12:40 p.m. She stated that catheter care and intake and output should be documented as ordered. She stated if it's not documented, it's not done. She stated the catheter care and intake and output were missing from the resident's record. An interview was conducted with a licensed practical nurse (LPN/staff #50) on (MONTH) 20, (YEAR) at 1:11 p.m. He stated that every time treatment is done, it should be signed off and that treatments should be done as ordered. He stated that catheter care should be done every shift, that intake and output should be monitored as ordered, that catheter tubing should be free of kinks and the catheter bag must be kept below the bladder level. The facility did not have a policy regarding the documentation of catheter care. However, the facility provided a document from the Lippincott website titled, Indwelling Urinary Catheter (Foley) Care and Management. Per the documentation, intake and output should be monitored as ordered, the catheter and drainage tubing should be free from kinks to allow the free flow of urine, the drainage bag should be kept below the bladder to prevent backflow of urine into the bladder. The documentation further included to document the procedures for catheter use, maintenance and findings.",2020-09-01
605,TEMPE POST ACUTE,35106,6100 SOUTH RURAL ROAD,TEMPE,AZ,85283,2017-04-20,334,D,0,1,UZSR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interview and policy review, the facility failed to ensure one resident (#32) was administered the influenza vaccine and failed to ensure that an informed consent, inclusive of the risk and benefits of the influenza and pneumonia vaccines were obtained for one resident (#64). Findings include: -Resident #32 was admitted on (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. A review of the clinical record revealed that an informed consent for the administration of the influenza vaccine had been obtained on (MONTH) 30, (YEAR), which indicated that the resident wished to receive the influenza vaccine. However, review of the resident's immunization record revealed that the influenza vaccine had been coded as, Not eligible. Continued review of the clinical record revealed no documentation as to why the resident was not eligible for the vaccine, and there was no documented evidence that the influenza vaccine was contraindicated. There was also no documentation that the influenza vaccine had been administered. -Resident #64 was admitted on (MONTH) 7, (YEAR), with [DIAGNOSES REDACTED]. A review of the resident's immunization record revealed documentation that the influenza and pneumonia vaccine had been administered on (MONTH) 20, (YEAR). However, an informed consent, inclusive of the risk and benefits of both vaccines was unable to be located in the clinical record. An interview was conducted on (MONTH) 19, (YEAR) at 1:00 p.m., with an Infection Control staff member (staff #27). Following a review of the above clinical records she stated, We dropped the ball. Staff #27 stated at the time of admission, licensed staff are responsible to review the influenza and pneumonia vaccination informed consent forms with the resident/responsible party and are to obtain consent or refusal of the vaccines. Staff 27 stated that once consent for the administration of the vaccines was obtained, a physician's orders [REDACTED]. A facility policy titled Influenza Vaccine Program included, It is the policy of this facility that annually residents will be offered immunization against influenza. The policy also included the following: 1. The vaccine program runs from early (MONTH) through (MONTH) 31, but is flexible depending upon recommendations form the Health Department and CDC (Centers for Disease Control) for each vaccine year. 3. a. Nursing staff does not need to contact the primary physician for orders pertaining to administration of the vaccine for each resident, unless orders were not obtained upon admission. 4. Every admission is screened using the criteria contained within the standing protocol and given the vaccine if indicated, after receiving education regarding the vaccine. 5. Licensed nursing staff performs the screening and vaccine administration. 6. A record of vaccination will be placed in the resident's medical record and their vaccination record. 7. a. Document in the resident's medical record and on the immunization record. Chart education provided, medication, route of administration, site of injection, temperature prior to administration, and the time the vaccine was given. 9. Document resident refusal and education of risk vs. benefits. Another facility policy titled, Administration of [MEDICATION NAME] Vaccine included the following: 7. Document in the resident's medical record and on the immunization record.",2020-09-01
606,TEMPE POST ACUTE,35106,6100 SOUTH RURAL ROAD,TEMPE,AZ,85283,2017-04-20,441,E,0,1,UZSR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and policies and procedures, the facility failed to ensure proper infection control procedures were implemented. Findings include: -During a random observation conducted on (MONTH) 18, (YEAR) at 12:00 p.m., a housekeeping staff member (staff #93) was observed exiting an isolation room wearing a gown, gloves and a mask. The resident in this room was on isolation for[DIAGNOSES REDACTED] (Clostridium Difficile) and MRSA (Methicillin Resistant Staphylococcus Aureus). Upon exiting the room, staff #93 walked into the hallway carrying a long handled dust pan and broom. Staff #93 then walked across the hallway and leaned the dust pan and broom against the wall. Staff #93 then re-entered the isolation room, with the same gown, gloves and mask on and discarded the items in the receptacle in the resident's room. Staff #93 then exited the isolation room and was not observed to wash or disinfect her hands. At this time an interview was conducted with staff #93. She acknowledged that the resident was in isolation for[DIAGNOSES REDACTED] and that she needed to wear protective equipment. Staff #93 stated that she had used the dust pan and broom in the isolation room and that she had exited the isolation room with her protective equipment on, because she needed to take the dust pan and broom out of the room. She stated the dust pan and broom were the only ones she had and that she needed to use them in the next room. Staff #93 was unable to state why she had not washed or disinfected her hands after the removal of the gown, gloves, and mask. She was also unable to state any potential infection control issues that could have been a result of re-using the equipment which had been used in an isolation room. An interview was conducted on (MONTH) 19, (YEAR) at 10:15 a.m. with the Director of Nursing (staff #42). She stated that all personal protective equipment was suppose to be removed prior to exiting an isolation room and that once removed, hand washing must be done. Staff #42 also stated that[DIAGNOSES REDACTED] requires strict precautions, because of the potential to spread the infection. Staff #42 further stated that another dust pan and broom should have been available for that room, and if not they could have purchased one, within 30 minutes. Staff #42 stated that staff #93 was a new employee, however, there were no excuses. A facility policy titled, Guidelines for Clostridium Difficile Associated Disease included the following: Section 2 C. Transmission Route 1.[DIAGNOSES REDACTED] is shed in feces. Any surface, device, or material (commodes, bathing tubs, electronic rectal thermometers) that become contaminated with feces may serve as reservoir for the[DIAGNOSES REDACTED] spores. 2.[DIAGNOSES REDACTED] spores are transferred to patients mainly via hands of healthcare personnel who have touched a contaminated surface or time. Section 4 Prevention [NAME] Strict adherence to hand hygiene using soap and water. Section 6 Isolation Precautions [NAME] Contact precautions should be used. Another facility policy titled, Hand Hygiene, included Hand hygiene continues to be the primary means of preventing the transmission of infection. The policy also included the following: Perform Hand Hygiene: 2. When entering and exiting a resident's room; 5. Before and after entering isolation precaution settings; 21. After removing gloves; Personal Protective Equipment: -Before leaving the patient's room or cubicle, remove and discard PPE. Gowns: -Remove gown and perform hand hygiene before leaving the patient's environment. Removing PPE: -Remove PPE at doorway before leaving patient room. -Perform hand hygiene immediately after removing all PPE. -On (MONTH) 19, (YEAR) at 11:00 a.m., an observation of the laundry area was conducted with staff #27 (Infection Control Nurse) present. In one area of the laundry room there were bins (some closed and others opened), which contained soiled, dirty clothing and linens. In this area there were double doors which led out into the hallway. At this time, staff #75 (laundry assistant) was observed in an adjacent room where the washers and dryers were located. Staff #75 was observed folding the clean clothing/linens at a table in this area. An interview was conducted with staff #75. She stated that all of the dirty items come in through the large double doors and are kept in the bins until they are washed. Staff #27 stated that any item from an isolation room would be keep in a yellow bag in this area until washed. Staff #75 stated that all of the clean clothing/linens are brought out of the clean laundry area, and taken out through the large double doors (which was where all of the dirty and potentially contaminated items are stored). During the observation, a second door was observed in the room where the clean clothing/linens were kept. This door also exited into the hallway. However, staff #75 stated that she has not used that door to take the clean clothing/linens out of in the last seven years. On (MONTH) 19, (YEAR) at 11:15 a.m. an interview was conducted with the the Maintenance Director (staff #18), who stated that the area with the large double doors was where all of the dirty clothing/linens go in through and that the small door on the opposite side is where the clean items are to go out of. At this time, staff #18 stated that he was not aware of the process that staff #75 had been using. On (MONTH) 19, (YEAR) at 11:30 a.m. an interview was conducted with the Infection Control nurse, staff #27. She stated that the housekeeping staff needed to be re-educated on proper infection control practices regarding handwashing, personal protective equipment and resident equipment. Staff #27 also stated that taking the clean laundry through the soiled laundry area could cause a potential infection control problem.",2020-09-01
607,TEMPE POST ACUTE,35106,6100 SOUTH RURAL ROAD,TEMPE,AZ,85283,2017-04-20,502,D,0,1,UZSR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and facility documentation, the facility failed to ensure that a STAT (immediate) laboratory study was obtained for one resident (#50). Findings include: Resident #50 was readmitted on (MONTH) 22, (YEAR), with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The order also included to perform a straight cauterization, if needed. However, a review of the clinical record including the nursing notes and MAR/TAR (Medication and Treatment Administration Records) for (MONTH) (YEAR), revealed no documented evidence that the urine specimen had been obtained STAT on (MONTH) 6. A Nurse Practitioner note dated (MONTH) 7, (YEAR) included that per nursing staff, the urine specimen was unable to be obtained. However, there was no documentation as to why the specimen was not able to be obtained on (MONTH) 6. Per the clinical record, the NP (Nurse Practitioner/staff #97) obtained the urine specimen on (MONTH) 7, (YEAR). An interview was conducted on (MONTH) 18, (YEAR) at 11:05 a.m., with the Director of Nursing (staff #42), who stated that STAT laboratory studies need to be obtain within four hours. At this time, staff #42 reviewed the laboratory test result report, which confirmed that the STAT laboratory test was not completed until (MONTH) 7, (YEAR) at 11:55 a.m. Staff #42 further stated that the facility did not have a specific policy regarding STAT laboratory services, however, she provided the facility's contract with the laboratory services provider. The contract included that all STAT services will be dispatched immediately.",2020-09-01
608,TEMPE POST ACUTE,35106,6100 SOUTH RURAL ROAD,TEMPE,AZ,85283,2017-04-20,520,E,0,1,UZSR11,"Based on concerns identified during the survey, staff interviews, QA (Quality Assurance) documentation and policy and procedures, the facility failed to identify quality concerns through their QA program regarding care and services for residents with pressure ulcers and regarding call lights not being answered in a timely manner. Findings include: During the survey, the following concerns regarding pressure sores were identified: pressure sores were not thoroughly assessed upon admission or when new pressure sores developed; they were not consistently assessing pressure sores thoroughly at least weekly; physician ordered treatments were not consistently being implemented and the plan of care was not revised to include additional interventions to prevent further skin breakdown. An interview regarding the facility's Quality Assurance Program was conducted on (MONTH) 20, (YEAR) at 2:37 p.m., with the Executive Director (staff #102), Quality Control Nurse (staff #27), and the Nurse Manager (staff #35). During the interview, staff stated that they had not identified concerns in QA regarding pressure ulcers. During the survey, concerns were also identified regarding call lights not being answered in a timely manner. Multiple residents complained of long call light response times. According to the facility's call light logs for (MONTH) (YEAR), call lights were on from 20 minutes to 4 hrs. During an interview conducted at 2:45 p.m. on (MONTH) 20, (YEAR), the Executive Director stated that the call light problem was identified in QA and staff were provided an in-service on (MONTH) 14, (YEAR), regarding answering call lights. She said the call light system is an electronic system that notifies the CNA's when a call light is turned on. She stated the call lights should be answered within five minutes, but if not answered in 8 minutes, the electronic call light system sends a message to the nurse manager's pager. The Executer Director further stated that if the call light is not answered within 10 minutes, a message is sent to the Director of Nursing's pager. The Executive Director provided QA documentation regarding call lights. Review of the QA documentation dated (MONTH) 29, (YEAR) revealed that Social Services had reported and discussed that in (MONTH) there were two complaints about call light response times. The documentation also included all have been resolved, call lights were addressed with staff members. The team action plan included that the Executive Director . has ordered pagers that alert room call lights for the CNAs. Although the facility did identify a concern regarding call light response times and implemented an action plan, the QA documentation showed that the issue was resolved. However, there were still ongoing concerns identified in (MONTH) (YEAR) regarding call lights not being answered in a timely manner. Review of a facility policy titled, Quality Management Plan revealed the purpose is to ensure that a process of monitoring performance is in place to ensure excellence and detect areas of deficiency. An additional policy titled, Quality Assessment and Assurance included that the QA committee should identify issues and should develop and implement appropriate plans of action to correct identified quality deficiencies.",2020-09-01
609,TEMPE POST ACUTE,35106,6100 SOUTH RURAL ROAD,TEMPE,AZ,85283,2018-05-16,552,D,0,1,05F711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy and procedure, the facility failed to inform one resident (#28) and/or the resident's responsible party of the risks and benefits of an antipsychotic medication. Findings include: Resident #28 was admitted to the facility on (MONTH) 21, (YEAR), with [DIAGNOSES REDACTED]. The clinical record included that the resident's responsible party was a family member. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 28, (YEAR), revealed the resident scored a 14 on the Brief Interview for Mental Status (BIMS) which indicated the resident was cognitively intact. The assessment also included that the resident had received antipsychotic medications every day during the assessment period. The resident's care plan included that she received antidepressant and antipsychotic medications related to her [DIAGNOSES REDACTED]. One of the interventions included to obtain informed consent for the use of psychoactive medications. Review of the physician's orders [REDACTED]. Further review of the physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Further review of the clinical record revealed no evidence that the risks and benefits of [MEDICATION NAME] were explained to the resident or her responsible party. An interview was conducted with a Licensed Practical Nurse (LPN/staff #43) on (MONTH) 15, (YEAR) at 1:50 p.m. She stated that before a resident is administered an antipsychotic medication, the informed consent form which includes the risks and benefits of the medication is completed and explained to the resident or the resident's responsible party. She also stated that she thought this resident's responsible party had already given informed consent for all of the resident's antipsychotic medications. During an interview conducted with the interim Director of Nursing (DON/staff #99) on (MONTH) 16, (YEAR) at 9:45 a.m., she stated that it is the expectation that the risks and benefits of an antipsychotic medication is explained to the resident or the resident's responsible party prior to the administration of the medication by the nurse on the floor or a member of nurse management. She reviewed the resident's clinical record and stated that the risks and benefits of [MEDICATION NAME] were not explained to this resident. The facility's policy for psychoactive medication use included that once a psychoactive medication has been ordered; the risks and benefits of the medication will be explained to the resident and/or the resident's responsible party. The policy included that informed consent including the effects and potential side effects will be obtained from the resident and/or the responsible party for each psychoactive medication. The policy also included that the resident and/or the resident's family will be notified with psychoactive medication dose changes (including both increase and decreases) and a new consent will be obtained.",2020-09-01
610,TEMPE POST ACUTE,35106,6100 SOUTH RURAL ROAD,TEMPE,AZ,85283,2018-05-16,607,D,0,1,05F711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a clinical record review, resident and staff interviews, facility documentation, and policy and procedure, the facility failed to implement their policy regarding an allegation of abuse for one resident (#17). Findings include: Resident #17 was admitted to the facility on (MONTH) 15, (YEAR), with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 8, (YEAR), revealed a Brief Interview for Mental Status score of 11, which indicated that the resident was moderately cognitive impaired. An interview was conducted on (MONTH) 14, (YEAR) at 11:05 a.m. with resident #17. She stated four months ago a certified nursing assistant (CNA) was rough and threw her around during care. She stated that she reported the allegation of abuse but could not recall the person's name she reported it to. She further stated that the CNA had been fired. On (MONTH) 14, (YEAR) at 11:59 a.m. the Administrator (staff #117) was notified of the abuse allegation. Review of the facility's investigation included an interview conducted with resident #17 on (MONTH) 14, (YEAR). The resident stated four months ago, a female CNA was rough with her during transfers and that the CNA would grab her tight. Further review of the investigation revealed no evidence that the abuse allegation was reported to the Adult Protective Services (APS), to the Long Term Care (LTC) Ombudsman, or to the police. An interview was conducted on (MONTH) 16, (YEAR) at 10:55 a.m. with the Director of Social Services (staff #57). She stated that once an allegation of abuse has been reported, the state agency, APS, and the LTC Ombudsman are notified immediately. She stated that the involved staff member is immediately suspended and an investigation is initiated. Staff #57 stated that at this time she has not notified APS, the LTC Ombudsman, or the police. During an interview conducted on (MONTH) 16, (YEAR) at 12:56 p.m. with the Interim Director of Nursing (staff #99), she stated that once an abuse allegation has been reported, local law enforcement, APS, and the state agency are to be notified within the required timeframe. The facility's policy and procedure Resident/Client/Participant Protections/Freedom from Abuse, Neglect and Misappropriate included that officials in accordance with state law must be contacted immediately regarding all allegations of abuse/neglect and to document the date and time of the notification. The policy also included to call law enforcement officials if the suspected concern is criminal in nature (theft, assault, unwanted touch. etc .). The policy further included that immediate reporting pertains to Long Term Care.",2020-09-01
611,TEMPE POST ACUTE,35106,6100 SOUTH RURAL ROAD,TEMPE,AZ,85283,2018-05-16,609,D,0,1,05F711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a clinical record review, resident and staff interviews, facility documentation, and policy and procedure, the facility failed to ensure an allegation of abuse for one resident (#17) was reported to the Adult Protective Services (APS) and other officials according to state law. Findings include: Resident #17 was admitted to the facility on (MONTH) 15, (YEAR), with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 8, (YEAR), revealed a Brief Interview for Mental Status score of 11, which indicated the resident was moderately cognitive impaired. An interview was conducted on (MONTH) 14, (YEAR) at 11:05 a.m. with resident #17. She stated four months ago a certified nursing assistant (CNA) was rough and threw her around during care. She stated that she reported the allegation of abuse but could not recall the person's name she reported it to. She further stated the CNA had been fired. On (MONTH) 14, (YEAR) at 11:59 a.m. the Administrator (staff #117) was notified of the abuse allegation. Review of the facility's investigation included an interview conducted with resident #17 on (MONTH) 14, (YEAR). The resident stated four months ago, a female CNA was rough with her during transfers and that the CNA would grab her tight. Further review of the investigation revealed no evidence that the abuse allegation was reported to the Adult Protective Services (APS), to the Long Term Care (LTC) Ombudsman, or to the police. An interview was conducted on (MONTH) 16, (YEAR) at 10:55 a.m. with the Director of Social Services (staff #57). She stated that once an allegation of abuse has been reported, the state agency, APS, and the LTC Ombudsman are notified immediately. She stated the involved staff member is immediately suspended and an investigation is initiated. Staff #57 stated that at this time she has not notified APS, the LTC Ombudsman, or the police. During an interview conducted on (MONTH) 16, (YEAR) at 12:56 p.m. with the Interim Director of Nursing (staff #99), she stated that once an abuse allegation has been reported, local law enforcement, APS, and the state agency are to be notified within the required timeframe. The facility's policy and procedure Resident/Client/Participant Protections/Freedom from Abuse, Neglect and Misappropriate included that officials in accordance with state law must be contacted immediately regarding all allegations of abuse/neglect and to document the date and time of the notification. The policy also included to call law enforcement officials if the suspected concern is criminal in nature (theft, assault, unwanted touch. etc .). The policy further included that immediate reporting pertains to Long Term Care.",2020-09-01
612,TEMPE POST ACUTE,35106,6100 SOUTH RURAL ROAD,TEMPE,AZ,85283,2018-05-16,658,D,1,1,05F711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, and policy, the facility failed to ensure that physician's medication orders were followed for one resident (#7). Findings include: Resident #7 was admitted to the facility on (MONTH) 21, 2012, with [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment dated (MONTH) 15, (YEAR), revealed a BIMS (Brief Interview for Mental Status) score of 11 which indicated the resident had cognitive impairment. Review of physician's orders [REDACTED]. A review of the MAR (Medication Administration Record) dated (MONTH) (YEAR), revealed the [MEDICATION NAME] was not administered from the p.m. shift on (MONTH) 6, (YEAR) through (MONTH) 16, (YEAR), with the exception of three doses. A review of the (MONTH) (YEAR) nursing notes revealed the following: April 6: Medication unavailable, awaiting delivery April 7: Waiting for delivery April 7: Waiting for delivery April 9: On order from the pharmacy April 10: On order from the pharmacy April 10: Medication unavailable, awaiting delivery April 11: On order from the pharmacy April 11: Awaiting on delivery April 12: Not available April 12: Not available, pharmacy notified April 13: On order April 14: On order from pharmacy April 14: Waiting for delivery April 15: Pharmacy states out for delivery April 16: p.m. dose of [MEDICATION NAME] not in cart. Spoke with pharmacy and they stated they had no order. Faxed order to them and med not in E-kit. Provider notified. DON notified. Med not received by end of shift. Further review of the MAR indicated [REDACTED]. An interview was conducted on (MONTH) 15, (YEAR) at 10:36 a.m. with the DON (Director of Nursing/staff #99). She stated that while conducting random chart audits, she discovered missing documentation regarding the potassium. She stated that she discovered the nurses were documenting on the MAR #5 and #8 indicating the medication was held, or the medication was not administered, and to see the nurses note. The DON stated the medication supply had been depleted but that the medication was on an automatic reorder status and should have been supplied by the pharmacy. She further stated the nursing staff did not retain faxed results for the medication request or document in the nursing notes who they had spoken with at the pharmacy. She stated the nursing staff neglected to document in the nurses notes that the physician was notified that the medication was not administered. The DON stated the pharmacy denied receiving any faxed request. An interview was conducted on (MONTH) 15, (YEAR) at 12:06 p.m. with a Licensed Practical Nurse (LPN/staff #48). He stated that he uses a computer program to identify the status of orders and to identify any reason the medication is not being delivered. He stated the system does not automatically resupply a medication if an incorrect choice is selected. Staff #48 stated the nursing staff received training regarding the correct way to order medications from the pharmacy including to document all pharmacy calls in the nursing notes and to notify the provider of any missed doses. The facility's Long Term Care Facility Pharmacy Services and Procedure Manual included .Facilities are encouraged to reorder medications electronically .Refill orders can be submitted verbally .",2020-09-01
613,TEMPE POST ACUTE,35106,6100 SOUTH RURAL ROAD,TEMPE,AZ,85283,2018-05-16,688,E,0,1,05F711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident interviews, and staff interviews, the facility failed to ensure two residents (#'s 10 and 35) received range of motion (ROM) services. The sample size was two. Findings include: -Resident #10 was initially admitted on (MONTH) 29, (YEAR) and was readmitted on (MONTH) 1, (YEAR) with [DIAGNOSES REDACTED]. The ADLs (activities of daily living) care plan dated (MONTH) 30, (YEAR), revealed the resident had limited range of motion. Some interventions included were .I require assist to turn, move up, sit in bed. Total assist with eating. I am non ambulatory . Review of a [MEDICAL CONDITION] care plan dated (MONTH) 30, (YEAR), revealed an intervention for .physical therapy to evaluate, treat as ordered. The quarterly MDS (Minimum Data Set) assessment dated (MONTH) 22, (YEAR), revealed the resident's BIMS (brief interview for mental status) score was a 13 which indicated the resident was cognitively intact. Review of a physician's orders [REDACTED].>Further review of the clinical record revealed no evidence in the clinical record regarding whether the physical therapy evaluation and treatment was conducted. Review of a CNA (certified nursing assistant) task sheet dated (MONTH) (YEAR), revealed Task: Restorative: Passive Range of Motion to bilateral upper extremities and bilateral legs for 15 minutes with a.m. and p.m. cares. Further review of the CNA task sheet dated (MONTH) (YEAR), revealed that passive range of motion was not provided in the morning on (MONTH) 5, 9, and 13, (YEAR) and in the afternoon on (MONTH) 3, 4, 6, 7, and 13, (YEAR). An interview was conducted with the resident on (MONTH) 14, (YEAR) at 11:58 a.m. The resident stated that he no longer receives range of motion because the person who used to do that no longer works at the facility. Another interview was conducted with the resident on (MONTH) 16, (YEAR) at 11:20 a.m. The resident stated that he had not received range of motion for quite some time, since the restorative aide quit. An interview was conducted with a CNA, staff #32 on (MONTH) 16, (YEAR) at 11:25 a.m. The CNA stated that she was not aware of the resident receiving any restorative nursing or range of motion. An interview was conducted with the interim DON (director of nursing), staff #99 on (MONTH) 16, (YEAR) at 11:30 a.m. The interim DON stated that she was unable to find evidence that a therapy evaluation was conducted. During an interview conducted with another CNA, staff #118 on (MONTH) 16, (YEAR) at 11:45 a.m., the CNA stated that she provides range of motion twice a day, in the morning and afternoon and documents it in the computer. Another interview was conducted with the interim DON, staff #99 on (MONTH) 16, (YEAR) at 12:55 p.m. The interim DON stated that the facility did not have a restorative nurse aide and that the CNAs were responsible for providing range of motion. The interim DON further stated that the CNAs were providing range of motion for the resident but that it was not consistently being done twice a day. The DON also stated that the facility did not have a policy regarding this as it was a nursing judgement as to how often the range of motion should be provided and that it is documented on the CNA task sheet. -Resident #35 was admitted to the facility on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. Review of the ADL (activities of daily living) care plan dated (MONTH) 24, (YEAR), revealed the resident had mobility and ADL self-care deficits. Interventions listed included the following: total dependence of two staff for bed mobility, two staff for transfers per Hoyer sling, extensive assist of two staff to reposition every 2 hours and as needed in the bed or the wheelchair. Further review of the care plan revealed a care plan for falls that included an intervention PT evaluate and treat as ordered or prn. A review of the annual Minimum Data Set assessment dated (MONTH) 24, (YEAR), revealed the resident's BIMS (Brief Interview for Mental Status) score was 15 which indicated the resident was cognitively intact. The resident's functional status included total dependence for ADLs of upper and lower extremities. Review of the CNA task sheet dated (MONTH) (YEAR), revealed the resident was to receive passive ROM to the arms and legs for 15 minutes during cares twice daily. Further review of the sheet revealed the following: May 4 a.m. shift 5 minutes May 5 No ROM documented May 6 No ROM documented May 7 p.m. shift No ROM documented May 8 a.m. shift No ROM documented May 9 a.m. shift No ROM documented May 10 a.m. and p.m. shifts 5 minutes documented May 11 a.m. shift 5 minutes documented May 11 p.m. shift No ROM documented May 12 a.m. shift 1 minute documented May 13 a.m. shift No ROM documented May 14 No ROM documented An interview was conducted with resident #35 on (MONTH) 14, (YEAR) at 11:31 a.m. He stated that he was not receiving ROM as often or as long as necessary to prevent decline and that it was getting harder for him to drive his electric wheelchair. An interview was conducted on (MONTH) 16, (YEAR) at 10:20 a.m. with the interim DON (staff #99). She stated that the facility does not have an RNA (Restorative Nursing Assistant) program. She stated the ROM responsibilities are assigned to the individual CNA providing the resident's care. Staff #99 further stated that the CNAs are aware of the expectation to provide 15 minutes of ROM twice a day and to document the minutes in the electronic record. After reviewing the CNA documentation for May, she agreed that ROM was inconsistently being provided. An interview was conducted on (MONTH) 16, (YEAR) at 11:20 a.m. with CNA (staff #15). She stated that the CNA assigned to the resident is expected to perform ROM exercise and document the care provided in the electronic record.",2020-09-01
614,TEMPE POST ACUTE,35106,6100 SOUTH RURAL ROAD,TEMPE,AZ,85283,2018-05-16,697,D,1,1,05F711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, resident interview, staff interviews, and policy and procedure, the facility failed to ensure that one resident (#21) received pain medication as ordered by the physician. The sample size was three. Findings include: Resident #21 was admitted to the facility on (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. Review of the annual MDS (Minimum Data Set) assessment dated (MONTH) 19, (YEAR), revealed the resident's BIMS (brief interview for mental status) score was 14 which indicated the resident was cognitively intact. Further review of the admission MDS assessment revealed the resident was on a scheduled pain medication regimen. Review of the clinical record revealed a physician's orders [REDACTED]. Give 2 tablets by mouth two times a day for chronic pain. Review of the resident's clinical record revealed a physician's orders [REDACTED]. Give 1 tablet by mouth one time a day (at 1:00 p.m.) for chronic pain. Review of a Nurse's Note dated (MONTH) 27, (YEAR), revealed Resident alerted to me just before dinner that she had a fall. Resident said she was using her wheelchair when it went into some gravel. She was stuck and so got up to move the wheelchair but fell on her right hip on the pavement. Another resident helped her get up in her wheelchair. She later reported the incident to me. Contacted nurse practitioner .who asked for right pelvic and right femur X-ray to rule out any damage . Review of a Nurse's Note dated (MONTH) 28, (YEAR), revealed status [REDACTED].X-ray negative for fracture/dislocation. The Medication Administration Record [REDACTED]. The reason for not administering the morning dose on (MONTH) 13, (YEAR) was Hold/See Nurses Notes. Reasons for not administering the evening dose on (MONTH) 13, (YEAR) and both doses on (MONTH) 14, (YEAR) were Other-See Progress Notes. Review of the (MONTH) Medication Administration Record [REDACTED]. The reason for not administering the (MONTH) 13, (YEAR) dose was not documented. The reason for not administering the (MONTH) 14, (YEAR) dose was Other-See Progress Notes. Review of a Nurse's Note dated (MONTH) 13, (YEAR) at 11:31 a.m. revealed, [MEDICATION NAME] HCl Tablet 50 milligrams. Give 2 tablets by mouth two times a day for chronic pain. Script faxed to pharmacy. A Nurse's Note dated (MONTH) 13, (YEAR) at 7:47 p.m. revealed, [MEDICATION NAME] HCl Tablet 50 milligrams. Give 2 tablets by mouth two times a day for chronic pain. Awaiting delivery. A Nurse's Note dated (MONTH) 14, (YEAR) at 7:46 a.m. revealed, [MEDICATION NAME] 50 milligrams. Give 2 tablets by mouth two times a day for chronic pain. Awaiting delivery. Review of a Nurse's Note dated (MONTH) 14, (YEAR) at 1:15 p.m. revealed, [MEDICATION NAME] HCl Tablet 50 milligrams. Give 1 tablet by mouth one time a day for chronic pain. Waiting for delivery. Further review of the clinical record revealed no evidence that the resident's physician was notified that the [MEDICATION NAME] was not available for administration for the resident's pain on (MONTH) 13 and 14, (YEAR). An interview was conducted with the resident on (MONTH) 15, (YEAR) at 10:20 a.m. The resident stated that she fell outdoors a while ago when her wheelchair became stuck in the gravel and she stood up to try to remove her wheelchair from the gravel. She stated that the X-rays revealed she did not fracture her hip. The resident stated that her hip was just badly bruised and painful. The resident stated that the facility ran out of [MEDICATION NAME] for two days on (MONTH) 13 and 14, (YEAR) and that she was in extreme pain. The resident further stated that she had to go two days without pain medication and that the facility did not tell her why the medication was not available. An interview was conducted with an LPN (licensed practical nurse), staff #43 on (MONTH) 15, (YEAR) at 10:40 a.m. The LPN stated that if a resident was out of a pain medication, she would call the physician to obtain a new prescription. The LPN stated that if the medication was available in the facility's emergency kit she would obtain a prescription so that the medication could be administered to the resident. The LPN stated that if she had called the physician on (MONTH) 14, (YEAR) to notify him the [MEDICATION NAME] was not available, that she would have documented it in the clinical record. The LPN further stated that she honestly could not remember if the physician was notified when the [MEDICATION NAME] was not available for the resident. An interview was conducted with another LPN, staff #48 on (MONTH) 15, (YEAR) at 11:00 a.m. The LPN stated that if a resident was out of a pain medication, he would notify the physician right away to get a refill and then call the pharmacy. The LPN stated that in the meantime he would check to see if the medication was available in the facility's emergency kit so that the resident did not go without the medication. The LPN further stated that he was unsure if [MEDICATION NAME] was available in the facility's emergency kit. An interview was conducted with the interim DON (director of nursing), staff #99 on (MONTH) 15, (YEAR) at 12:30 p.m. The interim DON stated that if a medication was unavailable, the physician should be notified for a new prescription. The interim DON further stated that she did not know why the [MEDICATION NAME] was not pulled from the facility's emergency kit and administered to the resident. Review of the listing of medications in the facility's Narcotic Emergency Box revealed that [MEDICATION NAME] was available. The facility's Long Term Care Facility Pharmacy Services and Procedure Manual included .Facilities are encouraged to reorder medications electronically .Refill orders can be submitted verbally .",2020-09-01
615,TEMPE POST ACUTE,35106,6100 SOUTH RURAL ROAD,TEMPE,AZ,85283,2018-05-16,727,E,0,1,05F711,"Based on staff interviews and facility documentation, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. Findings include: Review of the facility's staffing documentation revealed there was not a registered nurse on duty for the month of (MONTH) (YEAR) on the following dates: April 8 April 12 April 13 April 21 April 22 April 27 An interview was conducted with the staffing coordinator (staff #66) on (MONTH) 16, (YEAR) at 12:30 p.m. Staff #66 stated that he did not have any documentation that there was a registered nurse in the facility for 8 consecutive hours on those days in April. An interview was conducted with the Director of Nursing (staff #99) on (MONTH) 16, (YEAR) at 1:00 p.m. Staff #99 stated she was not able to provide documentation that there was a registered nurse on duty for eight consecutive hours a day for the indicated dates in April, especially the weekend dates. She also stated that she could not locate a policy regarding having a registered nurse for 8 consecutive hours, 7 days a week.",2020-09-01
616,TEMPE POST ACUTE,35106,6100 SOUTH RURAL ROAD,TEMPE,AZ,85283,2018-05-16,761,D,0,1,05F711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, manufacturers' instructions, and policy and procedure, the facility failed to ensure open medications were labeled with an open date, failed to discard expired medications, and failed to ensure the medication room refrigerator temperature was consistently checked and recorded on the log. Findings include: -During an observation of medication cart #2 conducted with a Licensed Practical Nurse (staff #48) on (MONTH) 16, (YEAR) at 10:37 a.m., an opened vial of Levimir insulin was observed without the date it was opened. Further observation of medication cart #2 revealed the following expired medications: [REDACTED] -One card of [MEDICATION NAME] Sodium 50 micrograms ([MEDICAL CONDITION] hormone replacement) which contained thirty tablets with an expiration date of (MONTH) 8, (YEAR). -One card of [MEDICATION NAME] (alpha-agonist hypotensive agents) which contained twenty-four tablets with an expiration date of (MONTH) 31, (YEAR). -One card of [MEDICATION NAME] which contained thirty tablets with an expiration date of (MONTH) 31, (YEAR). Following the observations, staff #48 stated the insulin should have been dated when it was opened and that once the Levimir is opened, you have 28 days to use it. He stated that the nurses are responsible for checking the medication carts for expired medications daily during each of their shifts. -An observation of the medication room was conducted on (MONTH) 16, (YEAR) at 11:08 a.m. with staff #48. Inside the intravenous cart, an opened 20 milliliter (ml) vial of 1% [MEDICATION NAME] was observed with no open date on it. Further observation of the medication room revealed the medication room refrigerator log dated (MONTH) (YEAR). Review of the refrigerator log revealed no a.m. temperatures documented (MONTH) 1-16, (YEAR) and no temperatures documented (MONTH) 7-10 and 14-16, (YEAR) for the p.m. shift. At this time, an observation was conducted of the medication room refrigerator. The following was observed: -Two 5 ml vials of [MEDICATION NAME] with no date of when they were opened. -One 1 ml vial of [MEDICATION NAME] with no date of when it was opened. Following these observations, staff #48 stated the 1% [MEDICATION NAME] vial should have been dated when it was opened and that the nurses are responsible for documenting the medication room refrigerator temperature. He stated that the [MEDICATION NAME] vials should have been dated when they were opened. An interview was conducted on (MONTH) 16, (YEAR) at 3:12 p.m., with the Director of Nursing (staff #99). She stated that it is their policy as recommended by the manufacturers' instructions to date all insulin, [MEDICATION NAME], and [MEDICATION NAME] vials after opening them. She stated that once opened, the vial of Levimir insulin is good for 28 days, the [MEDICATION NAME] vial is good for 30 days, and the 1% [MEDICATION NAME] is good for 28 days. She also stated that it is their policy to have the medication room refrigerator temperature checked and documented twice a day. Review of the manufacturers' instructions revealed the Levimir insulin can be used up to 28 days after opening, the [MEDICATION NAME] can be used up to 30 days after opening, and the [MEDICATION NAME] 1% can be used up to 28 days after opening. The facility's policy regarding Storage and Expiration of Medications, Biologicals, Syringes and Needles included that once any medication or biological package is opened, the facility should follow the manufacturer/supplier guidelines with respect to expiration dates for opened medications. The policy also included that the facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopoeia guidelines for temperature ranges and that the facility staff should monitor the temperature of vaccines twice a day.",2020-09-01
617,TEMPE POST ACUTE,35106,6100 SOUTH RURAL ROAD,TEMPE,AZ,85283,2019-06-21,578,D,0,1,25FM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy, the facility failed to ensure one of four sampled residents (#289) advance directive was offered and completed upon admission. The deficient practice could result in residents receiving services which are not in accordance with their wishes. The census was 44. Findings include: Resident #289 was admitted on (MONTH) 16, 2019, with [DIAGNOSES REDACTED]. Review of the clinical record revealed the advance directive paperwork had not been completed upon admission. An interview was conducted on (MONTH) 19, 2019 at 1:20 p.m. with a Registered Nurse (RN/staff #37). She stated, the advance directive is to be completed upon admit because if the resident codes prior to advance directives being offered there is a possibility that their wishes might not be followed. The RN also stated that if the resident refused to formulate the advance directive at that time, then the nurse would document it in their progress notes. During an interview conducted on (MONTH) 19, 2019 at 1:34 p.m. with the Director of Nursing (DON/staff #22), she stated the advance directive form is to be offered upon admission, not days after the admission. The DON stated that if the resident or the resident's representative refuses to formulate an advance directive, the resident would be considered a full code until the paperwork is completed. She stated the Health Information Manager (staff #47) completes the new admission paperwork and is responsible for getting the advance directive form signed. An interview was conducted with the Health Information Manager (staff #47) on (MONTH) 16, 2019 at 2:05 p.m. She stated she usually completes the admission paperwork and that the advance directive form is flagged in the resident's chart for the nurses to complete. Staff #47 stated her goal is to complete the admission paper the next day. She stated that chart audits are conducted every 48 hours and 72 hours to make sure that all new admit paperwork is complete including the advance directives. Staff #47 stated that if during her audit, she finds the advance directive has not been completed; she gives it to the nurses. She stated that if the resident does not want to formulate an advance directive, it has to be documented in the nurses' progress notes. The facility's policy Advance Directives revised 12/2018 revealed staff will inquire during the admission process whether or not a resident has an advance directive. Information and forms will be provided to those individuals wanting to develop an advance directive. The policy also included staff will provide written information about advance directive policies upon admission.",2020-09-01
618,TEMPE POST ACUTE,35106,6100 SOUTH RURAL ROAD,TEMPE,AZ,85283,2019-06-21,641,B,0,1,25FM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure a discharge MDS (Minimum Data Set) assessment was accurate for one of three sampled residents (#40). This deficient practice could affect continuity of care. Findings include: Resident #40 was admitted on (MONTH) 10, 2019, with [DIAGNOSES REDACTED]. The resident was discharged (MONTH) 15, 2019. A nursing note dated (MONTH) 12, 2019, revealed the resident was scheduled for transfer to a memory care facility next week. A physician's orders [REDACTED]. However, review of the discharge MDS assessment dated (MONTH) 15, 2019, revealed the resident was discharged to an acute hospital. An interview was conducted on (MONTH) 21, 2019 at 9:25 a.m. with the MDS/Assistant Director of Nursing (staff #52). After reviewing the clinical record, staff #52 stated that the MDS assessment was inaccurate and it should have been coded as discharge to the community not discharge to hospital. During an interview conducted with the Director of Nursing (staff #22) on (MONTH) 21, 2019 at 9:30 a.m. Staff #22 stated that the MDS assessment should have been coded as transfer to the community. The RAI manual instructs to review the medical record including the discharge plan and discharge orders for documentation of discharge location and code MDS assessment accordingly. The RAI manual also included that it is required that the assessment accurately reflects the resident's status and that the importance of accurately completing and submitting the MDS assessments cannot be over-emphasized.",2020-09-01
619,TEMPE POST ACUTE,35106,6100 SOUTH RURAL ROAD,TEMPE,AZ,85283,2019-06-21,677,D,0,1,25FM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure one sampled resident (#23) received an adequate number of showers. The universe was 14. The deficient practice could result in hygiene needs not being met. Findings include: Resident #23 was readmitted to the facility on (MONTH) 26, (YEAR), with [DIAGNOSES REDACTED]. Review of the care plan dated (MONTH) 12, 2019, revealed the resident needed assistance with Activities of Daily Living related to a [MEDICAL CONDITION] disorder and impaired vision. Interventions included the resident needed one person assistance for showering. Review of the facility's shower schedule located in the staffing book revealed residents are scheduled at least 2 times a week for showers and to document it in the electronic record. The quarterly Minimum Data Set assessment dated (MONTH) 2, 2019, revealed a Brief Interview for Mental Status score of 15, which indicated the resident had intact cognition. The assessment also included the resident required the assistance of one person for bath/showers. Review of the shower assignment sheet for resident #23 revealed showers were scheduled every Tuesday and Friday on the p.m. shift. Review of the Point of Care documentation (P[NAME]) for showers revealed that from (MONTH) 22 to (MONTH) 20, 2019, resident #23 was provided showers on (MONTH) 24, 31 and (MONTH) 11. The documentation also revealed the resident did not refuse any showers. During an interview conducted with the resident #23 on (MONTH) 18, 2019 at 9:56 a.m., the resident was observed to be wearing clothes with stains and untrimmed nails. The resident stated that he has not been provided showers twice a week that showers are mostly missed. An interview was conducted with a Certified Nursing Assistant (CNA/staff #77) on (MONTH) 20, 2019 at 9:16 a.m. She stated that all residents are scheduled to be offered a shower at least two times a week and that the schedule is located at the nurse's station. The CNA stated that they document the showers and refusals in P[NAME]. The CNA stated that the expectation is that showers be offered to the residents as scheduled and documented. She stated that when they are short staffed, they are unable to provide all of their scheduled showers. During an interview conducted with a Licensed Practical Nurse (LPN/staff #27) on (MONTH) 20, 2019 at 9:33 a.m., she stated that they have a shower schedule and each resident is scheduled for two showers a week. She stated that the CNA is expected to offer the shower as scheduled and to document the showers and any refusals in P[NAME]. The LPN stated that when they are short staff the CNAs might not be able to offer all their scheduled showers. She stated that if that happens, the CNA will notify the LPN and report it to the oncoming shift and that the next shift can give the shower. An interview was conducted with the Director of Nursing (DON/ staff #22) on (MONTH) 20, 2019 at 3:13 p.m. She stated that she expects staff to offer showers to the residents on their scheduled shower days. She stated that when a shower is given or a shower is refused by a resident it should be documented in P[NAME]. The DON stated that when a shower is missed because of staffing issues, it should be offered on the next shift and documented. Review of the facility's policy regarding Shower Assignments revealed each resident will be provided a shower/bath two times a week and as needed.",2020-09-01
620,TEMPE POST ACUTE,35106,6100 SOUTH RURAL ROAD,TEMPE,AZ,85283,2019-06-21,690,D,0,1,25FM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, clinical record review, and policy and procedures, the facility failed to ensure two sampled residents (#8 and #6) with an indwelling catheter received the appropriate care and services. The deficient practice could result with residents having urinary complications. Findings include: -Resident #8 was admitted to the facility on (MONTH) 12 2019 and readmitted on (MONTH) 29, 2019, with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 19, 2019 revealed a Brief Interview for Mental Status (BIMS) score of 3 which indicated the resident had severe cognitive impairment. The assessment also included the resident had an indwelling urinary catheter and an ostomy, Review of the care plan regarding the catheter/[MEDICATION NAME] revised on (MONTH) 7, 2019, revealed a goal that the resident would not sustain injury secondary to catheter manipulation. Interventions included educating the resident on the importance of fluids, keeping the drainage bag below the level of the bladder, monitoring/recording output every shift, providing adequate fluids, and securing the catheter to the leg or abdomen to avoid tension. Review of the physician's orders dated (MONTH) 23, 2019 revealed an order for [REDACTED].>The Treatment Administration Record (TAR) for (MONTH) 2019 revealed documentation routine catheter care was provided twice daily (MONTH) 23 through (MONTH) 30, 2019 except when the resident was out of the facility. A Nursing Progress Note dated (MONTH) 28, 2019 revealed documentation the resident was sent to the hospital for pulling out the suprapubic catheter and that the resident was being admitted to the hospital. Review of the Nursing Progress Note dated (MONTH) 29, 2019 revealed the resident returned from the hospital with a dressing over what was the suprapubic catheter. The note also included that the Foley catheter, size 20 gauge French with a 10 cubic centimeter (cc) balloon was intact and draining yellow urine. Review of the physician's orders dated (MONTH) 29, 2019 revealed an order to replace the Foley catheter if the resident pulls it out. The order contained no instructions regarding the catheter size, balloon size, catheter care, or when to routinely change the catheter. Review of the clinical record revealed no documentation that catheter care was provided (MONTH) 1 through (MONTH) 19, 2019. The TAR did include documentation the catheter was replaced on (MONTH) 5, 2019 at 11:40 p.m. An interview was conducted with a Certified Nursing Assistant (CNA/staff #8) on (MONTH) 19, 2019 at 9:30 a.m. The CNA stated that she empties the urine bag and cleans the outlet tip at least twice a shift. She stated that the resident wears leg bags which do not hold large quantities of urine, so she has to empty the bag more frequently. An interview was conducted with a Licensed Practical Nurse (LPN/staff #55) on (MONTH) 20, 2019 at 10:20 a.m. The LPN stated the resident used to have a suprapubic catheter but he kept pulling it out, so the urologist surgically inserted a urethral catheter. She stated that the nurses do not routinely change his catheter because of the difficulty of insertion. She further stated that she provides catheter care daily and that she was unaware that there were no orders for catheter care. During an interview conducted with the Director of Nursing (DON/staff #22) on (MONTH) 19, 2019 at 10:50 a.m., the DON stated that she expects the nurses to follow physician orders and facility policy in regard to residents with catheters. Review of the facility's policy regarding Indwelling Catheter Care revealed the purpose of catheter care is to prevent infection and reduce irritation. The policy also included the indwelling catheter care procedure. -Resident #6 was readmitted to the facility on (MONTH) 6, (YEAR) with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated (MONTH) 12, 2019 revealed a BIMS score of 12 which indicated the resident had moderate cognitive impairment. The assessment also included the resident had an indwelling urinary catheter and an ostomy. The care plan regarding the indwelling suprapubic catheter revealed a goal that the resident would remain free from complications related to an indwelling catheter. Interventions included instructions to see physician's orders for care. Review of the physician recap orders for (MONTH) 2019, revealed an order with an initial date of (MONTH) 7, (YEAR) to cleanse the suprapubic site with soap and water, pat dry, and apply split drainage gauze twice daily. On (MONTH) 20, 2019 at 10:10 a.m., an observation was conducted of suprapubic catheter care. The Licensed Practical Nurse (LPN/staff #55) washed her hands and donned gloves. She removed the dressing from the suprapubic catheter site, cleaned the area around the catheter and down the catheter away from the stoma using sterile water. She then applied split gauze dressing, removed her gloves and washed her hands. Immediately following this observation, the LPN stated that she always uses sterile water for this procedure. Review of the facility policy regarding Suprapubic Catheter Care revealed the purpose of suprapubic catheter care was to keep the area clean and prevent infection. The policy included instructions to check the physician's order for catheter care and clean the area around the catheter well with soap and warm water.",2020-09-01
621,TEMPE POST ACUTE,35106,6100 SOUTH RURAL ROAD,TEMPE,AZ,85283,2019-06-21,692,D,0,1,25FM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident representative and staff interviews, clinical record review, and policy and procedure, the facility failed to ensure nutritional care and services were provided and documented for two of two sampled residents (#10 and #88). The deficient practice places residents at risk for potential nutritional decline and/or dehydration. Findings include: -Resident #10 was admitted to the facility on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated (MONTH) 5, 2019, revealed a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. Review of a care plan for nutrition revised on (MONTH) 9, 2019, revealed the resident was at nutritional risk with an intervention to monitor meal intakes. A hydration care plan revised on (MONTH) 9, 2019, revealed the resident was at risk for alteration in hydration related to a [DIAGNOSES REDACTED]. Review of the resident's meal and fluid intake documentation for (MONTH) 1, 2019 through (MONTH) 19, 2019, revealed no documentation of meal or fluid intake for 21 out of the 57 meals. An observation of the resident's room was conducted on (MONTH) 19, 2019 at 9:06 a.m. There no water pitcher observed at the resident's bedside. An interview was conducted on (MONTH) 19, 2019 at 2:43 p.m. with a Certified Nursing Assistant (CNA/staff #49). He stated the CNA was responsible for documenting the resident's meal and fluid intake. He stated that every resident should have a water pitcher in their room. The CNA said there was also a self-serve beverage cart in the hallway which was available for residents and guests; however, he stated residents did not use the cart very often. Another observation of the resident's room was conducted on (MONTH) 20, 2019 at 8:29 a.m. No water pitcher was observed at the resident's bedside. An interview was conducted on (MONTH) 20, 2019 at 9:18 a.m. with a CNA (staff #58). She stated the CNA was responsible for documenting meal and fluid intake. She said if the resident did not eat a meal, it would be documented as refused. She stated that meal and fluid intake documentation should not be left blank. She stated that if a resident did not have a water pitcher in their room, she would wait for the resident to request one before replacing it. -Resident #88 was admitted to the facility on (MONTH) 17, 2019, with [DIAGNOSES REDACTED]. Review of the admission nursing assessment dated (MONTH) 17, 2019, revealed the resident was confused and was dependent on staff for eating. Review of the care plan for nutrition dated (MONTH) 18, 2019, revealed the resident was at nutritional risk, with an intervention to monitor meal intake. The care plan regarding activities of daily living dated (MONTH) 20, 2019 revealed the resident was dependent on staff for eating. Review of the resident's meal intake documentation for (MONTH) 17, 2019 through (MONTH) 19, 2019, revealed no documentation for 5 out of the 7 meals. A meal observation and interview was conducted on (MONTH) 19, 2019 at 12:27 p.m. A staff member brought a meal tray into the resident's room and set it on a table that was out the resident's reach. The staff member left the room. When asked about the tray left away from the resident, the staff member said the resident was sleeping and the resident's representative said it was okay to leave the tray until the resident woke up. An interview was conducted on (MONTH) 20, 2019 at 10:55 a.m. with the resident's representative. She stated she had told staff that the resident could not eat on her own. She said staff would not feed the resident. She said the only time the resident ate was when she fed the resident herself. A meal observation was conducted on (MONTH) 20, 2019 at 12:24 p.m. A staff member brought a meal tray into the resident's room and set it on a bedside table that was two to three feet away from the resident's bed. The staff member left the food covered and exited the room. At 1:02 p.m., a staff member removed the meal tray from the resident's room and placed it on the kitchen cart. All of the food was still on the tray, including the main dish, salad and dessert. An interview was conducted on (MONTH) 20, 2019 at 2:15 p.m. with the Director of Nursing (DON/staff #22). She stated the CNA was responsible for documenting meal and fluid intake. She said meal documentation was reviewed by the nurse on duty. She said that ideally, meal documentation would also be audited weekly for completion by herself and the Assistant Director of Nursing. She said if the CNA was not documenting meal intake, then we have an issue. She further stated her expectation is that interventions on the care plan should be followed as long as they were reasonable and doable. She said it may not be reasonable to include an intervention to keep a water pitcher at the bedside for a resident with dementia. Review of the facility's policy for meal service revealed the purpose is to ensure each resident received the amount of assistance necessary and to record the percentage of food the resident consumed. Procedures included to place food containers within easy reach of the resident, assist as necessary, return periodically to determine if the resident required further assistance, and take note of the percentage of food consumed. The facility's policy regarding Hydration revealed each resident will be provided with sufficient fluid intake to maintain proper hydration. The policy included fluids will be offered during meals, between meals, and at bedside unless contraindicated. The policy also included fresh water is delivered to applicable residents three times a day and as needed.",2020-09-01
622,TEMPE POST ACUTE,35106,6100 SOUTH RURAL ROAD,TEMPE,AZ,85283,2019-06-21,761,E,0,1,25FM11,"Based on observation, interview, and policy review, the facility failed to ensure that medications and biologicals were stored in locked compartments and under proper temperature controls and that expired medical supplies were not available for resident use. The deficient practice could result in failure to prevent loss, inaccurate laboratory results, and ineffective vaccines. Findings include: -An observation of a medication storage room was conducted on (MONTH) 20, 2019 at 1:55 p.m., with a Licensed Practical Nurse (LPN/staff #55). The observation revealed two culture swabs with an expiration date of (MONTH) 2019. There was also a refrigerator in the room that contained vaccines and medications. Review of the refrigerator temperature log for (MONTH) 2019, revealed spaces to record the temperature twice daily, however, review of the log revealed missing documentation for the following dates: -May 1st a.m. and p.m. -May 2nd a.m. -May 4th a.m. and p.m. -May 5th a.m. -May 6th a.m. -May 9th a.m. -May 10th p.m. -May 11th a.m. and p.m. -May 12th p.m. -May 14th a.m. -May 15th a.m. Review of the refrigerator temperature log for (MONTH) 2019 revealed missing documentation for the following dates: -June 1st p.m. -June 2nd p.m. -June 6th a.m. and p.m. -June 7th p.m. -June 11th p.m. -June 12th a.m. and p.m. -June 13th p.m. -June 14th a.m. and p.m. -June 15th p.m. -June 17th p.m. -June 18th p.m. -June 19th p.m. -June 20th a.m. An interview was conducted with staff #55 at the time of the observation. She stated that she would not be able to tell if the vaccines in the refrigerator were still effective if the temperature log had blank spaces. An interview was conducted on (MONTH) 20, 2019 at 2:15 p.m. with the Director of Nursing (DON/staff #22). She stated that the pharmacy conducted a full audit of the medication room and medication carts checking for expired medications, over-the-counter medications, and supplies. She said medication rooms and carts should also be checked by the nurses and the unit manager. The DON stated that expired medications and supplies should be stored separately in the medication room until destroyed or returned to the pharmacy. She said the expired culture swabs should have been removed from the inventory in the medication room. She stated the refrigerator temperature log should be recorded daily and that she believed the temperature log was maintained and audited by maintenance. She also made a follow-up comment on (MONTH) 21, 2019 at 9:54 a.m. regarding the refrigerator temperature log, stating that based on the trending of the refrigerator temperature logs, she believed the temperature had been maintained and did not exceed the recommended range. -An observation of an unlocked, unattended medication cart was conducted on (MONTH) 20, 2019 from 2:58 p.m. to 3:16 p.m. During this time, five staff members, three visitors, and one resident passed by the cart, however, no one was observed opening the cart. At the end of the time period, the nurse was observed returning to the cart, opening a drawer, closing a drawer, and locking the cart. An interview was conducted with the LPN (staff #55) on (MONTH) 20, 2019 at 3:25 p.m. She stated the only time the medication cart should be unlocked is when the nurse is preparing medications. Otherwise, the cart should be locked. She stated that she did not realize she left the cart unlocked until she returned to the cart. An interview was conducted on (MONTH) 21, 2019 at 9:54 a.m. with the DON (staff #22). She stated her expectation was that medications carts would be secured when not in sight of the nurse. Review of the facility's Medication Storage policy revealed medications should be securely stored in a locked cart or locked medication room that is inaccessible by residents and visitors. The facility should ensure that medications and supplies have an expiration date on the label, and that expired products are stored separate from other medications until destroyed or returned to the pharmacy. The policy also included the facility should monitor the temperature of vaccines twice daily and store at the appropriate temperature according to the United States Pharmacopoeia guidelines, including refrigeration temperatures ranging from 36 to 46 degrees Fahrenheit.",2020-09-01
623,TEMPE POST ACUTE,35106,6100 SOUTH RURAL ROAD,TEMPE,AZ,85283,2019-06-21,880,E,0,1,25FM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on personnel record review, observations, staff interviews and policy review, the facility failed to ensure that 4 of 10 sampled staff (#24, #34, #40, and #59) had evidence of freedom from [MEDICAL CONDITION] and failed to ensure infection control practices were implemented during a medication administration observation and during a wound observation. The deficient practice could result in the potential exposure of infectious TB disease, cross contamination, spreading infections to others, and potential contamination of wounds. The facility census was 44. Findings include: -Review of the personnel record for the Activities Director (staff #24) revealed a hire date of (MONTH) 9, (YEAR). The file did not contain evidence that staff #24 was free of TB. -Review of the personnel record for Registered Nurse (RN/ staff #34) revealed a hire date of (MONTH) 11, 2011. The file did not contain evidence that staff #34 was free of TB -Review of the personnel record for Certified Nursing Assistant (CNA/staff #40) revealed a hire date of (MONTH) 25, (YEAR). The file did not contain evidence that staff # 40 was free of TB. -Review of the personnel record for Licensed Practical Nurse (LPN/staff #59) revealed a hire date of (MONTH) 18, (YEAR). The filed did not contain evidence that staff #59 was free of TB. An interview was conducted with the Administrator (staff #62) on (MONTH) 20, 2019 at 1:30 p.m. She stated she did not have any further documentation showing the above staff received a TB test. She stated that she has been unable to locate the files for TB tests that had been completed in the past. The Administrator stated the leadership team has only been at the facility for three months and that they are trying to make sure all staff have evidence of being free from TB. An interview was conducted on (MONTH) 21, 2019 at 10:18 a.m. with the Director of Nursing (DON/staff #22). The DON stated that they currently have a process in place to ensure staff are receiving the TB test prior to working at the facility. -During a medication administration observation conducted on (MONTH) 20, 2019 at 7:40 a.m., a LPN (staff #55) was observed to push four different medication tablets out of their containers into her bare hand and then place the tablets into a medication cup. The nurse dropped a fifth tablet onto the surface of the medication cart, picked it up with her bare hand, and placed it in the medication cup. An interview was conducted with staff #55 following the medication administration at 7:59 a.m. The LPN stated that it was difficult to control the tablets when popping them out of their containers. She said the pills tend to fall on the cart and the floor. The LPN stated that she prefer to pop the tablets into her hand to catch them before placing them in the medication cup. She said she could wear gloves, but that she made it a point to have clean hands before preparing each resident's medications. The LPN stated that it was better than having a tablet land on a dirty surface such as the medication cart. She said the cart would be considered dirty because multiple residents' medications were prepared on that surface. She stated that she did not realize she dropped a tablet onto the medication cart surface, picked it up, and put it in the cup. The LPN stated she should not have done that. She said she was not aware of the facility's policy regarding touching resident medications. -During an observation conducted of a medication cart with a LPN (staff #27) on (MONTH) 20, 2019 at 12:44 p.m., two canisters of supplement powder were observed in a drawer of the cart. The seal of the canisters had been removed and the canisters contained a scoop with a handle that was touching the powder. An interview was conducted at the time of the observation with staff #27. The LPN stated that she did not know how it would be possible to remove the scoop from the canisters without touching the powder. An interview was conducted with the DON (staff #22) on (MONTH) 20, 2019 at 2:15 p.m. The DON stated that if a medication was touched or dropped, it should be discarded in the sharps container or destroyed. Review of the facility's infection control and medication administration policies revealed no policy that addressed touching or contaminating medications with bare hands, medication scoops, or the surface of the medication cart. -An observation of wound care was conducted on 06/20/19 at 10:41 a.m. with a LPN (staff #27). Staff #27 gathered the necessary supplies and entered the resident's room. After cleaning the resident's wound, the LPN washed her hands, put on gloves, picked up a bottle of Dakins solution with her right hand and removed the cap with her left hand. The LPN then picked up a gauze pad in her left hand and poured the Dakins solution over the gauze pad. Staff #27 was then observed to transfer the gauze to her right hand and proceed to pack the gauze into the resident's wound with her right hand fingers. The bottle of Dakins solution was not observed being wiped down or cleaned before use. In an interview with the LPN conducted on 06/20/19 at 11:02 AM., the LPN stated that she did not think the wound could be contaminated by her touching the bottle of Dakins solution and then using her fingers to pack the wound. She admitted that the risk of potential bacterial transfer from the bottle to the wound would be reduced if she had of poured the Dakins solution into a clean cup and pre-soaked the gauze before starting the procedure and used Q-tips to pack the wound. An interview was conducted with the DON (staff #22) on 06/20/19 at 11:40 AM. The DON stated that as a matter of best practice, pre-soaking the dressing would have been the better choice to prevent wound contamination. Review of the facility's infection control policy revealed the policy did not include the possible contamination that can occur during wound treatment.",2020-09-01
624,TEMPE POST ACUTE,35106,6100 SOUTH RURAL ROAD,TEMPE,AZ,85283,2019-06-21,883,D,0,1,25FM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy and procedures, the facility failed to ensure two of five sampled residents (#139 and #289) received information regarding the benefits and potential side effects of pneumococcal vaccines and failed to offer the vaccination on admission according to their policy. The deficient practice could maximize the risk of residents acquiring, transmitting, or experiencing complications from pneumococcal disease. Findings include: -Resident #139 was admitted to the facility on (MONTH) 11, 2019, with [DIAGNOSES REDACTED]. Review of the Admission Nursing Data Collection form dated (MONTH) 11, 2019, revealed the resident was alert and oriented. Review of the resident's clinical record revealed no documentation that the resident was provided information regarding the benefits and potential side effects of pneumococcal vaccines or that the resident was offered the pneumococcal vaccines. -Resident #289 was admitted to the facility on (MONTH) 14, 2019 with [DIAGNOSES REDACTED]. Review of the Admission Nursing Data Collection form dated (MONTH) 14, 2019, revealed the resident was alert and forgetful. Review of the resident's clinical record revealed no documentation that the resident was provided information regarding the benefits and potential side effects of pneumococcal vaccines or that the resident was offered the pneumococcal vaccines. In an interview with the Director of Nursing (DON/staff #22) on (MONTH) 19, 2019 at 10:52 a.m., the DON stated that she expects the nurses to follow the facility's policy and procedure and that the facility uses the Centers for Disease Control and Prevention (CDC) algorithm for determining who is eligible for pneumococcal vaccination. In an interview conducted on (MONTH) 19, 2019 at 12:10 PM with a Registered Nurse (RN/staff #37), the RN stated pneumococcal vaccination education and the offer of the vaccine should be documented in the clinical record. She stated that the nurses review the pneumococcal vaccination informed consent form on admission and then if the resident wants the vaccine, the nurse will enter the order and administer the vaccine. During an interview conducted with the Health Information Manager (HIM/staff #48) on (MONTH) 19, 2019 at 12:21 PM, the HIM stated the pneumococcal vaccination information should be in the clinical record. She also stated that there would be an entry on the Medication Administration Record [REDACTED] Review of the facility's policy regarding the Pneumococcal Vaccine Program revealed residents will be offered immunization against pneumococcal disease. Every admission is screened using the criteria contained within the standing protocol and given the vaccine if indicated after receiving education regarding the vaccine. The resident or the resident's representative has the opportunity to refuse the immunization. If the immunization is refuse, document the education and refusal in the clinical record. The policy also included that if the resident chooses to be immunized after education is provided, give the vaccine and document it in the resident's clinical record and on the immunization record.",2020-09-01
625,HAVEN OF PHOENIX,35107,4202 NORTH 20TH AVENUE,PHOENIX,AZ,85015,2019-01-16,658,D,0,1,S3S311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and staff and resident interviews, the facility failed to ensure one resident (#286) with dysphagia was monitored by a nurse while taking medications. Findings include: Resident #286 was admitted to the facility on (MONTH) 2, 2019, with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 9, 2019, revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS), which indicated the resident was cognitively intact. An observation was conducted on (MONTH) 14, 2019 at 8:51 a.m., of resident #286 standing in front of a sink, across from the nurses station. The resident was observed with a medication cup which contained approximately 4 pills. At this time, there was no nurse with the resident. The resident then left the medication cup on the sink and turned away and walked approximately three steps away from the sink. A licensed practical nurse (staff #55/LPN) then walked up to the medication cart which was in front of the resident. The resident asked staff #55 for some water. After giving the resident water, staff #55 walked away. The resident returned to the sink and started taking the medications. The resident then stated to this surveyor that he normally does not take medications out in the hallway, however, today staff wanted to watch him take his pills to monitor for aspiration. The resident stated he needed more water and then waited for the nurse who was coming down the hall. Staff #55 then gave the resident more water and remained at the medication cart. A nurse practitioner was then observed talking to the resident and was overheard saying that he had finished all of his pills. The resident then returned to his room. Shortly thereafter, staff #55 stated to another staff member that she did not stay with the resident, while he took his medications. An interview was conducted on (MONTH) 16, 2019 at 10:03 a.m., with a LPN (staff #48). She stated the nurses are to stay with the resident until all medications have been taken. She stated for a resident to self administer medications there must be an order and it must be care planned. An interview was conducted on (MONTH) 16, 2019 at 11:08 a.m., with a LPN (staff #55). She stated when administering medications, the process is to stay with the resident to ensure all medications have been taken. She stated she was caring for resident #286 that morning and was also training a new nurse (staff #107). She stated she did not dispense the resident's medications and that staff #107 dispensed the medications. She stated the resident often stands outside of his door and the nurse will stay at the cart and ensure he took all of the medications. She stated that she did not watch him take the medications and assumes that he did. She stated that staff #107 should have stayed with the resident, as he took the medications. At this time, she reviewed the Medication Administration Record [REDACTED]. Staff #55 said that staff #107 was using her login, and that she did not witness the resident take the medications. An interview was conducted on (MONTH) 16, 2019 at 11:36 a.m. with a registered nurse (staff #107). She stated that she started working on (MONTH) 14, and is currently on orientation with staff #55. She stated that during medication administration, the nurse is to stay with the resident to ensure that all medications are taken and then document it on the MAR. She stated on (MONTH) 14, the resident requested to take the medications out in the hall. She stated they went out to the hall and she figured the other nurse (staff #55) could watch the resident, while she went to get ice for the resident. She stated that after returning with the ice, staff #55 verbalized that she would stay with the resident and to her knowledge she did. She stated at that time, she did not have a login and was using staff #55's login. An interview was conducted on (MONTH) 16, 2019 at 11:53 a.m., with the Director of Nursing (staff #29/DON). He stated the nurses are expected to ensure that a resident takes their medication. He stated the nurses are to ensure that medications are administered and to document the administration. Staff #29 stated the nurses are to watch the resident take the medications, unless the resident has a preference to not be watched and that would be included in the care plan. He stated if the resident is not ready to take the medication, then the nurse can take the medication until the resident is ready.",2020-09-01
626,HAVEN OF PHOENIX,35107,4202 NORTH 20TH AVENUE,PHOENIX,AZ,85015,2019-01-16,689,E,0,1,S3S311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and policy review, the facility failed to ensure the resident environment remains free of accident hazards as is possible, by failing to ensure safety measures were implemented for one resident (#14), who had a history of [REDACTED]. Findings include: Resident #14 was admitted to the facility on (MONTH) 10, (YEAR), with [DIAGNOSES REDACTED]. Per a quarterly Minimum Data Set assessment dated (MONTH) 7, (YEAR), the resident was assessed to have severe cognitive impairment and was assessed to have had a fall in the facility since admission. A care plan dated (MONTH) 7, (YEAR) identified that the resident was at high risk for falls, due to being unaware of safety needs. The goal was for the resident to be free from falls. An intervention included to always keep a floor mat next to the bed. Review of the clinical record revealed the resident sustained [REDACTED]. -April 1, (YEAR): fall without injury. Care plan reviewed and intervention of floor mats next to the bed continued. -April 17, (YEAR): fall without injury. Care plan reviewed and intervention of floor mats next to the bed continued. -August 18, (YEAR): fall with a hematoma/laceration of head. Care plan reviewed and intervention of floor mats next to the bed continued. -November 16, (YEAR): fall with skin tear with subsequent treatment in the emergency room . Care plan reviewed and intervention of floor mats next to the bed continued. -December 30, (YEAR): fall and landed on floor mat, no injury. Care plan reviewed and intervention of floor mats next to the bed continued. An observation was conducted on (MONTH) 14, 2019 at 9:27 a.m. of the resident laying in bed. However, there were no floor mats that were next to the bed. Additional observations this same day were conducted at 10:48 a.m. and at 2:13 p.m., and the resident was laying in bed, with no mats on the floor next to the bed. An interview was conducted with a Certified Nursing Assistant (CNA/staff #71) on (MONTH) 16, 2019 at 10:29 a.m. She stated that she is assigned to care for resident #14 and knew the resident was at high risk for falls and needed floor mats next to the bed. She stated she looked in the resident's room this morning and could not find any floor mats, so she called maintenance staff and they brought the floor mats to the resident's room. Staff #71 said this resident needs the floor mats, because she has a history of falls from her bed. An interview was conducted with a Licensed Practical Nurse (staff #46) on (MONTH) 16, 2019 at 10:34 a.m. She stated the resident is at high risk for falls and needs floor mats next to the bed. Staff reviewed the current care plan, with documentation of the intervention of floor mats to be used when in bed and stated that since there is no where in the clinical record for staff to actually document that the mats are in place, it is more difficult to ensure they are on the floor next to her bed. Staff stated it is the responsibility of all nurses and CNA's to make sure the floor mats are next to the bed. An interview was conducted with the Director of Nursing (staff #29) on (MONTH) 16, 2019 at 10:48 a.m. He stated the resident is known to him and is at high risk for falls. He said that an in-service was done previously regarding the need for placement of floor mats for residents at high risk for falls, such as resident #14. Staff #29 stated it was their policy for all nurses and CNA's to be responsible to make sure the floor mats are in place and that care plans are followed. A policy regarding falls included that this facility is to develop a culture of safety for our residents to thrive. The policy included that residents assessed to be at high risk for falls will have a care plan in place, with individual interventions. The Director of Nursing oversees all steps of the fall program and coordinates implementation of individualized care plans.",2020-09-01
627,HAVEN OF PHOENIX,35107,4202 NORTH 20TH AVENUE,PHOENIX,AZ,85015,2019-01-16,812,E,0,1,S3S311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and policy review, the facility failed to ensure that two containers of cookies were stored properly, and failed to discard multiple boxes of orange juice, which had expired. Findings include: The initial tour of the kitchen was conducted on [DATE] at 8:52 AM, with the Assistant Food Service Manager (staff #222). In the dry storage area on a shelf, there were two containers of cookies which were open to air, and there were 16 boxes of orange juice, which were expired by one month. On another shelf, there were 16 boxes of orange juice with an expiration date of (MONTH) (YEAR). An interview was conducted on [DATE] at 9:11 AM, with staff #222. She stated that it appears someone forgot to cover and seal the cookies from the previous days meals. She also stated that she had no idea that the orange juice was expired, and both would be thrown out immediately. An interview with the Food Service Manager (staff #223) was conducted on [DATE] at 9:40 AM. The manager stated that he suspects that over the weekend the employees had not followed the food storage protocol, and that the expired orange juice was missed on his last inspection. He also stated that there is no excuse for not following food storage safety standards. A review of the facility's Food Storage and Date Marking policy revealed that perishable food items must be stored in tight-fitting containers and must be labeled and dated with legible writing. Date marking is to be used with all food items which may expire using an open date. The policy also stated that expired food items should be discarded.",2020-09-01
628,HAVEN OF PHOENIX,35107,4202 NORTH 20TH AVENUE,PHOENIX,AZ,85015,2018-09-13,658,E,1,0,KPZY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interview, and policies, the facility failed to ensure the administration of controlled medications were documented on the Medication Administration Records for 4 residents (#1, #2, #3, #4, and #5). Findings include: -Resident #1 was admitted to the facility on [DATE] and discharged to the hospital on (MONTH) 5, (YEAR). [DIAGNOSES REDACTED]. A physician order dated 11/22/17 ordered [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg, ([MEDICATION NAME]) one tablet every 4 hours as needed for pain. Review of the Medication Administration Record (MAR) for (MONTH) (YEAR) revealed documentation that the resident received one administration of [MEDICATION NAME] for pain on 11/23/17. Review of the MAR record for (MONTH) (YEAR) revealed the resident had no administrations of [MEDICATION NAME] for pain. Review of the controlled Drug Record revealed the resident had received a total of 15 doses of [MEDICATION NAME] in (MONTH) and one dose of [MEDICATION NAME] for pain in December. Fourteen doses of pain medication were not recorded on the MAR for resident #1. -Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician order dated 08/16/18 ordered [MEDICATION NAME] tablet 5-325 mg, give one tablet by mouth every 4 hours as needed for pain 1-10 on the pain scale. A review of the MAR for (MONTH) (YEAR) revealed between the dates of 09/08/18 and 09/13/18 the resident had received 3 doses of [MEDICATION NAME] for pain. A review of the Controlled Substance Record for the same time frame revealed the resident had received 16 doses of [MEDICATION NAME] for pain. Thirteen doses of [MEDICATION NAME] were not recorded on the MAR for resident #2. -Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician order dated 08/01/18 ordered [MEDICATION NAME] 30 mg tablets, give two tablets (60 mg) by mouth every 6 hours as needed for pain 7-10 on the pain scale. A review of the MAR for (MONTH) (YEAR) between the dated of 09/10/18 and 09/13/18 revealed revealed the resident had received 4 doses of [MEDICATION NAME] 60 mg medication for pain. Review of the Controlled Substance Record for the same time revealed the resident had received 11 doses of [MEDICATION NAME] for pain. Seven doses of [MEDICATION NAME] were not recorded on the MAR for resident #3 -Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician order dated 08/09/18 ordered [MEDICATION NAME] 10 mg, give one tablet ever 4 hours as needed for pain 1-10 on the pain scale. A review of the MAR for (MONTH) (YEAR) between the dated of 09/09/18 to 09/13/18 revealed the resident received 9 doses of [MEDICATION NAME] for pain. A review of the Controlled Substance Record for the same time frame revealed the resident received 17 doses of [MEDICATION NAME] for pain. Eight doses of [MEDICATION NAME] were not documented on the MAR for resident #4. -Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician order dated 08/22/18 ordered [MEDICATION NAME] ([MEDICATION NAME]) 5-300 mg, give 1 tablet by mouth event 4 hours as needed for pain 1-10 on the pain scale. Review of the MAR for (MONTH) (YEAR) between the dates on 09/07/18 and 09/13/18 revealed the resident had received 6 doses of [MEDICATION NAME] for pain. Review of the Controlled Substance Record revealed the resident had received 15 doses of [MEDICATION NAME] for pain. Nine doses of [MEDICATION NAME] were not documented on the MAR for resident #5. An interview was conducted on 09/13/18 at 10:49 AM with Licensed Practical Nurse (LPN/staff #60), who stated if a medication is given for the pain, the medication is obtained from the double locked drawer and the medication is signed out in the narcotic Book on the Controlled Substance Record for that resident and the count is verified, then the medication is documented on the MAR that it was administered. Staff #60 stated we are supposed to sign the medications in both placed, the Controlled Substance Record and the MAR. Staff #60 stated the computer electronic health record (MAR) charting is documenting the care and picture of what is going on with a patient and the Controlled Substance Record is a paper log just for the count of the narcotics. An interview was conducted on 09/13/18 at 10:53 AM with the Registered Nurse/director of Nursing (RN/DON/staff #4) who stated the process for administration of the narcotic starts with clarification of the order, assess the patient for pain parameters. The the nurse would go to the narcotic drawer, withdraw the pills and document on the Controlled Substance Record and they also have to document on the MAR. The DON stated the Controlled Substance Record is for the count and the nurse validates the resident has actually received the medication by documenting it on the MAR. Review of the facility policy titled Administering Medications the policy statement documented that medications shall be administered in a safe and timely manner, and as prescribed. The policy documented , 19. The individual administering the medication must initial the resident's MAR on the appropriate line after giving the medication and before administering the next ones. According to the Department of Health and Human Services, BDS Medication Administration Curriculum Section IV 2011, p12, retrieved from https://www.dhhs.nh.gov/dcbcs/bds/nurses/documents/sectionIV.pdf, the documented, Each time a medication is administered, it must be documented. Your documentation of medication administration must be done at the time that you give the medication. The American Nurses Association (2010) Principles of Nursing Documentation included the uses for nursing documentation included, Communication within the Health Care Team: Nurses and other health care providers aim to share information about patients and organizational functions that is accurate, timely, contemporaneous, concise, thorough, organized, and confidential. Information is communicated verbally and in written and electronic formats across all settings. Written and electronic documentation are formats that provide durable and retrievable records. Foremost of such electronic documentation is the electronic health record (EHR), provides an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient ' s EHR to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care. Assessments Clinical problems Communications with other health care professionals regarding the patient Communication with and education of the patient, family, and the patient ' s designated support person and other third parties Medication records (MAR) Order acknowledgement, implementation, and management Patient clinical parameters Patient responses and outcomes, including changes in the patient ' s status Plans of care that reflect the social and cultural framework of the patient",2020-09-01
629,HAVEN OF PHOENIX,35107,4202 NORTH 20TH AVENUE,PHOENIX,AZ,85015,2018-09-13,755,D,1,0,KPZY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview, observation of current practice, and policy review, the facility failed to ensure Schedule II-IV medications were destroyed in a manner that rendered them unusable and inaccessible. Findings include: During review of narcotic administration and destruction processes, an interview was conducted on [DATE] at 11:50 AM Licensed Practical Nurse (LPN/staff #10) who stated to destroy narcotics we get two nurses, then we pop the medications out of the blister pack and place then into a clean sharps container. Two nurses verify the count and sign the Controlled Substance Record. Then water is added to the pills or liquids, the container is closed and then taken to hazardous materials disposal. An interview was conducted on [DATE] at 11:55 AM with LPN (staff #60) who stated to destroy narcotics two nurses place the narcotics in a sharps container, verify the count, and sign off the Controlled substance Record. Then we add water to the pills and place it outside in the hazardous container. On [DATE] at 12:05 PM, LPN/staff #60 demonstrated the hazardous material disposal, which is a chain-link fence enclosed area that was approximately ,[DATE] feet wide and was secured with a combination lock. The enclosed area was adjacent to the parking lot where staff enter the building and where the gates are not secured, per staff #60. The area is visible from the parking lot. The hazardous bin that held the sharps container was not closed and visible in the bin were at least 3 sharps containers. An interview was conducted with the Registered Nurse/Director of Nursing (staff #4) on [DATE] who confirmed the destruction process for controlled medications was to have two nurses sign off the Controlled Substance Record and place the medications into a sharps container and add water. The DON stated he didn't realize just adding water would still leave the controlled substances available for use or human consumption. He also stated he didn't realize the container for the hazardous materials was open and the sharps containers were visible from the parking lot. An interview was conducted with the Pharmacy representative (staff #105) on [DATE] at 2:19 PM who stated we do not recommend our clients use water to destroy schedule medications. We recommend they use something else like coffee ground or kitty litter to make the medication unusable. The current destruction process for controlled medications created a poly-drug slurry of medications and water, thereby maintaining the medications available for human consumption. Review of the facility policy titled Disposal/Destruction of Expired or Discontinued Medications documented the facility should destroy and dispose of medications in accordance with Facility policy and Applicable Law, and applicable environmental regulations. The policy included, 11. Facility should destroy discontinued or outdated non-controlled medications by one of three (3) methods: 11.1 Prior to destruction, an authorized Facility staff member should remove the medications, including pills, capsules, liquids, creams, etc., from their dispensing containers and pour the medications into a container or plastic bag. An authorized Facility staff member may add a substance that renders the medications unusable to the plastic container or bag . 11.2. An authorized Facility staff member should placed medication containers in a container or box. Facility staff member should then seal the box with strong tape and label the box .The container or box should be secured in a locked cabinet or room until it is disposed or picked up .11.3 Facility-approved commercially available drug disposal kits. The policy also included that , Facility should destroy controlled substances as detailed above . and included the witness and documentation requirements. The Drug Enforcement Agency (2011) guidelines for the destruction of controlled substances retrieved from https://www.deadiversion.usdoj.gov/drug_disposal/dear_registrant_disposal.pdf documented Destruction of Controlled Substances: The final rule implements a standard of destruction: non-retrievable. The process utilized to render a substance non-retrievable shall permanently alter the substance's physical or chemical condition or state through irreversible means and thereby render the substance unavailable and unusable for all practical purposes. A substance is considered non-retrievable when it cannot be transformed to a physical or chemical condition or state as a controlled substance or controlled substance analogue.",2020-09-01
630,HAVEN OF PHOENIX,35107,4202 NORTH 20TH AVENUE,PHOENIX,AZ,85015,2016-09-21,247,D,0,1,0FQ511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, and policy review, the facility failed to notify one resident (#78) prior to a room change. Findings include: Resident #78 was admitted on (MONTH) 24, (YEAR), with [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed documentation that the resident was his own responsible party. According to a health status note dated (MONTH) 15, (YEAR) at 2:36 p.m., the resident was transferred to another room and that all personal belongings and medications were accounted for. An interview with resident #78 was conducted on (MONTH) 16, (YEAR) at 2:09 p.m. The resident stated that he had a room change and the facility did not give him prior notice. The resident stated that staff told him, maybe five minutes before the actual move and that was not ok. An interview was conducted on (MONTH) 20, (YEAR) at 1:19 p.m., with a case manager (staff #55), who stated that they could not find any documentation of the resident being provided advance notice of the room change. Staff #55 stated that they should have had the resident sign a form acknowledging the room change. Review of the facility policy regarding room changes revealed documentation that prior to changing a room or roommate assignment, all parties involved in the change would be given notice of such change. The policy further documented that when making a change in room or roommate assignments, the resident's needs and preferences would be considered and to the extent practical, would be accommodated.",2020-09-01
631,HAVEN OF PHOENIX,35107,4202 NORTH 20TH AVENUE,PHOENIX,AZ,85015,2016-09-21,441,D,0,1,0FQ511,"Based on observation, staff interviews, and review of policies and procedures, the facility failed to ensure that one staff member transported soiled linen in a sanitary manner to prevent the spread of infection. Findings include: During an observation on (MONTH) 20, (YEAR) at 2:30 p.m., a CNA (certified nursing assistant/staff #100) was observed walking down the hallway with bed linens that were not placed in a bag. Staff #100 was observed to walk into a shower room. When staff #100 exited the shower room, she did not have the bed linens. Following the observation, an interview was conducted with staff #100. When questioned regarding the bed linens, staff #100 stated that there was loose BM (bowel movement) and an incontinence pad that she had bagged up in the resident's room and then wrapped the bed linens around the bag. Staff #100 stated that she carried the bed linens from the resident's room to the shower room, which was approximately 90 feet. She further stated that she should have placed the soiled linens in a plastic bag before she transported it down the hallway. An interview was conducted with the DON (Director of Nursing/staff member #4) on (MONTH) 20, (YEAR) at 2:45 p.m. The DON stated that it was the policy of the facility to bag soiled linen, when transporting in the hallway. The DON stated that by bagging soiled linen, it would avoid the chance of contamination. A review of the facility's policy titled, Soiled Laundry and Bedding revealed that Soiled laundry/bedding shall be handled in a manner that prevents gross microbial contamination of the air and persons handling the linen .Place contaminated laundry in a bag or container at the location where it is used .Place and transport contaminated laundry in bags or containers in accordance with established polices governing the handling and disposal of contaminated items .",2020-09-01
632,SUN WEST CHOICE HEALTHCARE & REHAB,35110,14002 WEST MEEKER BLVD,SUN CITY WEST,AZ,85375,2017-02-16,241,D,0,1,91FY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and review of policy and procedure, the facility failed to ensure one resident (#158) was treated in a dignified manner. Findings include: Resident #158 was admitted to the facility on (MONTH) 21, (YEAR), with [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set (MDS) assessment dated (MONTH) 29, (YEAR), revealed the resident had severe cognitive impairment. Review of a current care plan revealed a problem related to a potential for alteration in comfort to the right elbow, due to bursitis. The care plan also included that the resident had short and long term memory loss and impaired decision making, due to Alzheimer's. An intervention included to have pleasant interactions/patience and reassure the resident when confused. The care plan was updated on (MONTH) 17, (YEAR) to reflect the resident displays behaviors of resisting care. Interventions included verbal redirection and to provide choices. During an observation on the Remberance Unit on (MONTH) 16, (YEAR) at approximately 10:10 a.m., six residents were participating in activities in the activity/dining room. The residents were being monitored by one activity staff member (staff #108). At this time, two residents attempted to stand activating both chair alarms. One resident sat back down, but resident #158 attempted to ambulate. Staff #108 was observed standing in front of resident #158 and cradled his right elbow with her left hand. She asked the resident to sit down several times and was then observed to shake the resident's elbow while yelling sit down. At this time, a Licensed Practical Nurse (LPN/staff #25) entered the room and assisted the resident. An interview was conducted with staff #108 on (MONTH) 16, (YEAR) at 10:17 a.m. Staff #108 stated It does get stressful in here as you saw a little bit ago. Staff #108 stated she was nervous that he was going to fall. She stated that she tries to re-direct, but when residents stand up, she is afraid they are going to fall and she doesn't want that to happen. In an interview with staff #25 on (MONTH) 16, (YEAR) at 10:21 a.m., staff #25 stated that all staff should be using distraction/redirecting techniques. In an interview with the Activities Director (staff #31) on (MONTH) 16, (YEAR) at 12:00 p.m., staff #31 stated she would expect the activity staff would try and re-direct a resident that is exhibiting behaviors, as the activity staff know what the resident's likes and dislikes are. Review of the facility policy titled, Resident Rights included The facility will promote and protect each resident's right to a dignified existence .",2020-09-01
633,SUN WEST CHOICE HEALTHCARE & REHAB,35110,14002 WEST MEEKER BLVD,SUN CITY WEST,AZ,85375,2017-02-16,323,D,0,1,91FY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, resident and staff interviews, and policy review, the facility failed to ensure the resident environment was free from accident hazards, as evidenced by one resident (#64) who kept smoking materials in their possession. Findings include: Resident #64 was readmitted to the facility on (MONTH) 15, (YEAR), with a [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment dated (MONTH) 15, (YEAR), documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had no cognitive impairment. Review of the clinical record revealed a facility supervised smoking contract, which was signed by the resident on (MONTH) 30, (YEAR) and included the following: - It is the policy of this facility to promote the health and safety of all residents. We acknowledge and respect an individual's right to smoke. -You must surrender your smoking materials to the nursing staff for safekeeping. - By signing this form the resident acknowledges receipt of the facility's smoking policy and hazardous smoking fire hazard awareness form. -By signing this contract the resident agrees to abide by the smoking policy, not carry any smoking materials or keep smoking materials in the resident rooms, and store all smoking materials (tobacco products and lighters) with facility staff. A current care plan included the following: Problem: Potential for injury related to smoking safely, due to Parkinson's disease and tremors. Goal: Will remain free from injury secondary to smoking. Approaches: Supervise resident while smoking and all smoking materials (i.e.; cigarettes, lighters/matches) are to be kept locked at the nursing station and not in the resident's possession. An observation was conducted on (MONTH) 13, (YEAR) at 1:07 p.m. of the resident smoking in the designated smoking area, with the unit secretary (staff #81) present. The resident was observed to pull out a package of cigarettes from his coat pocket and take out a cigarette. Staff #81 then lit the resident's cigarette. The resident then placed the package of cigarettes back in his coat pocket. An interview was conducted with staff #81 on (MONTH) 13, (YEAR) at 3:15 p.m. She stated that she knew resident #64 had taken a pack of cigarettes from his coat pocket at the 1:00 p.m. smoking time earlier today. She stated she thought the package was empty and therefore, did not tell any of the nursing staff about the incident. She then informed the Director of Nursing (DON/staff #138). An interview was conducted with the resident and the DON on (MONTH) 13, (YEAR) at 3:20 p.m. The resident stated he had both cigarettes and a lighter in his coat pocket and gave them to the DON. The resident stated he knew having cigarettes and a lighter was against facility rules and that he had previously signed a smoking contract. An interview was conducted with the DON immediately following this interview. The DON stated she expected all residents to follow the smoking policy and for staff to immediately report if a resident is not following the policy. She further stated this would be for the safety of not only the residents who smoke, but for the safety of all residents in the facility. She stated staff #81 should have immediately reported this incident to nursing staff. A nursing note dated (MONTH) 13, (YEAR) included the resident admitted to having cigarettes and a lighter in his room earlier in the day and that he understood the smoking contract. Another interview was conducted with staff #81 on (MONTH) 16, (YEAR) at 9:43 a.m. She stated that despite knowing that resident #64 had a cigarette on him on (MONTH) 13, she did not inform any nursing staff that the resident was not following the smoking policy. A review of the Smoking policy revealed the following: Purpose: This center believes nicotine in any form represents serious risks to a person's health and safety. In the skilled nursing home and long term care environment, smoking presents even greater risks. It is the intent of this facility to provide an environment which allows residents who smoke the opportunity to do so in a safe environment, with optimal safety to themselves and others. It is the policy of this facility to prohibit possessing ignition sources such as lighters and matches. All tobacco products will be kept locked up at the nursing station and issued by the facility staff. Lighters must be kept at the nursing station.",2020-09-01
634,SUN WEST CHOICE HEALTHCARE & REHAB,35110,14002 WEST MEEKER BLVD,SUN CITY WEST,AZ,85375,2017-02-16,364,D,0,1,91FY11,"Based on observations, staff interviews and policy and procedures, the facility failed to ensure that food was maintained at a safe and appetizing temperature. Findings include: During a lunch observation on the Solaria Unit (secured dementia unit) on (MONTH) 13, (YEAR) at 11:35 a.m., staff were observed serving an uncovered plate of hot food to one resident. The resident sat parallel to the table instead of perpendicular and staff were not observed to reposition the resident's chair. The resident was observed to reach over and take small pieces of food from the plate on two occasions. At 11:58 a.m., a staff member turned the resident's chair toward the table and sat down next to the resident and started to fed the resident. At this time, a request was made for the kitchen staff to check the temperature of the resident's food, however, staff did not arrive to check the meal until 12:30 p.m., and the resident had already completed the meal. In a follow-up dining observation on (MONTH) 14, (YEAR) at 11:07 a.m. in the Solaria Unit, one resident was noted to be sleeping, with an uncovered plate of hot food on the table in front of him. Two staff members attempted to wake up the resident without success. At 11:39, a staff member offered the resident a bite of meat. At this time, the kitchen staff checked the food temperature of the resident's food and revealed the following: The potatoes were 94 Fahrenheit (F), the meat was 82 F, and the carrots were 77 F. In an interview with the Food Services Director (staff #46) immediately following the food temperature check, the Director stated she would expect staff would either keep the food in the heated transport cart until they were ready for it, or leave the cover on the food. The Director stated food is to be served at 140 to 145 F and the eating temperature should be around 120 F. Another dining observation was conducted on (MONTH) 15, (YEAR) at 7:55 a.m. Staff were observed to place an uncovered plate of hot breakfast food in front of a resident, who was seated at the table. At 8:09 a.m., a Certified Nursing Assistant (CNA) sat to feed the resident. At this time, the kitchen staff completed a temperature check of the egg dish and the temperature was 105 F. In an interview conducted with a CNA (staff #60) on (MONTH) 16, (YEAR) at 10:48 a.m., staff #60 stated the covers should be kept on the food until they are ready to assist the resident with feeding. She further stated that if food sits for 15 minutes they are supposed to take it away and obtain one that is hot. In an interview conducted on (MONTH) 16, (YEAR) at 10:59 a.m. with the LPN/Unit Manager (staff #32), staff #32 stated the trays should be kept in the heated cart, if a staff member is not ready to feed a resident. Review of the facility policy titled, Cultural Change in Dining Services revealed the community has the responsibility to .Ensure temperature control (hot food hot, cold food cold).",2020-09-01
635,SUN WEST CHOICE HEALTHCARE & REHAB,35110,14002 WEST MEEKER BLVD,SUN CITY WEST,AZ,85375,2017-02-16,366,D,0,1,91FY11,"Based on observations, staff interviews, and review of policy and procedures, the facility failed to ensure residents were offered alternative choices when they chose not to eat food which was served. Findings include: During a lunch observation on the Solaria Unit (secured dementia unit) on (MONTH) 13, (YEAR) at 11:35 a.m., a resident was served a plate of food. At 11:49 a.m., the resident was observed to take 2-3 bites of food and pushed his wheelchair away from the table and began to leave the dining room. A Certified Nursing Assistant (CNA) who was sitting at the same table assisting another resident asked the resident if he was finished. The resident then stated that he didn't like the food and left the dining room. At this time, no alternate meal was offered to this resident. During the same lunch observation, another resident who was being assisted to eat by a CNA was observed to eat less than 25% of his meal, when he told the CNA to stop. The CNA then fed the resident a dessert, however, did not offer the resident an alternate meal or any other type of food. In an interview with the Food Services Director (staff #46) on (MONTH) 13, (YEAR) at 11:40 a.m., the Director stated there are always at least two alternatives on the menu, along with sandwiches. She stated the alternates change each week and staff should be offering an alternate, if a resident does not want what is served. A follow-up dining observation was conducted on (MONTH) 14, (YEAR) at 11:07 a.m., in the Solaria Unit. The same resident (who had left the dining room the day before) was again observed to eat only two bites of food, then pushed himself away from the table and left the dining room. Another CNA returned the resident to the table approximately three minutes later, however, within one minute, the CNA then removed the resident's clothing protector and wheeled the resident out of the dining room. The resident ate a dinner roll from the plate, but was not asked if he was hungry or if he wanted anything else. During this same dining observation, another resident was observed to eat a few bites of food and began to wheel himself out of the dining room. A CNA who was feeding a different resident asked if he wanted a sandwich and the resident replied yes. However, the CNA was not observed to order a sandwich for the resident, nor request for another staff member to order the sandwich. Following the observation, the resident was interviewed at 12:15 p.m. and stated that he never received a sandwich. In an interview conducted with a CNA (staff #60) on (MONTH) 16, (YEAR) at 10:48 a.m., staff #60 stated any time a resident does not want what is provided, an alternate or a sandwich should be offered. Staff #60 stated they can call the kitchen to get something else for the resident. In an interview conducted on (MONTH) 16, (YEAR) at 10:59 a.m. with the LPN/Unit Manager (staff #32), staff #32 stated if a resident doesn't want the food that is served, they should be offered an alternative meal or a sandwich. Review of the policy titled, Menu Alternatives revealed the following: An alternative meal or entree and vegetable should be provided at every meal in the event of personal food preference or refusals. The policy further included, 1.The alternate must be offered to the resident within 15 minutes of refusal of the main course. 2. In addition, the following foods should always be available to the residents in the event that they refuse the scheduled alternative: soup, cheese, cottage cheese, peanut butter and/or jelly, juice and fruit .4. If a food is disliked, an appropriate equivalent substitution must be made .",2020-09-01
636,SUN WEST CHOICE HEALTHCARE & REHAB,35110,14002 WEST MEEKER BLVD,SUN CITY WEST,AZ,85375,2018-04-19,600,G,1,1,2Y6W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, facility documentation, staff, resident and interviews, hospital documentation and policy and procedures, the facility failed to ensure that one resident (#25) was free from neglect and that one resident (#6) was free from abuse by a staff member. Findings include: -Resident #25 was admitted on (MONTH) 29, (YEAR), with [DIAGNOSES REDACTED]. Review of an incident report dated (MONTH) 12, (YEAR) at 10:30 a.m., revealed the resident was leaning forward in the wheelchair while reaching for something that she had dropped on the floor, and staff lowered the resident to the floor. Review of a fall risk evaluation dated (MONTH) 21, (YEAR) revealed the resident was at high risk for falls. Review of the activities of daily living (ADL) care plan dated (MONTH) 12, (YEAR) revealed the resident was to be kept in common areas as much as possible and to lie her down after meals and activities, as soon as she reaches her room. A nursing progress note dated (MONTH) 17, (YEAR) included the resident was found by a CNA (Certified Nursing Assistant) lying on the floor. The note included the resident had blood on her forehead from a 2 centimeter (cm) cut above her right eye, and had swelling and bruising to the left forehead above the left eye. Review of the Nursing Post fall assessment with a fall committee review date of (MONTH) 23, (YEAR), revealed the resident had a fall on (MONTH) 17 at 6:00 p.m. with injury. The documentation included that the resident was lying on the floor next to her bed. The resident had been seen in her room sitting in a wheelchair 10 minutes prior to the fall. The assessment included the resident said that she slid from the wheelchair. The committee recommendations included to keep the resident in common areas as much as possible, and to lie her down as soon as she returns to her room after meals and activities. Review of the Fall Risk Evaluation dated (MONTH) 19, (YEAR) revealed the resident was at high risk for falls. Review of a significant change Minimum Data Set (MDS) assessment dated (MONTH) 20, (YEAR), revealed a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. Per the MDS, the resident required extensive assistance with bed mobility, transfers and total assistance with toileting and locomotion. The MDS further included that the resident had a fall with injury, since the prior assessment. A fall care plan revised on (MONTH) 25, (YEAR) included a problem for the potential for injuries related to falls. A goal was for the resident to be free from injuries from falls. Approaches included to keep the resident in common areas as much as possible, and to lie the resident down as soon as possible after she returns from the dining room or activities. A nursing progress note dated (MONTH) 20, (YEAR) at 12:21 p.m. included the resident slid from her wheelchair and complained of left shoulder pain. A physician's orders [REDACTED]. Review of the x-ray report dated (MONTH) 20, (YEAR) revealed the resident had a subacute [MEDICAL CONDITION] left clavicle. A physician's orders [REDACTED]. Review of the Emergency Department documentation dated (MONTH) 20, (YEAR) revealed the resident had a closed displaced [MEDICAL CONDITION] clavicle. A nursing progress note dated (MONTH) 20, (YEAR) at 11:30 p.m. revealed the resident returned from the hospital. An addendum to the nursing progress note regarding the fall on (MONTH) 20, (YEAR) was added on (MONTH) 28, (YEAR). The note included that the resident was observed on the floor next to her bed, with her feet still in the footrests of the wheelchair. The note also included that the resident was observed in her wheelchair, prior to the fall. A Nurse Practitioner progress note dated (MONTH) 28, (YEAR) revealed the resident had a fall on (MONTH) 20, (YEAR), while trying to reach for the remote which was on the floor. Although the resident's plan of care included that the resident was to lie down after meals and activities, or be placed in common areas and was not to be left alone in the wheelchair in her room, the resident was left in her room alone and fell from the wheelchair and sustained a clavicle fracture on (MONTH) 20. An interview was conducted with the resident's family member on (MONTH) 17, (YEAR) at 3:30 p.m. She stated that the resident falls when she tries to get herself from the wheelchair to the bed. She stated that staff were not supposed to leave the resident alone in the wheelchair and that staff are supposed to take the resident out of the dining room last, and then put her right into bed. An interview was conducted with resident #25 on (MONTH) 18, (YEAR) at 8:45 a.m. She stated that she remembers that she fell about a month ago and broke her shoulder. She stated that she was in her room alone when she fell and that she had wanted to go to bed. She stated that she put her call light on and staff did not come quickly enough, so she tried to get herself to bed without help. A phone interview was conducted with a Licensed Practical Nurse (LPN/staff #177) on (MONTH) 18, (YEAR) at 9:47 a.m. She stated that she was caring for the resident at the time of the fall in February. She stated that she was at the desk and an activity aide came and told her that the resident was on the floor. She stated that she did not know how long the resident had been in the room. An interview was conducted with the Activity Director (staff #31) on (MONTH) 18, (YEAR) at 2:00 p.m. She stated that none of the activity aides who worked on the day when the resident fell had any recollection of finding the resident on the floor and reporting it to the nurse. An interview was conducted with a Certified Nursing Assistant (CNA/staff #80) on (MONTH) 19, (YEAR) at 9:00 a.m. She stated that they have to follow the plan of care for a resident. She stated that if the plan of care includes the resident needs to be put in bed as soon as she returns to her room, and the resident was in her room in the wheelchair alone and the resident had a fall and broke a bone, then that would be neglect. An interview was conducted with a LPN (staff #148) on (MONTH) 19, (YEAR) at 9:10 a.m. He stated that they are required to follow the plan of care for residents. He stated that if the care plan for a resident stated the resident needed to be put in bed as soon as she returned to her room, and the resident was left unsupervised in the room and fell and broke a bone, that should have been identified as neglect. An interview was conducted with the Director of Nursing (DON/staff #143) on (MONTH) 19, (YEAR) at 10:58 a.m. She stated that she expects staff to know the plan of care and follow it for the residents. She stated the definition of neglect is not taking care of a resident properly. She stated that sometimes the resident takes herself to her room and tries to go to bed and at times the family puts her in her room and leaves her alone in the wheelchair when they leave. She stated that the family was there that day and the DON does not know if the family notified staff that she was leaving. Staff #143 stated that when staff noted that the resident was up in the room in the wheelchair prior to the fall, they should have identified the risk. An interview was conducted with a LPN (staff#151) on (MONTH) 19, (YEAR) at 12:03 p.m. She stated that the family was not visiting prior to the resident's fall on (MONTH) 20, (YEAR). She stated that the family came to visit the resident after the fall, because she called the family about the fall. Staff #151 stated that she did not know the resident was in the room alone, until she was notified of the fall. She said the CNA's bring the residents back to their room after meals. Another interview was conducted with staff #151 on (MONTH) 19, (YEAR) at 12:25 p.m. She stated that she interviewed the CNA who was working in the resident's section at the time of the fall for the IDT post fall assessment dated (MONTH) 21. She stated the CNA reported that the resident had last been checked at 10:30 a.m. on (MONTH) 20, however staff #151 stated that she does not remember the name of the CNA she interviewed. Review of the Fall and Risk Assessment policy revealed the facility will do a timely assessment of resident's fall risk, in order to put corresponding interventions in place to minimize injury. The policy further included that staff will determine what equipment and interventions are appropriate to keep the resident safe and the interventions will be included in the plan of care. -Resident #6 was admitted to the facility on (MONTH) 10, 2009, with [DIAGNOSES REDACTED]. Review of the clinical record revealed that resident #6 resided on the secured dementia behavioral unit. Review of a quarterly MDS assessment dated (MONTH) 10, (YEAR) revealed the resident scored a 3 on the BIMS, indicating severe cognitive impairment. Per the MDS, the resident was assessed as having physical behavior symptoms directed toward others during 1 to 3 days of the 7 day look-back period, had verbal behavior symptoms directed toward others daily, had behaviors of refusing care daily, and had delusions. The resident was also assessed to require extensive assistance with bed mobility and total assistance with transfers. Review of the facility's investigation revealed that on (MONTH) 9, (YEAR) at approximately 4:30 p.m., staff reported that the resident had a bruise to the right forearm and an investigation was initiated regarding the injury of unknown origin. Per the report, during the investigation two additional allegations were reported as follows: a CNA (staff #170) spit on the resident and poured water on the resident. The investigative report included the following staff statements: -A CNA (staff #144) reported that she was with staff #170 in the resident's room providing care. She reported that staff #170 was mad at resident #6, as the resident was upset about receiving care. She reported the resident spit at staff #170 and staff #170 spit back at the resident. She also reported that staff #170 held down the resident's arm, but she did not know how hard. Staff #144 said that staff #170 was pulling the resident's arm to get her to hold onto the mobility bar on the bed. She said the bruise was not present before the resident received care. Staff #144 also reported that the resident threw a cup full of liquid at staff #170, and then staff #170 got mad and took a pitcher of juice and poured it on the resident and then threw a cup of water on the resident as well. Further review of the investigative documentation revealed that staff #144 was the only witness regarding holding down the resident's arm and the spitting incident, however, there were other witnesses to the water incident. The documentation included additional statements as follows: -A LPN (staff #78) who was the charge nurse at the time of the water incident reported that he entered the dining room and observed that the resident had a wet, soaked face and torso. He said staff #170 told him that the resident was going to throw a glass of water on her, but she slapped it out of her hand and the resident got wet. -A CNA (staff #178) wrote that her back was turned, so she did not see what happened, but said she saw that the resident was wet and there was juice on the floor. -A CNA (staff #98) wrote that she saw staff #170 come into the area and then the resident started yelling that the CNA had beat her. She stated that the resident threw juice on staff #170 and staff #170 then took a pitcher of water and poured it on the resident's face and head. -A LPN (staff #179) wrote that the resident did not have a bruise on her forearm prior to (MONTH) 9, (YEAR), and that staff notified her of the bruise. Per the statement, the bruise measured 6 centimeters (cm) by 5.75 cm and was raised by 1.5 cm. Staff #179 stated she notified the nurse practitioner and an x-ray was ordered. -The CNA (staff #170) who was providing care to the resident with staff #144 reported that prior to this incident, the resident had said her arm was hurting, but she could not see any injury. She said on that day the resident was upset. She said she turned the resident from side to side and helped the resident put her hands on the bed rails, because the resident could not do this on her own. She said the resident started screaming. She reported that she did not turn the resident roughly. Staff #170 said that during care the resident spit at her, but she did not spit back. Staff #170 also said that the resident threw a cup of water on her and in the process of throwing water, the resident got herself wet and got her (staff #170's) pants wet. She said that she got the pitcher of water, so she could give the resident more water. The report included that the resident was interviewed and stated that she did throw water on the CNA(staff #170), but only after the CNA threw water on her. Per the investigation, additional staff interviews revealed that staff #170 was often difficult to work with, would rush residents and was rough with them at times. Further review of the investigative report revealed the facility substantiated the allegation regarding the water incident. However, the other two allegations regarding the bruise and the spitting could not be substantiated. Review of the x-ray results revealed that they were negative for a fracture. A quarterly MDS dated (MONTH) 5, (YEAR) revealed the resident scored a 3 on the BIMS, which indicated the resident had severe cognitive impairment. An interview was conducted with the unit manager (LPN/staff #78) at 2:00 p.m. on (MONTH) 17, (YEAR). He said that he did remember the incident between the resident and staff #170. He said that he was not involved in the issue with the bruising or the spitting, but did see the resident after the water incident. He said he walked into the dining room and saw that the resident had water dripping from her face. He stated that he asked what had happened and staff #170 said that the resident was going to spill the water, so she grabbed it and it splashed on the resident's face. He said the resident was pretty wet and the water was dripping down her face. Staff #78 stated the resident seemed to be in shock and was just sputtering. In an interview with staff #170 at 2:30 p.m. on (MONTH) 17, (YEAR), she said that she remembers the day in question. Staff #170 stated that she and another CNA (staff #144) were providing care to the resident. She said the resident was spitting at them and calling them names. She said the resident has bruises often and was complaining of pain in her arm, prior to that day. She stated that the charge nurse had asked the resident what happened and the resident said that the big girl hurt her arm. She denied holding the resident's arm to restrain her and denied spitting back at the resident. Staff #170 stated that she was only trying to provide care to the resident and the resident was resisting and swinging at her. She said the only thing that she did do that maybe she should not have done was when in the dining room, the resident tried to throw water at her and she instinctively swatted the cup away, which caused the resident and herself to get wet. She said there was not much water on the resident and none on the ground. She said the resident does not like some of the CNA's, so she makes allegations toward them. During the survey, a telephone interview was attempted with staff #98, however, she was unable to be reached. An interview was conducted with a CNA (staff #144) at 12:00 p.m. on (MONTH) 18, (YEAR). Staff #144 stated that she remembered the incident. She said that she first noticed a bruise on the resident's arm, after providing the resident care with staff #170. She said that they were in the resident's room and the resident was getting combative and when she did, staff #170 held the resident's arm tight against the resident's body. She said she did not know if this caused the bruise, but it seemed like the CNA was holding the resident's arm pretty tight. She also said that at one point, the resident spit at staff #170 and staff #170 spit back, but she was unable to tell if spit had gotten on the resident. Staff #144 said that after this, the resident was wheeled into the dining room. She said she observed staff #144 pour a pitcher of juice on the resident's head. She said after this, the charge nurse came in and asked who did it and the resident indicated that staff #170 had done it. She said that sometimes staff #170 would be rough with residents, but never in an abusive manner. She said that she was just rude at times. She said the resident is difficult to work with and does yell at staff and tries to kick or hit them. She said she felt that the water incident was abuse and that the resident seemed pretty upset by it. During an interview with the Administrator (staff #58) at 8:55 a.m. on (MONTH) 19, (YEAR), he stated that he recalled the incident and there were three separate allegations. He said it was difficult to substantiate the allegations regarding rough handling and the spitting, as there was only one witness, but they did substantiate the water incident because there were a few witnesses. He said after substantiating this, he terminated the CNA and reported her to the board of nursing. Review of the Abuse policy and procedures revealed the facility is to take appropriate steps to prevent the occurrence of abuse and neglect. The policy included that each resident has the right to be free from abuse and neglect. The policy defined abuse as the willful infliction of injury, intimidation or punishment with resulting physical harm, pain or mental anguish. Neglect was defined as the failure of the facility to provide services to a resident that are necessary to avoid physical harm, pain mental anguish or emotional distress. Mistreatment was defined as inappropriate treatment of [REDACTED].",2020-09-01
637,SUN WEST CHOICE HEALTHCARE & REHAB,35110,14002 WEST MEEKER BLVD,SUN CITY WEST,AZ,85375,2018-04-19,607,E,1,1,2Y6W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, resident, family and staff interviews, hospital documentation and policies and procedures, the facility failed to implement their abuse policy involving four residents (#'s 25, 66, 99 and 315). Findings include: -Resident #25 was admitted on (MONTH) 29, (YEAR), with [DIAGNOSES REDACTED]. Review of an incident report dated (MONTH) 12, (YEAR) at 10:30 a.m., revealed the resident was leaning forward in the wheelchair while reaching for something that she had dropped on the floor, and staff lowered the resident to the floor. Review of a fall risk evaluation dated (MONTH) 21, (YEAR) revealed the resident was at high risk for falls. Review of the activities of daily living (ADL) care plan dated (MONTH) 12, (YEAR) revealed the resident was to be kept in common areas as much as possible and to lie her down after meals and activities, as soon as she reaches her room. A nursing progress note dated (MONTH) 17, (YEAR) included the resident was found by a CNA (Certified Nursing Assistant) lying on the floor. The note included the resident had blood on her forehead from a 2 centimeter (cm) cut above her right eye, and had swelling and bruising to the left forehead above the left eye. Review of the Nursing Post fall assessment with a fall committee review date of (MONTH) 23, (YEAR), revealed the resident had a fall on (MONTH) 17 at 6:00 p.m. with injury. The documentation included that the resident was lying on the floor next to her bed. The resident had been seen in her room sitting in a wheelchair 10 minutes prior to the fall. The assessment included the resident said that she slid from the wheelchair. The committee recommendations included to keep the resident in common areas as much as possible, and to lie her down as soon as she returns to her room after meals and activities. Review of the Fall Risk Evaluation dated (MONTH) 19, (YEAR) revealed the resident was at high risk for falls. Review of a significant change Minimum Data Set (MDS) assessment dated (MONTH) 20, (YEAR), revealed a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. Per the MDS, the resident required extensive assistance with bed mobility, transfers and total assistance with toileting and locomotion. The MDS further included that the resident had a fall with injury, since the prior assessment. A fall care plan revised on (MONTH) 25, (YEAR) included a problem for the potential for injuries related to falls. A goal was for the resident to be free from injuries from falls. Approaches included to keep the resident in common areas as much as possible, and to lie the resident down as soon as possible after she returns from the dining room or activities. A nursing progress note dated (MONTH) 20, (YEAR) at 12:21 p.m. included the resident slid from her wheelchair and complained of left shoulder pain. A physician's orders [REDACTED]. Review of the x-ray report dated (MONTH) 20, (YEAR) revealed the resident had a subacute [MEDICAL CONDITION] left clavicle. A physician's orders [REDACTED]. Review of the Emergency Department documentation dated (MONTH) 20, (YEAR) revealed the resident had a closed displaced [MEDICAL CONDITION] clavicle. A nursing progress note dated (MONTH) 20, (YEAR) at 11:30 p.m. revealed the resident returned from the hospital. An addendum to the nursing progress note regarding the fall on (MONTH) 20, (YEAR) was added on (MONTH) 28, (YEAR). The note included that the resident was observed on the floor next to her bed, with her feet still in the footrests of the wheelchair. The note also included that the resident was observed in her wheelchair, prior to the fall. A Nurse Practitioner progress note dated (MONTH) 28, (YEAR) revealed the resident had a fall on (MONTH) 20, (YEAR), while trying to reach for the remote which was on the floor. Although the resident's plan of care included that the resident was to lie down after meals and activities, or be placed in common areas and was not to be left alone in the wheelchair in her room, the resident was left in her room alone and fell from the wheelchair and sustained a clavicle fracture on (MONTH) 20. An interview was conducted with the resident's family member on (MONTH) 17, (YEAR) at 3:30 p.m. She stated that the resident falls when she tries to get herself from the wheelchair to the bed. She stated that staff were not supposed to leave the resident alone in the wheelchair and that staff are supposed to take the resident out of the dining room last, and then put her right into bed. An interview was conducted with resident #25 on (MONTH) 18, (YEAR) at 8:45 a.m. She stated that she remembers that she fell about a month ago and broke her shoulder. She stated that she was in her room alone when she fell and that she had wanted to go to bed. She stated that she put her call light on and staff did not come quickly enough, so she tried to get herself to bed without help. A phone interview was conducted with a Licensed Practical Nurse (LPN/staff #177) on (MONTH) 18, (YEAR) at 9:47 a.m. She stated that she was caring for the resident at the time of the fall in February. She stated that she was at the desk and an activity aide came and told her that the resident was on the floor. She stated that she did not know how long the resident had been in the room. An interview was conducted with the Activity Director (staff #31) on (MONTH) 18, (YEAR) at 2:00 p.m. She stated that none of the activity aides who worked on the day when the resident fell had any recollection of finding the resident on the floor and reporting it to the nurse. An interview was conducted with a Certified Nursing Assistant (CNA/staff #80) on (MONTH) 19, (YEAR) at 9:00 a.m. She stated that they have to follow the plan of care for a resident. She stated that if the plan of care includes the resident needs to be put in bed as soon as she returns to her room, and the resident was in her room in the wheelchair alone and the resident had a fall and broke a bone, then that would be neglect. An interview was conducted with a LPN (staff #148) on (MONTH) 19, (YEAR) at 9:10 a.m. He stated that they are required to follow the plan of care for residents. He stated that if the care plan for a resident stated the resident needed to be put in bed as soon as she returned to her room, and the resident was left unsupervised in the room and fell and broke a bone, that should have been identified as neglect. An interview was conducted with the Director of Nursing (DON/staff #143) on (MONTH) 19, (YEAR) at 10:58 a.m. She stated that she expects staff to know the plan of care and follow it for the residents. She stated the definition of neglect is not taking care of a resident properly. She stated that sometimes the resident takes herself to her room and tries to go to bed and at times the family puts her in her room and leaves her alone in the wheelchair when they leave. She stated that the family was there that day and the DON does not know if the family notified staff that she was leaving. Staff #143 stated that when staff noted that the resident was up in the room in the wheelchair prior to the fall, they should have identified the risk. An interview was conducted with a LPN (staff#151) on (MONTH) 19, (YEAR) at 12:03 p.m. She stated that the family was not visiting prior to the resident's fall on (MONTH) 20, (YEAR). She stated that the family came to visit the resident after the fall, because she called the family about the fall. Staff #151 stated that she did not know the resident was in the room alone, until she was notified of the fall. She said the CNA's bring the residents back to their room after meals. Another interview was conducted with staff #151 on (MONTH) 19, (YEAR) at 12:25 p.m. She stated that she interviewed the CNA who was working in the resident's section at the time of the fall for the IDT post fall assessment dated (MONTH) 21. She stated the CNA reported that the resident had last been checked at 10:30 a.m. on (MONTH) 20, however staff #151 stated that she does not remember the name of the CNA she interviewed. -Resident #99 was admitted to the facility on (MONTH) 15, (YEAR), with [DIAGNOSES REDACTED]. Review of a Theft/Loss Monitoring form dated (MONTH) 2, (YEAR) revealed Items Lost .Coin purse with $11.00 in $1.00 bills and coins .Today housekeeper brought in (resident's name) wallet from outside saying she found on ground in parking lot. (Resident's name) said nothing is missing from the wallet Maintenance director looked at cameras in parking lot but nothing was on cameras regarding the wallet .(Resident's name) given option of filing police report but declined . Review of a quarterly MDS (Minimum Data Set) assessment dated (MONTH) 21, (YEAR) revealed the resident had a BIMS score of 15, which indicated intact cognition. Review of another Theft/Loss Monitoring form dated (MONTH) 10, (YEAR) revealed Items Lost .Vintage Oakley wrap around sunglasses (yellow in color) .Estimated value of items: $300.00 .Had them morning of (MONTH) 10, (YEAR). Came to room, sunglasses put on bedside table by CNA (certified nursing assistant). Resident laid down for rest. When woke up, realized sunglasses missing .Nursing searched resident's room. Laundry and kitchen staff made aware of missing items. CNA's/nursing involved with resident's care were asked if they had seen missing item .Declined filing police report. Glasses not located as of this date. Will continue to search . Review of the resident's clinical record revealed a Social Services Progress Note dated (MONTH) 11, (YEAR), which documented Social services spoke with resident in regard to missing item (sunglasses). Theft/Loss Monitoring Form filled out with input from resident. Social services and Nursing staff made aware of missing item. This writer will follow up with Administrator and continue to monitor. Another Social Services Progress Note dated (MONTH) 13, (YEAR) included Missing item form completed. Resident declined to file police report. Missing glasses have not been found to date. Staff to continue to search. All other departments made aware. Resident notified of actions being taken. The facility was unable to provide any documentation that the two allegations regarding misappropriation of resident property were reported to the State agency or were thoroughly investigated. An interview was conducted with resident #99 on (MONTH) 16, (YEAR) at 11:49 a.m. The resident stated that a week ago she had a pair of vintage Oakley brand sunglasses that were worth about $300.00, which turned up missing. The resident stated that she reported it to the facility. The resident also stated that a month ago someone went into her purse and took her wallet, which did not have money in it and that her wallet was found in the facility's parking lot. The resident further stated that last month someone took $11.00 and her change purse and that she reported it to social services. An interview was conducted with the social worker (staff #16) on (MONTH) 18, (YEAR) at 10:20 a.m. Staff #16 stated that about six weeks ago the resident reported that she was missing $10.00 and a week ago the resident reported that her sunglasses were missing. The social worker stated that the facility searched for the sunglasses but never found them. She said that when she is notified that something is missing she gets a statement from the resident and looks for the item. She said that all departments and the laundry are notified. The social worker stated that she asked the resident if she wanted to file a police report and she declined. Staff #16 further stated that the facility normally does not report missing items to the State agency. An interview was conducted with the Administrator (staff #58) on (MONTH) 18, (YEAR) at 1:05 p.m. Staff #58 stated that he did not think the resident's sunglasses were ever found and that he interpreted the incident as a missing item and not misappropriated. Staff #58 stated that the resident was offered to file a police report, but did not want too. He said if the resident wanted to file a police report that would be the trigger to indicate that the item was misappropriated. The Administrator stated that when the resident's wallet was found in the parking lot, he did not consider that to be misappropriation, as the wallet was found intact. The Administrator also stated that the resident does not go out into the parking lot. Another interview was conducted with staff #16 on (MONTH) 19, (YEAR) at 9:30 a.m. Staff #16 stated that the Theft/Loss Monitoring form dated (MONTH) 2, (YEAR) included two separate incidents, the resident's wallet and a coin purse with $11.00 in it. The social worker further stated that the wallet was found in the parking lot, but the coin purse was never found. Another interview was conducted with staff #58 on (MONTH) 19, (YEAR) at 9:42 a.m. Staff #58 stated that he was under the assumption that the wallet which was found in the parking lot contained the $11.00. -Resident #66 was admitted to the facility on (MONTH) 21, (YEAR), with [DIAGNOSES REDACTED]. Review of the admission MDS assessment dated (MONTH) 28, (YEAR) revealed a BIMS score of 15, which indicated that the resident was cognitively intact. A Nursing Progress Note dated (MONTH) 4, (YEAR) included the resident's wallet was found in the public restroom this morning per housekeeping and maintenance. According to patient only monetary content missing. Review of a Theft/Loss Monitoring form dated (MONTH) 5, (YEAR) revealed .Said his wallet was found by housekeeper in staff bathroom. $10.00 missing. Resident last saw wallet over weekend .Wallet was reportedly found in staff bathroom by housekeeper. Then housekeeper brought back to (name of resident) .(Name of resident) given choice to file police report but declined . The facility was unable to provide any documentation that a thorough investigation had been completed regarding the allegation of misappropriation of resident property. There was also no documentation this was reported to the State agency. An interview was conducted with staff #16 on (MONTH) 19, (YEAR) at 11:00 a.m. The social worker stated that the resident was asked if he wanted to file a police report and the resident stated no, and that someone must have needed the money more than he did. Staff #16 stated the facility looked in the laundry and in the resident's room, but were unable to find the money. Staff #16 stated that she let the department heads know about the missing money, but they usually do not interview other residents to determine if they also had property taken. Staff #16 said that they did not report the allegation of misappropriation of resident property to the State agency, as they thought the money was just missing. An interview was conducted with staff #58 on (MONTH) 19, (YEAR) at 11:10 a.m. The Administrator stated that they should have done a better job on this. -Resident #315 was admitted to the facility on (MONTH) 16, (YEAR), with [DIAGNOSES REDACTED]. A review of the admitting physician's history and physical dated (MONTH) 16, (YEAR) revealed the resident had mild dementia and left hip pain, due to a loose prosthesis and declined surgery. A care plan dated (MONTH) 27, (YEAR) identified a potential for injuries related to a history of falls, cognitive impairment, dementia, pain and loose left hip prosthesis. A goal included the resident would be free of injuries through (MONTH) 13, (YEAR). Approaches were for one on one as necessary, encourage the resident to lie down in bed during the day, and when resident is in his wheelchair leave in common area for observation and not alone in his room. A review of the nurses note dated (MONTH) 2, (YEAR) at 12:34 p.m. revealed the resident was oriented to person only, had complaints of hip pain, and continues to position himself crooked in chair and in bed. A nurses note dated (MONTH) 2, (YEAR) at 3:25 p.m. revealed the resident was complaining of left hip pain and was lying in bed with his left lower leg extended. Obvious internal rotation was noted with an area of swelling to the left hip. There were no signs or symptoms of pain unless the resident moves. No discoloration. The doctor was notified and an order was obtained for a left hip x-ray. Will continue to monitor. A physician's orders [REDACTED]. Review of the x-ray report dated (MONTH) 2, (YEAR) revealed the resident had a dislocation of the left hip prosthesis and acute angulated [MEDICAL CONDITION] femur. A physician's orders [REDACTED]. According to the hospital emergency room record dated (MONTH) 2, (YEAR) at 11:48 p.m., the resident was found to have a left hip dislocation on imaging studies done earlier. The injury was reported to have occurred between 2:00 p.m. and 6:00 p.m. and was unwitnessed. The patient is unable to provide history due to dementia. X-rays were repeated in the emergency department on (MONTH) 3, (YEAR) and revealed a left hip dislocation and fracture. The facility was unable to provide any documentation that this injury of unknown origin was investigated or reported to the State agency. The Administrator (staff #58) was interviewed on (MONTH) 17, (YEAR) at 2:40 p.m. He stated the resident has a documented history of a failed left hip prosthesis and often thrashes about in bed. He stated he did not investigate or report the fracture/dislocation to the State agency, because he did not consider this to be an injury of unknown origin. An interview was conducted on (MONTH) 18, (YEAR) at 8:25 a.m., with a LPN (staff #63). She stated the resident's left leg was normally deformed. She stated she looked in on the resident (on (MONTH) 2 in the afternoon) and noticed that his leg was flat in bed, where it would normally be bent at the knee. An interview was conducted on (MONTH) 18, (YEAR) at 8:35 a.m. with a LPN (staff #26), who was the resident's day nurse on (MONTH) 2. Staff #26 stated the CNA's transferred the resident from his wheelchair to his bed after lunch via the Hoyer lift and noticed that his left leg was lying flat in bed, which was unusual as the resident's lower extremities have significant contractures. She stated that the DON (Director of Nursing/staff #143) also examined his leg and they agreed that his hip appeared to be dislocated. She then notified the physician and obtained orders for an x-ray. An interview with the Director of Nursing (DON/staff #143) was conducted on (MONTH) 18, (YEAR) at 9:15 a.m. She stated the resident had a long standing history of failed hip prosthesis, with significant contractors to his lower extremities. She said that she assessed the resident's leg, which was extended and was flat on the bed, with obvious internal rotation. She further stated that she was aware of the expectation to investigate and report injuries of undetermined origin to the State agency, but she did not suspect abuse due to the resident's history of failed prosthesis. Review of the Abuse policies and procedures revealed the facility is to take appropriate steps to prevent the occurrence of abuse and neglect and that each resident has the right to be free from all types of abuse and neglect. The policy defined abuse as the willful infliction of injury, intimidation or punishment with resulting physical harm, pain or mental anguish. Neglect was defined as the failure of the facility to provide services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Mistreatment was defined as inappropriate treatment of [REDACTED]. The Abuse policies further included that injuries of an unknown source means an injury should be classified as an injury of unknown source, when both of the following conditions are met: The source of the injury could not be explained by the resident, and the injury is suspicious because the extent of the injury or the location of the injury e.g., the injury is located in an area not generally vulnerable to trauma, or the number of injuries observed at one particular time or the incidence of injuries over time. The Abuse policies also included that the facility shall identify abuse, report suspected or alleged violations involving abuse or neglect immediately, and investigate the circumstances of the incident. The policy noted that the investigation will include names of witnesses and actions taken by the administrator to prevent the alleged violation from occurring in the future and that the results of the investigation are to be reported to the State agency. Further review of the Abuse policies and procedures revealed that misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. Any employee who suspects an alleged violation shall immediately notify the Administrator. The Administrator/designee immediately notifies the State agency. The Administrator or Director of Nursing will designate the individual who is to conduct each investigation. The investigation may include interviews of employees, visitors, and/or residents who may have knowledge of the alleged incident.",2020-09-01
638,SUN WEST CHOICE HEALTHCARE & REHAB,35110,14002 WEST MEEKER BLVD,SUN CITY WEST,AZ,85375,2018-04-19,609,E,1,1,2Y6W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, family, resident and staff interviews, hospital documentation and review of policies and procedures, the facility failed to report allegations of abuse, neglect, and misappropriation of property to the State agency for four (#'s 25, 66, 99, and 315) residents. Findings include: -Resident #25 was admitted on (MONTH) 29, (YEAR), with [DIAGNOSES REDACTED]. Review of an incident report dated (MONTH) 12, (YEAR) at 10:30 a.m., revealed the resident was leaning forward in the wheelchair while reaching for something that she had dropped on the floor, and staff lowered the resident to the floor. Review of the activities of daily living (ADL) care plan dated (MONTH) 12, (YEAR) revealed the resident was to be kept in common areas as much as possible and to lie her down after meals and activities, as soon as she reaches her room. A nursing progress note dated (MONTH) 17, (YEAR) included the resident was found by a CNA (Certified Nursing Assistant) lying on the floor. The note included the resident had blood on her forehead from a 2 centimeter (cm) cut above her right eye, and had swelling and bruising to the left forehead above the left eye. Review of the Nursing Post fall assessment with a fall committee review date of (MONTH) 23, (YEAR), revealed the resident had a fall on (MONTH) 17 at 6:00 p.m. with injury. The documentation included that the resident was lying on the floor next to her bed. The resident had been seen in her room sitting in a wheelchair 10 minutes prior to the fall. The assessment included the resident said that she slid from the wheelchair. The committee recommendations included to keep the resident in common areas as much as possible, and to lie her down as soon as she returns to her room after meals and activities. A fall care plan revised on (MONTH) 25, (YEAR) revealed a problem for the potential for injuries related to falls. A goal was for the resident to be free from injuries from falls. Approaches included to keep the resident in common areas as much as possible, and to lie the resident down as soon as possible after she returns from the dining room or activities A nursing progress note dated (MONTH) 20, (YEAR) at 12:21 p.m. included the resident slid from her wheelchair and complained of left shoulder pain. A physician's orders [REDACTED]. Review of the x-ray report dated (MONTH) 20, (YEAR) revealed the resident had a subacute [MEDICAL CONDITION] left clavicle. A physician's orders [REDACTED]. Review of the hospital Emergency Department documentation dated (MONTH) 20, (YEAR) revealed the resident had a closed displaced [MEDICAL CONDITION] clavicle. A nursing progress note dated (MONTH) 20, (YEAR) at 11:30 p.m. revealed the resident returned from the hospital. An addendum to the nursing progress note regarding the fall on (MONTH) 20, (YEAR) was added on (MONTH) 28, (YEAR). The note included that the resident was observed on the floor next to her bed, with her feet still in the footrests of the wheelchair. The note also included that the resident was observed in her wheelchair, prior to the fall. A Nurse Practitioner progress note dated (MONTH) 28, (YEAR) revealed the resident had a fall on (MONTH) 20, (YEAR), while trying to reach for the remote which was on the floor. Although the resident's plan of care included that the resident was to lie down after meals and activities, or be placed in common areas and was not to be left alone in the wheelchair in her room, the resident was left in her room alone and fell from the wheelchair and sustained a clavicle fracture on (MONTH) 20. The facility was unable to provide any documentation that this incident of neglect was reported to the State agency. An interview was conducted with the resident's family member on (MONTH) 17, (YEAR) at 3:30 p.m. She stated that staff were not supposed to leave the resident alone in the chair and that staff are supposed to take the resident out of the dining room last and put her right into the bed. An interview was conducted with resident #25 on (MONTH) 18, (YEAR) at 8:45 a.m. She stated that she remembers that she fell about a month ago and broke her shoulder. She stated that she was in her room alone when she fell and that she had wanted to go to bed. She stated that she put her call light on and staff did not come quickly enough, so she tried to get herself to bed without help. An interview was conducted with a Certified Nursing Assistant (CNA/staff #80) on (MONTH) 19, (YEAR) at 9:00 a.m. She stated that they have to follow the plan of care for a resident. She stated that if the plan of care includes the resident needs to be put in bed as soon as she returns to her room, and the resident was in her room in the wheelchair alone and the resident had a fall and broke a bone, then that would be neglect. An interview was conducted with a LPN (staff #148) on (MONTH) 19, (YEAR) at 9:10 a.m. He stated that they are required to follow the plan of care for residents. He stated that if the care plan for a resident stated the resident needed to be put in bed as soon as she returned to her room, and the resident was left unsupervised in the room and fell and broke a bone, that should have been identified as neglect and reported. An interview was conducted with the Director of Nursing (DON/staff #143) on (MONTH) 19, (YEAR) at 10:58 a.m. She stated that the definition of neglect is not taking care of a resident properly. She stated that when staff noted that the resident was up in the room in the wheelchair prior to the fall they should have identified the risk. She stated that if there is a suspicion of abuse and bodily harm, the facility would report it within two hours. She stated that this incident was not reported to the State agency as they do not feel that they were neglectful, -Resident #99 was admitted to the facility on (MONTH) 15, (YEAR), with [DIAGNOSES REDACTED]. Review of a Theft/Loss Monitoring form dated (MONTH) 2, (YEAR) revealed Items Lost .Coin purse with $11.00 in $1.00 bills and coins .Today housekeeper brought in (resident's name) wallet from outside saying she found on ground in parking lot. (Resident's name) said nothing is missing from the wallet Maintenance director looked at cameras in parking lot but nothing was on cameras regarding the wallet .(Resident's name) given option of filing police report but declined . Review of a quarterly MDS (Minimum Data Set) assessment dated (MONTH) 21, (YEAR) revealed the resident had a BIMS score of 15, which indicated intact cognition. Review of another Theft/Loss Monitoring form dated (MONTH) 10, (YEAR) revealed Items Lost .Vintage Oakley wrap around sunglasses (yellow in color) .Estimated value of items: $300.00 .Had them morning of (MONTH) 10, (YEAR). Came to room, sunglasses put on bedside table by CNA (certified nursing assistant). Resident laid down for rest. When woke up, realized sunglasses missing .Nursing searched resident's room. Laundry and kitchen staff made aware of missing items. CNA's/nursing involved with resident's care were asked if they had seen missing item .Declined filing police report. Glasses not located as of this date. Will continue to search . Review of the resident's clinical record revealed a Social Services Progress Note dated (MONTH) 11, (YEAR), which documented Social services spoke with resident in regard to missing item (sunglasses). Theft/Loss Monitoring Form filled out with input from resident. Social services and Nursing staff made aware of missing item. This writer will follow up with Administrator and continue to monitor. Another Social Services Progress Note dated (MONTH) 13, (YEAR) included Missing item form completed. Resident declined to file police report. Missing glasses have not been found to date. Staff to continue to search. All other departments made aware. Resident notified of actions being taken. The facility was unable to provide any documentation that the two allegations regarding misappropriation of resident property were reported to the State agency. An interview was conducted with the social worker (staff #16) on (MONTH) 18, (YEAR) at 10:20 a.m. Staff #16 stated that about six weeks ago the resident reported that she was missing $10.00 and that a week ago the resident reported that her sunglasses were missing. The social worker stated that the facility searched for the sunglasses, but never found them. Staff #16 further stated that the facility normally does not report missing items to the State agency. An interview was conducted with the administrator (staff #58) on (MONTH) 18, (YEAR) at 1:05 p.m. The administrator stated that he interpreted the incident as missing items and not misappropriated. -Resident #66 was admitted to the facility on (MONTH) 21, (YEAR), with [DIAGNOSES REDACTED]. Review of the admission MDS assessment dated (MONTH) 28, (YEAR) revealed a BIMS score of 15, which indicated that the resident was cognitively intact. A Nursing Progress Note dated (MONTH) 4, (YEAR) included the resident's wallet was found in the public restroom this morning per housekeeping and maintenance. According to patient only monetary content missing. Review of a Theft/Loss Monitoring form dated (MONTH) 5, (YEAR) revealed .Said his wallet was found by housekeeper in staff bathroom. $10.00 missing. Resident last saw wallet over weekend .Wallet was reportedly found in staff bathroom by housekeeper. Then housekeeper brought back to (name of resident) .(Name of resident) given choice to file police report but declined . The facility was unable to provide any documentation that the allegation of misappropriation of resident property was reported to the State agency. An interview was conducted with staff #16 on (MONTH) 19, (YEAR) at 11:00 a.m. The social worker stated that the resident was asked if he wanted to file a police report and the resident stated no, and that someone must have needed the money more than he did. Staff #16 stated the facility looked in the laundry and in the resident's room, but were unable to find the money. Staff #16 said that they did not report the allegation of misappropriation of resident property to the State agency, as they thought the money was just missing. An interview was conducted with staff #58 on (MONTH) 19, (YEAR) at 11:10 a.m. The Administrator stated that they should have done a better job on this. -Resident #315 was admitted to the facility on (MONTH) 16, (YEAR), with [DIAGNOSES REDACTED]. A review of the admitting physician's history and physical dated (MONTH) 16, (YEAR), revealed the resident had mild dementia and left hip pain, due to a loose prosthesis and declined surgery. A care plan dated (MONTH) 27, (YEAR) identified a potential for injuries related to a history of falls, cognitive impairment, dementia, pain and loose left hip prosthesis. A goal included the resident would be free of injuries through (MONTH) 13, (YEAR). Approaches were for one on one as necessary, encourage the resident to lie down in bed during the day, and when resident is in his wheelchair leave in common area for observation and not alone in his room. A review of the nurses note dated (MONTH) 2, (YEAR) at 12:34 p.m. revealed the resident was oriented to person only, had complaints of hip pain, and continues to position himself crooked in chair and in bed. A nurses note dated (MONTH) 2, (YEAR) at 3:25 p.m. revealed the resident was complaining of left hip pain and was lying in bed with his left lower leg extended. Obvious internal rotation was noted with an area of swelling to the left hip. There were no signs or symptoms of pain unless the resident moves. No discoloration. The doctor was notified and an order was obtained for a left hip x-ray. Will continue to monitor. A physician's orders [REDACTED]. Review of the x-ray report dated (MONTH) 2, (YEAR) revealed the resident had a dislocation of the left hip prosthesis and acute angulated [MEDICAL CONDITION] femur. A physician's orders [REDACTED]. According to the hospital emergency room record dated (MONTH) 2, (YEAR) at 11:48 p.m., the resident was found to have a left hip dislocation on imaging studies done earlier. The injury was reported to have occurred between 2:00 p.m. and 6:00 p.m. and was unwitnessed. The patient is unable to provide history due to dementia. X-rays were repeated in the emergency department on (MONTH) 3, (YEAR) and revealed a left hip dislocation and fracture. The facility was unable to provide documentation that the injury of undetermined origin had been reported to the State agency at the time of the injury. The Administrator (staff #58) was interviewed on (MONTH) 17, (YEAR) at 2:40 p.m. He stated the resident has a documented history of a failed left hip prosthesis and often thrashes about in bed. He stated he did not report the fracture/dislocation to the State agency, because he did not consider this to be an injury of unknown origin. An interview with the DON staff #143 was conducted on (MONTH) 18, (YEAR) at 9:15 a.m. She stated the resident had a long standing history of failed hip prosthesis with significant contractors to his lower extremities. She stated that she observed the resident's left leg to be extended and was flat on the bed, with obvious internal rotation. She further stated that she was aware of the expectation to report suspected abuse, including injuries of undetermined origin to the State Agency, but did not suspect abuse due to the resident's long history of failed prosthesis. Review of the Abuse policies and procedures revealed that the facility shall identify abuse, report suspected or alleged violations involving abuse or neglect immediately to the administrator and investigate the circumstances of the incident. The policy included that the facility will take appropriate steps to ensure that all suspected or alleged violations involving mistreatment, neglect, abuse, injuries of unknown source, exploitation and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation is made to the State agency. The Abuse policies further included that injuries of an unknown source means an injury should be classified as an injury of unknown source, when both of the following conditions are met: The source of the injury could not be explained by the resident, and the injury is suspicious because the extent of the injury or the location of the injury e.g., the injury is located in an area not generally vulnerable to trauma, or the number of injuries observed at one particular time or the incidence of injuries over time. Further review of the Abuse policies and procedures revealed Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent .Any employee who suspects an alleged violation shall immediately notify the Administrator. The Administrator/designee immediately notifies the State agency.",2020-09-01
639,SUN WEST CHOICE HEALTHCARE & REHAB,35110,14002 WEST MEEKER BLVD,SUN CITY WEST,AZ,85375,2018-04-19,610,E,1,1,2Y6W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff, resident and family interviews, and policies and procedures, the facility failed to ensure that allegations of abuse, neglect, and misappropriation of resident property were thoroughly investigated for four residents (#'s 25, 66, 99, and 315). Findings include: -Resident #25 was admitted on (MONTH) 29, (YEAR), with [DIAGNOSES REDACTED]. Review of an incident report dated (MONTH) 12, (YEAR) at 10:30 a.m., revealed the resident was leaning forward in the wheelchair while reaching for something that she had dropped on the floor, and staff lowered the resident to the floor. Review of the activities of daily living (ADL) care plan dated (MONTH) 12, (YEAR) revealed the resident was to be kept in common areas as much as possible and to lie her down after meals and activities, as soon as she reaches her room. A nursing progress note dated (MONTH) 17, (YEAR) included the resident was found by a CNA (Certified Nursing Assistant) lying on the floor. The note included the resident had blood on her forehead from a 2 centimeter (cm) cut above her right eye, and had swelling and bruising to the left forehead above the left eye. Review of the Nursing Post fall assessment with a fall committee review date of (MONTH) 23, (YEAR), revealed the resident had a fall on (MONTH) 17 at 6:00 p.m. with injury. The documentation included that the resident was lying on the floor next to her bed. The resident had been seen in her room sitting in a wheelchair 10 minutes prior to the fall. The assessment included the resident said that she slid from the wheelchair. The committee recommendations included to keep the resident in common areas as much as possible, and to lie her down as soon as she returns to her room after meals and activities. A fall care plan revised on (MONTH) 25, (YEAR) revealed a problem for the potential for injuries related to falls. A goal was for the resident to be free from injuries from falls. Approaches included to keep the resident in common areas as much as possible, and to lie the resident down as soon as possible after she returns from the dining room or activities A nursing progress note dated (MONTH) 20, (YEAR) at 12:21 p.m. included the resident slid from her wheelchair and complained of left shoulder pain. A physician's orders [REDACTED]. Review of the x-ray report dated (MONTH) 20, (YEAR) revealed the resident had a subacute [MEDICAL CONDITION] left clavicle. A physician's orders [REDACTED]. Review of the hospital Emergency Department documentation dated (MONTH) 20, (YEAR) revealed the resident had a closed displaced [MEDICAL CONDITION] clavicle. A nursing progress note dated (MONTH) 20, (YEAR) at 11:30 p.m. revealed the resident returned from the hospital. An addendum to the nursing progress note regarding the fall on (MONTH) 20, (YEAR) was added on (MONTH) 28, (YEAR). The note included that the resident was observed on the floor next to her bed, with her feet still in the footrests of the wheelchair. The note also included that the resident was observed in her wheelchair, prior to the fall. A Nurse Practitioner progress note dated (MONTH) 28, (YEAR) revealed the resident had a fall on (MONTH) 20, (YEAR), while trying to reach for the remote which was on the floor. The facility was unable to provide documentation that the incident of neglect was thoroughly investigated. An interview was conducted with the resident's family member on (MONTH) 17, (YEAR) at 3:30 p.m. She stated that staff were not supposed to leave the resident alone in the chair and that staff are supposed to take the resident out of the dining room last and put her right into the bed. An interview was conducted with resident #25 on (MONTH) 18, (YEAR) at 8:45 a.m. She stated that she was in her room alone when she fell and had wanted to go to bed. An interview was conducted with a Certified Nursing Assistant (CNA/staff #80) on (MONTH) 19, (YEAR) at 9:00 a.m. She stated that they have to follow the plan of care for a resident. She stated that if the plan of care includes the resident needs to be put in bed as soon as she returns to her room, and the resident was in her room in the wheelchair alone and the resident had a fall and broke a bone, then that would be neglect. An interview was conducted with a LPN (staff #148) on (MONTH) 19, (YEAR) at 9:10 a.m. He stated that they are required to follow the plan of care for residents. He stated that if the care plan for a resident stated the resident needed to be put in bed as soon as she returned to her room, and the resident was left unsupervised in the room and fell and broke a bone, that should have been identified as neglect. -Resident #99 was admitted to the facility on (MONTH) 15, (YEAR), with [DIAGNOSES REDACTED]. Review of a Theft/Loss Monitoring form dated (MONTH) 2, (YEAR) revealed Items Lost .Coin purse with $11.00 in $1.00 bills and coins .Today housekeeper brought in (resident's name) wallet from outside saying she found on ground in parking lot. (Resident's name) said nothing is missing from the wallet Maintenance director looked at cameras in parking lot but nothing was on cameras regarding the wallet .(Resident's name) given option of filing police report but declined . Review of a quarterly MDS (Minimum Data Set) assessment dated (MONTH) 21, (YEAR) revealed the resident had a BIMS score of 15, which indicated intact cognition. Review of another Theft/Loss Monitoring form dated (MONTH) 10, (YEAR) revealed Items Lost .Vintage Oakley wrap around sunglasses (yellow in color) .Estimated value of items: $300.00 .Had them morning of (MONTH) 10, (YEAR). Came to room, sunglasses put on bedside table by CNA (certified nursing assistant). Resident laid down for rest. When woke up, realized sunglasses missing .Nursing searched resident's room. Laundry and kitchen staff made aware of missing items. CNA's/nursing involved with resident's care were asked if they had seen missing item .Declined filing police report. Glasses not located as of this date. Will continue to search . Review of the resident's clinical record revealed a Social Services Progress Note dated (MONTH) 11, (YEAR), which documented Social services spoke with resident in regard to missing item (sunglasses). Theft/Loss Monitoring Form filled out with input from resident. Social services and Nursing staff made aware of missing item. This writer will follow up with Administrator and continue to monitor. Another Social Services Progress Note dated (MONTH) 13, (YEAR) included Missing item form completed. Resident declined to file police report. Missing glasses have not been found to date. Staff to continue to search. All other departments made aware. Resident notified of actions being taken. The facility was unable to provide any documentation that the two allegations regarding misappropriation of resident property were reported to the State agency. An interview was conducted with the social worker (staff #16) on (MONTH) 18, (YEAR) at 10:20 a.m. Staff #16 stated that about six weeks ago the resident reported that she was missing $10.00 and that a week ago the resident reported that her sunglasses were missing. The social worker stated that the facility searched for the sunglasses, but never found them. An interview was conducted with the administrator (staff #58) on (MONTH) 18, (YEAR) at 1:05 p.m. The administrator stated that he interpreted the incident as missing items and not misappropriated. -Resident #66 was admitted to the facility on (MONTH) 21, (YEAR), with [DIAGNOSES REDACTED]. Review of the admission MDS assessment dated (MONTH) 28, (YEAR) revealed a BIMS score of 15, which indicated that the resident was cognitively intact. A Nursing Progress Note dated (MONTH) 4, (YEAR) included the resident's wallet was found in the public restroom this morning per housekeeping and maintenance. According to patient only monetary content missing. Review of a Theft/Loss Monitoring form dated (MONTH) 5, (YEAR) revealed .Said his wallet was found by housekeeper in staff bathroom. $10.00 missing. Resident last saw wallet over weekend .Wallet was reportedly found in staff bathroom by housekeeper. Then housekeeper brought back to (name of resident) .(Name of resident) given choice to file police report but declined . The facility was unable to provide any documentation that the two allegations regarding misappropriation of resident property were thoroughly investigated. An interview was conducted with the administrator (staff #58) on (MONTH) 18, (YEAR) at 1:05 p.m. Staff #58 stated that he did not think the resident's sunglasses were ever found and that he interpreted the incident as missing and not misappropriated. Staff #58 stated that the resident was offered to file a police report, but did not want too. He said if the resident wanted to file a police report that would be the trigger to indicate that the item was misappropriated. The administrator stated that when the resident's wallet was found in the parking lot, he did not consider that to be misappropriation, as the wallet was found intact. The Administrator also stated that the resident does not go out into the parking lot. Staff #58 stated that staff were interviewed but no residents were interviewed, as no other residents came forward stating that they were missing items. An interview was conducted with staff #16 on (MONTH) 19, (YEAR) at 11:00 a.m. The social worker stated that the resident was asked if he wanted to file a police report and the resident stated no, and that someone must have needed the money more than he did. Staff #16 stated the facility looked in the laundry and in the resident's room, but were unable to find the money. -Resident #66 was admitted to the facility on (MONTH) 21, (YEAR), with [DIAGNOSES REDACTED]. A Nursing Progress Note dated (MONTH) 4, (YEAR) documented .Patient had wallet found in public restroom this morning per housekeeping/maintenance. According to patient only monetary content missing. Review of a Theft/Loss Monitoring Form dated (MONTH) 5, (YEAR) revealed .Said his wallet was found by housekeeper in staff bathroom. $10.00 missing. Resident last saw wallet over weekend .Wallet was reportedly found in staff bathroom by housekeeper. Then housekeeper brought back to (name of resident) .(Name of resident) given choice to file police report but declined . The facility was unable to provide any documentation that the allegation of misappropriation of resident property was thoroughly investigated. An interview was conducted with the social worker, staff #16 on (MONTH) 19, (YEAR) at 11:00 a.m. The social worker stated that she let the facility's department heads know about the missing money but that the facility usually does not interview other residents to determine if they also had property taken. An interview was conducted with staff #58 on (MONTH) 19, (YEAR) at 11:10 a.m. The administrator stated that they should have done a better job on these. -Resident #315 was admitted to the facility on (MONTH) 16, (YEAR), with [DIAGNOSES REDACTED]. A review of the admitting physician's history and physical dated (MONTH) 16, (YEAR), revealed the resident had mild dementia and left hip pain, due to a loose prosthesis and declined surgery. A care plan dated (MONTH) 27, (YEAR) identified a potential for injuries related to a history of falls, cognitive impairment, dementia, pain and loose left hip prosthesis. A goal included the resident would be free of injuries through (MONTH) 13, (YEAR). Approaches were for one on one as necessary, encourage the resident to lie down in bed during the day, and when resident is in his wheelchair leave in common area for observation and not alone in his room. A review of the nurses note dated (MONTH) 2, (YEAR) at 12:34 p.m. revealed the resident was oriented to person only, had complaints of hip pain, and continues to position himself crooked in chair and in bed. A nurses note dated (MONTH) 2, (YEAR) at 3:25 p.m. revealed the resident was complaining of left hip pain and was lying in bed with his left lower leg extended. Obvious internal rotation was noted with an area of swelling to the left hip. There were no signs or symptoms of pain unless the resident moves. No discoloration. The doctor was notified and an order was obtained for a left hip x-ray. Will continue to monitor. A physician's orders [REDACTED]. Review of the x-ray report dated (MONTH) 2, (YEAR) revealed the resident had a dislocation of the left hip prosthesis and acute angulated [MEDICAL CONDITION] femur. A physician's orders [REDACTED]. According to the hospital emergency room record dated (MONTH) 2, (YEAR) at 11:48 p.m., the resident was found to have a left hip dislocation on imaging studies done earlier. The injury was reported to have occurred between 2:00 p.m. and 6:00 p.m. and was unwitnessed. The patient is unable to provide history due to dementia. X-rays were repeated in the emergency department on (MONTH) 3, (YEAR) and revealed a left hip dislocation and fracture. The facility was unable to provide documentation that the injury of undetermined origin had been thoroughly investigated. The Administrator (staff #58) was interviewed on (MONTH) 17, (YEAR) at 2:40 p.m. He stated the resident has a documented history of a failed left hip prosthesis and often thrashes about in bed. He stated he did not investigate the fracture/dislocation because he did not consider this to be an injury of unknown origin, as it was not suspicious in nature due to his loose hip prosthesis. Review of the Abuse policies and procedures revealed the facility is to take appropriate steps to prevent the occurrence of abuse and neglect and that each resident has the right to be free from all types of abuse and neglect. The policy defined neglect as the failure of the facility to provide services to a resident that are necessary to avoid physical harm. The Abuse policies included that injuries of an unknown source means an injury should be classified as an injury of unknown source, when both of the following conditions are met: The source of the injury could not be explained by the resident, and the injury is suspicious because the extent of the injury or the location of the injury e.g., the injury is located in an area not generally vulnerable to trauma, or the number of injuries observed at one particular time or the incidence of injuries over time. The Abuse policies also included that the facility shall identify abuse, report suspected or alleged violations involving abuse or neglect immediately to the administrator and investigate the circumstances of the incident. The policy noted that the investigation will include names of witnesses and interviews of employees, visitors and/or residents who may have knowledge of the alleged incident, actions taken by the administrator to prevent the alleged violation from occurring in the future and that the results of the investigation are to be reported to the State agency. Further review of the Abuse policies and procedures revealed that misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. Any employee who suspects an alleged violation shall immediately notify the Administrator. The Administrator/designee immediately notifies the State agency. The Administrator or Director of Nursing will designate the individual who is to conduct each investigation. The investigation may include interviews of employees, visitors, and/or residents who may have knowledge of the alleged incident, as appropriate.",2020-09-01
640,SUN WEST CHOICE HEALTHCARE & REHAB,35110,14002 WEST MEEKER BLVD,SUN CITY WEST,AZ,85375,2018-04-19,880,D,0,1,2Y6W11,"Based on a review of the facility's infection control program documentation and staff interview, the facility failed to ensure that the water management program included specifics regarding control measures and testing which were to be done for Legionnaires disease and other waterborne pathogens. Findings include: Review of the facility's water management program documentation revealed that the plan did not address the need for control measures and testing which were to be done for Legionnaires disease and other waterborne pathogens. An interview was conducted with Maintenance staff (#109) on (MONTH) 19, (YEAR) at 12:00 p.m. He stated that the facility's water management plan did not include specific testing protocols and control measures that were to be completed, nor any corrective actions which were to be taken when control limits were not maintained. He stated that he missed that specific requirement in the CDC (Center for Disease Control) directions. A review of the facility's water system policy for the facility revealed no documentation of specific testing protocols and control measures which were to be done, nor corrective actions which were to be taken when control limits were not maintained.",2020-09-01
641,SUN WEST CHOICE HEALTHCARE & REHAB,35110,14002 WEST MEEKER BLVD,SUN CITY WEST,AZ,85375,2019-07-12,600,E,1,1,GW3511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews, facility documentation and policies and procedures, the facility failed to ensure two residents (#80 and #81) were free from physical abuse by one resident (#310). The deficient practice could result in further abuse of residents. Findings include: -Resident #80 was readmitted to the facility on (MONTH) 8, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed that resident #80 resided on the secured behavioral unit. A care plan dated (MONTH) 3, (YEAR) included the resident had impaired cognitive function and impaired thought processes related to [MEDICAL CONDITION] dementia. Interventions included to administer medications as ordered, identify yourself at each interaction and for social services to provide psychosocial support as needed. Review of a quarterly Minimum Data Set (MDS) assessment dated (MONTH) 14, (YEAR), revealed resident #80 had short and long term memory problems and had moderate cognitive impairment. The resident was also assessed to require extensive assistance with bed mobility, transfers, dressing and hygiene. A nursing note dated (MONTH) 31, (YEAR) included that resident #80 was sitting in a wheelchair in the doorway to the dining room refusing to allow peers to pass, was making mean faces toward peers who were attempting to pass, and was sticking up his middle finger and mouthing f . you to peers. The note included that resident #310 was attempting to enter the dining room and hit resident #80. The residents were separated and no injuries were noted. A nursing note dated (MONTH) 3, (YEAR) included that around 1:40 p.m., resident #80 had an altercation with resident #310. Resident #310 was aggressively posturing with his fist pulled back, ready to strike resident #80, who was in his wheelchair with his hands up in a guarded position. Resident #80 had his hat knocked to the floor and sustained redness to his left eye and left check. The residents were immediately separated and taken to their rooms in order to prevent further interaction, and were put on 30 minute checks for 72 hours. Per the note, safety precautions were in place and the residents will continue to be monitored frequently. A nursing note dated (MONTH) 4, (YEAR) included the swelling to resident #80's left eye and cheek was subsiding and mild purple/blue bruising to the left eyebrow/eyelid was present. Review of an annual MDS assessment dated (MONTH) 14, 2019, revealed that resident #80 had short and long term memory problems and had moderate cognitive impairment. The resident was also assessed to require extensive assistance with bed mobility, transfers, dressing and hygiene. A nursing note dated (MONTH) 4, 2019 included that a Certified Nursing Assistant (CNA) was assisting residents in the dining room, when he heard a noise and turned around and saw resident #310 strike resident #80 on the right side of the face. The residents were separated. Resident #80 had mild redness to his right eye and cheekbone. -Resident #310 was admitted to the facility on (MONTH) 15, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed that resident #310 resided on the secured behavioral unit. A care plan dated (MONTH) 6, (YEAR) included the resident had a potential for behaviors related to dementia with behaviors. Interventions included to give medications as ordered, have a clear observation of the resident when in activity room, separate from peers and redirect when behavior is inappropriate. Review of a quarterly MDS assessment dated (MONTH) 3, (YEAR) revealed the resident scored a 5 on the Brief Interview for Mental Status (BIMS), which indicated severe cognitive impairment. The MDS included the resident was assessed to require supervision with bed mobility, transfers and dressing, limited assistance with hygiene and was independent with walking in corridors. The MDS also included that the resident did not have any behaviors. A nursing note dated (MONTH) 31, (YEAR) included that resident #310 was involved in a resident to resident altercation with resident #80. Resident #310 requested that resident #80 move out of the doorway, so he could go into the dining room. Resident #80 refused and then resident #310 started hitting resident #80. Staff intervened and resident #310 was redirected to his room. Review of the facility's investigative documentation revealed that on (MONTH) 31, (YEAR) at approximately 3:45 p.m., resident #80 was sitting in the doorway to the dining room refusing to allow peers to pass, was making mean faces towards peers and was sticking up his middle finger and mouthing obscenities to peers. Resident #310 was attempting to enter the dining room, when he hit resident #80. The residents were immediately separated and no injuries were noted to either resident. Both residents will continue to be monitored closely when up and wandering the unit. The report included that both residents did not remember what happened. A statement from an activity staff member (staff #124) stated that staff does their best to keep these residents separated, and that the resident's don't understand resident #80's facial expressions, which can be misperceived by other residents. The behavioral care plan was revised on (MONTH) 14, (YEAR) to include background information that the resident had tried to strangle a family member in their sleep, prior to admission to the facility. Per the care plan, this was not the first time the resident had assaulted a family member and that the resident had spent 2 nights in jail, prior to being transferred to a different facility for acute behavior management. The care plan further included that the family member is fearful of him and that a restraining order against him was obtained following this incident. The care plan also included a functional assessment which stated the resident could independently ambulate and walks with a steady gait. Target behaviors included verbally aggressive towards peers in (MONTH) (YEAR), and was territorial and physically aggressive towards peers in (MONTH) (YEAR). Staff approaches for verbally aggressive behaviors toward peers included at the first signs of resident #310 being upset with a peer, staff is to immediately separate them and have him go to his room for a minimum of 15 minutes. Staff approaches for the resident being physically aggressive towards peers included, If resident #310 postures or acts physically aggressive in any way towards peers, staff should immediately separate them and take resident #310 to his room so he can calm down. Once he is calm, staff should then try offering him pleasant activities and snacks. Staff should take extra precautions to keep resident #310 and resident #80 away from each other. Resident #310 perceives the facial expressions/hand gestures from resident #80 as a challenge. A Weekly Behavior Chart form dated (MONTH) (YEAR) included that resident #310 was physically aggressive with peers on 13 occasions. No specifics behaviors were documented. Review of a nursing note dated (MONTH) 3, (YEAR) revealed that it was reported to the nurse at 1:40 p.m. that resident #310 was aggressively posturing with his fist pulled back ready to strike resident #80, who was in his wheelchair with his hands up in a guarded position. Resident #80 had redness to his left eye and left cheek. Resident #310 was taken to his room and placed on 30 minute checks for 72 hours. Review of the facility's investigative documentation revealed that on (MONTH) 3, (YEAR) at 1:40 p.m., both residents (#80 and #310) were observed in a physical altercation by nursing staff, in the main dining room on the secured behavioral unit. Staff reported that resident #310 was posturing over resident #80 with a raised fist, and resident #80 had his hands up in a guarded position. Staff quickly got between both residents and they were taken to their rooms. Resident #80 was given a head to toe assessment and had slight redness to his left eye and cheek. Resident #310 was assessed and had no injuries or complaints of pain. Several hours later, resident #310 complained of pain/swelling in his right hand. An x-ray of the right hand was ordered and resident #310 was found to have a [MEDICAL CONDITION] metatarsal of the right hand. Resident #310 was transported to the emergency room where he was treated and released on the same day (December 3, (YEAR)). Both residents were put on 15 minute checks for 72 hours. Upon interviewing staff and peers, this most recent incident appears to be an inadvertent accident, caused by the congestion at the entrance to the dining room and we are looking into ways to modify this area to make it more open and less congested. Resident #80 does not exhibit fearfulness towards resident #310 at this time. Neither resident remembers the incident. The investigative documentation further included that this was the second incident between resident #310 and resident #80 in the past five weeks. Staffing has been increased on this particular unit during the hours of 1:00 p.m. and 9:00 p.m. We have also increased the access to behavioral distracters (treats) to be used to divert attention away from potential conflicts. We have discussed the behaviors of both residents and are adjusting both behavioral care plans to reflect additional monitoring and interventions. We are also looking at how to make this dining room entrance larger and more open to avoid points of contention and conflict. Both residents #80 and #310 continue to be monitored closely when up and wandering the unit, with no further aggression or incidents occurring between them. A nursing note dated (MONTH) 3, (YEAR) included that resident #310's right hand above the 5th knuckle had swelling and the resident reported a pain level of 3 out of 10. The resident was able to open and close his hand with no problem. The physician was notified and a x-ray of the right hand was ordered. Review of the x-ray results dated (MONTH) 3, 2019 revealed, The views of the hand show an acute and mildly angulated [MEDICAL CONDITION] fifth metacarpal. This is commonly referred to as a boxer fracture. This does not appear to be a pathological fracture. [MEDICAL CONDITION] is noted .Conclusion: Acute angulated [MEDICAL CONDITION] metacarpal. Another nursing note dated (MONTH) 3, (YEAR) at 11:20 p.m. included that resident #310 had returned from the emergency room with an acute and mildly angulated [MEDICAL CONDITION] metacarpal. A Weekly Behavior Chart form for the month of (MONTH) (YEAR) included that a peer to peer altercation happened on (MONTH) 3, resulting in a fracture of resident #310's 5th right metatarsal. Additionally under a section regarding discharge notes, the documentation included there were no plans for discharge, and the resident continues to demonstrate the need for a secured dementia/behavioral unit and skilled nursing facility. A physician's note dated (MONTH) 20, (YEAR) included the resident was involved in a peer to peer altercation on (MONTH) 3, (YEAR), during which he sustained a fracture to his 5th metatarsal right hand. The note also included that resident #310 had been responding to medication changes until this incident. Per the note, He is more aggressive towards male peers. Staff are not able to redirect or distract him as before. Postures quite a bit in the dining room. According to a Weekly Behavior Chart form for the month of (MONTH) (YEAR), resident #310 was physically aggressive with peers 12 times. However, there were no specific behaviors documented. A note stated that a peer to peer altercation happened on (MONTH) 3, resulting in a fracture of resident #310's 5th right metatarsal. Under the section regarding discharge notes, the documentation included there were no plans for discharge, and the resident continues to demonstrate the need for a secured dementia/behavioral unit and skilled nursing facility. Review of an annual MDS assessment dated (MONTH) 3, 2019, revealed resident #310 had a BIMS score of 3, which indicated severe cognitive impairment. The MDS included the resident required supervision with bed mobility, transfers, dressing, hygiene and walking in corridors. The MDS also included the resident exhibited physical behaviors (e.g. hitting, kicking, pushing, grabbing) and verbal behaviors (e.g. threatening others, screaming at others, cursing at others). A physician's note dated (MONTH) 3, 2019 stated the resident's behaviors included verbal aggression to staff and peers, and physical aggression with peers. The note also included the resident had a history of [REDACTED]. A Weekly Behavior Chart form for the month of (MONTH) 2019 included the resident was physically aggressive with peers 15 times, however, there were no specifics regarding the behaviors. A Weekly Behavior Chart form for the month of (MONTH) 2019 included the resident was physically aggressive with peers 9 times. There were no specifics documented regarding these behaviors. A behavior note dated (MONTH) 9, 2019 included that resident #310 was observed sitting in the middle of the dinning room, while resident #80 was propelling himself in the dining room. A CNA was assisting another resident in the dining room when he heard noises and before he was able to intervene, resident #310 punched resident #80 in the face one time. A head to toe assessment was done on resident #80 and no injuries were noted. A behavior note dated (MONTH) 10, 2019 included due to history of physical aggression towards a specific resident, social services was notified to find alternative placement for resident. A behavioral health provider note dated (MONTH) 10, 2019 included, Patient has a history of severe physical aggression and violence and was involved in a resident to resident altercation yesterday. This has not been an isolated event for this patient. As such, patient is to be transferred out of this facility .The patient's current symptoms and behaviors significantly interfere with social functioning. The patient is incapable of completing activities of daily living (ADLs) independently and of assuming responsibility for cares. Secondary to known cognitive, behavioral, and functional limitations, the patient's functioning is expected to decline. The behavior care plan was revised on (MONTH) 10, 2019 to include that social services was to assist in finding alternative placement for resident #310, as soon as possible. A behavior note dated (MONTH) 11, 2019 included an interdisciplinary team (IDT) meeting determined the resident will be transferring to alternate placement, due to resident #310 being in three altercations as an aggressor. The note included a representative from another facility was going to come on (MONTH) 15, 2019 to determine if resident #310 would be a candidate for placement in their facility. Review of the facility's investigation dated (MONTH) 16, 2019 revealed that on (MONTH) 9, 2019 at approximately 9:50 a.m., resident #80 was sitting in his wheelchair in the main dining room, and resident #310 was in the dining room some distance away from resident #80. A CNA heard a commotion behind him, turned around and reported that he thought resident #310 hit resident #80. Both residents were separated immediately, resident #80 denied injury or pain, and did not remember the incident. Staff implemented frequent checks and close monitoring for both residents for 72 hours, however, since resident #310 appeared to be targeting resident #80, he was to be transferred out of our facility as soon as alternative placement could be arranged. Before that occurred, resident #310 had another non-injury minor altercation with another resident (#81) and was sent to the hospital for being a danger to others. -Resident #81 was readmitted to the facility on (MONTH) 5, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed that resident #81 resided on the secured behavioral unit. A care plan dated (MONTH) 7, (YEAR) (from a previous admission) included the resident had a potential for a behavior problem related to alcohol induced dementia and [MEDICAL CONDITION]. Interventions included to approach the resident in a calm manner, intervene as necessary to protect the rights and safety of others, divert attention, and remove resident from the situation and take him to an alternate location as needed. A quarterly MDS assessment dated (MONTH) 14, 2019 included a BIMS score of 11 out of 15, which indicated the resident had moderate cognitive impairment. The MDS also indicated the resident required extensive assistance for most activities of daily living (ADLs). A progress note dated (MONTH) 15, 2019 included that resident #81 was by the social service office, when another resident (#310) came up to him and struck in in the face. Resident #81 did not provoke the altercation. The residents were separated and resident #310 was taken back to his room. A head to toe evaluation was completed and resident #81 had no injuries, pain or bruising noted. A behavior note dated (MONTH) 15, 2019 included that resident #310 was walking back from the dining room, when a licensed practical nurse and unit manger of the secured behavioral unit, (staff #28) observed resident #310 come up to resident #81 who was sitting in his wheelchair by the social service office door and strike resident #81 on the face. Staff #28 immediately separated them and took resident #310 to his room and placed him on one to one care. A head to toe evaluation was done on resident #310 and no injuries were noted. 911 was called and resident #310 was sent to the emergency room , due to increased aggression, agitation and was a danger to others. A physician's discharge summary dated (MONTH) 15, 2019 included the patient struck another resident and had done so previously. Per the note, the resident is a danger to others and was sent to the emergency room for an evaluation for aggressive behavior. Review of the facility's investigative documentation by the administrator (staff #136) dated (MONTH) 17, 2019 included that on (MONTH) 15, 2019 at 3:50 p.m., residents #81 and #310 were observed by staff in a physical altercation on the secured unit. A Licensed Practical Nurse (LPN/staff #28) and a social service staff (staff #46) witnessed the altercation. Staff #28 observed resident #310 approach resident #81, who was sitting outside of staff #46's office and resident #310 started striking resident #81 on top of his head and face, seemingly unprovoked. Staff #28 immediately put herself in between the two residents and separated them. Resident #310 was escorted back to his room, while staff #46 stayed with resident #81 to assure he was uninjured and to calm him down. Both residents were given a head to toe assessment with no injuries noted. Resident #310 was immediately put on one to one supervision and eventually transferred to the hospital for further psychological evaluation for increased physical aggression and for being a danger to others. The facility determined that resident #310 was in need of alternative placement and would not be returning to the facility. The report further included that upon interviewing staff and residents, It appears that this altercation was an inadvertent unprovoked incident which resulted in no injuries to either resident. Resident #81 does not exhibit any signs of fearfulness or anxiety. Resident #310 no longer resides at this facility. We are therefore unable to substantiate that any abuse occurred. In an interview with a CNA (staff #41) on (MONTH) 12, 2019 at 9:58 a.m., she stated that she remembers resident #310. She stated resident #310 could be unpredictable and staff were to keep him at arms distance away from other residents. She stated that he was able to ambulate on his own throughout the unit. In an interview with the unit manager of the secured behavioral unit (LPN/staff #28) on (MONTH) 12, 2019 at 10:21 a.m., she stated that part of her responsibilities include having weekly behavior meetings with various staff and the behavioral health provider, assisting nurses with their rounds, and reporting behaviors to the behavioral heath provider. She stated that if there is a resident to resident altercation, the residents are immediately separated, both are kept safe, her supervisor is notified, both residents are assessed and an investigation is begun. She stated if the altercation involved one resident hitting another resident that would be considered abuse. She said that she remembers resident #310 and he had a history of [REDACTED]. She said he was physically fit and would ambulate independently throughout the unit. She stated he did have some aggressive behaviors and had three altercations with resident #80. She stated she witnessed the incident between resident #310 and resident #81 in (MONTH) 2019. She stated she was standing by the nurses station and resident #81 was outside of the social services office in his wheelchair, and resident #310 came up and punched resident #81 in the face. She stated it was very spontaneous and no injuries were noted to either resident. She said that resident #310 was put on one to one supervision. She also stated that after discussions with superiors, the decision was made to send resident #310 to the emergency room for an evaluation. An interview with activities staff (staff #124) was conducted on (MONTH) 12, 2019 at 12:38 p.m. Staff #124 said that she remembers resident #310 and that she witnessed resident #310 hit resident #80 on a couple of occasions, but was unable to recall the dates. Staff #124 stated on one occasion, resident #310 hit resident #80 with a fist. She said resident #80 never hit resident #310 back and resident #80 did not act afraid of resident #310. She stated when they had altercations, they were immediately separated. She said staff did their best to keep these two residents separated. During an interview with social services staff (staff #46) on (MONTH) 12, 2019 at 1:09 p.m., she stated that she remembers resident #310. She stated he had a domestic violence incident with a family member, before he was admitted to the facility. She stated he was unpredictable and would have unprovoked altercations out of the blue. Staff #46 said that resident #310 had a couple of incidents with resident #80, so they would keep them at arms length at all times. She stated resident #310 and resident #80 were always seated apart in the dining room and had rooms on different halls. She stated there was an incident in (MONTH) and another one in April, so no pattern was identified. She stated after one incident, resident #80 had some swelling and redness around his eye and resident #310 broke his pinky finger. She stated that resident #310 was determined not to be an immediate threat to anyone, but after his fourth altercation, we couldn't take the risk of keeping him in the facility. She stated she witnessed one incident between resident #310 and resident #81. She said resident #81 was outside her office when resident #310 came charging toward resident #81. An interview with the Director of Nursing (DON/staff #94) was conducted on (MONTH) 12, 2019 at 1:35 p.m. She stated that her definition of physical abuse is someone hitting or smacking someone else, or something that results in harm from one resident to another. She stated she remembers resident #310 and that he was very unpredictable in his altercations and had behaviors of aggression. Staff #94 said that resident #80 had no major injuries, as a result of the altercations with resident #310, only a light reddened area. She stated the residents were unable to remember the incidents after they occurred, and they were kept separated. She stated in (MONTH) 2019 they began to seek outside placement for resident #310. An interview with the administrator (staff #136) was conducted on (MONTH) 12, 2019 at 2:00 p.m. He stated that protecting the residents is first and foremost when there is an allegation of abuse. He stated a resident to resident altercation triggers the same protocol for investigating an allegation of abuse and it triggers a higher level of monitoring of the residents. He stated there tend to be more resident to resident altercations on the secured behavioral unit and in their experience, those residents can be somewhat unpredictable. He stated in those instances, visual awareness is increased, the residents are separated and in some cases we have sent the residents out of the facility. He stated he did not consider the incidents between resident #310 and #80 to be abuse, because resident #310's actions were not really intentional and were a reaction to resident #80's behaviors. He stated the action of resident #310 was spontaneous and not willful. Review of a facility policy titled, Abuse: Prevention of and Prohibition Against dated (MONTH) 11, (YEAR) revealed that each resident has the right to be free from abuse and neglect .The facility will provide oversight and monitoring to ensure that its staff, who are agents of the facility, deliver care and services in a way that promotes and respects the rights of the residents to be free from abuse and neglect. The facility will take action to protect and prevent abuse and neglect from occurring by having structures and processes to provide needed care and services to all residents, which includes identifying, assessing, care planning for appropriate interventions and monitoring of residents with needs and behaviors that might lead to conflict such as; physically aggressive behavior (e.g. hitting, kicking, grabbing, pushing/shoving, threatening gestures, throwing objects); and verbally aggressive behavior (e.g. screaming, cursing, bossing/demanding, intimidating). The facility will assist staff in identifying abuse and neglect .This includes identifying the different types of abuse (physical, verbal .). The policy also stated Because some cases of abuse are not directly observed, understanding resident outcomes of abuse can assist in identifying whether abuse is occurring or has occurred. Possible indicators of abuse include, but are not limited to: Occurrences, patterns, and trends that may constitute abuse, episodes of resident to resident altercation, willful or accidental, with or without injury. The policy included that if the allegation of abuse involves another resident, the facility will continue to assess, monitor and intervene as necessary to maximize resident health and safety. The policy further included a definition of abuse as follows: Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes physical abuse, verbal abuse, sexual abuse and mental abuse. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Another facility policy titled, Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment dated (MONTH) 15, (YEAR) included Depending on the nature of the allegation, immediately put effective measures in place to ensure that further potential abuse, neglect, mistreatment, exploitation, or misappropriation of resident property does not occur while the investigation is in process.",2020-09-01
642,LAKE PLEASANT POST ACUTE REHABILITATION CENTER,35111,20625 NORTH LAKE PLEASANT ROAD,PEORIA,AZ,85382,2017-02-03,281,E,0,1,G8OV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, clinical record review, the Rules of the Arizona State Board of Nursing, and facility policy review, the facility failed to ensure that treatment was administered as ordered by the physician for one resident (#106). Findings include: Resident #106 was admitted at the facility on (MONTH) 1, (YEAR) with [DIAGNOSES REDACTED]. Review of physician recapitulation orders revealed an order dated (MONTH) 30, (YEAR) for [MEDICATION NAME] HCl ([MEDICATION NAME]) 1000 milligram (mg) in the evening for 14 days for [MEDICAL CONDITION]. The route of administration was not present. Review of a nursing note dated (MONTH) 1, (YEAR) revealed the resident was transferred to the hospital for placement of a central line or PICC (peripherally inserted central line) line for IV (intravenous) antibiotic. Continued review of the physician recapitulation orders revealed an order dated (MONTH) 1, (YEAR) to change the IV tubing every 24 hours. Review of the IV MAR (medication administration record) from (MONTH) 1, (YEAR) through (MONTH) 31, (YEAR) revealed that the tubing was changed as ordered on (MONTH) 2, 5, 23, and 26, (YEAR). Review of the IV MAR from (MONTH) 1, (YEAR) through (MONTH) 25, (YEAR) revealed the tubing was changed as ordered on (MONTH) 3, 4, 5, 6, 16, 17, 18, 19, 23 and 24, (YEAR). There was no documentation in the clinical record that the resident's tubing was changed on the dates that were not marked on the IV MARs. There was also no documentation in the clinical record that the physician changed the tubing order. During an interview conducted with the clinical service team nurse (staff #105) on (MONTH) 3, (YEAR) at 10:25 a.m., she stated the lack of documentation of medications and/or treatments on the eMAR and eTAR (electronic treatment administration record) were identified as an issue and was brought to the facility's Quality Assessment (QA) program in (MONTH) (YEAR). Review of the QA documentation revealed that the facility identified medications and/or treatments were not documented in the eMAR and eTAR on (MONTH) 12, (YEAR). The causal factors included lack of knowledge of staff on double checking documentation at the end of shift and the lack of auditing for documentation completion. Facility intervention included in-servicing staff on documentation requirements and establishing an audit tool. The QA documentation also revealed on (MONTH) 15, (YEAR), staff were provided an in-service on completion and documentation of all medications, IVs and TARs prior to leaving the shift. However, the in-service did not include following treatments or medications as ordered and it did not include measures for ensuring checking and changing of IV tubing as ordered by the physician. Further, the eMAR checks and Audits conducted by the facility did not include checking that IV tubing was changed as ordered. Despite the facility's identification of a problem and implementing a plan of correction by conducting an in-service to all staff to correct the problem, the staff still failed to ensure that the IV tubing of resident #106 who has a history of repeated infections was changed every 24 hours as ordered. During an interview conducted with a licensed practical nurse (LPN/staff #57) on (MONTH) 2, (YEAR) at 12:43 p.m., she stated the order for changing tubing every 24 hour hours referred to IV tubing. She stated this order indicated the IV tubing is good for 24 hours and must be changed as ordered. She also stated once the tubing is changed, she documents her initials on the IV MAR with the date. She further stated if the tubing change is not documented on the IV MAR, then it was not performed. An interview with the assistant director of nursing (ADON/staff # 79) was conducted on (MONTH) 2, (YEAR) at 1:06 p.m. She stated the tubing in a physician order [REDACTED]. She stated the tubing is changed every 24 hours as ordered by the night shift nurse who will date and initial the label on the new tubing. She further stated that the IV tubing change will be documented on the eMAR or eTAR and if there is no date and initial in the box, it means the IV tubing change was not performed. During an interview conducted with the director of nursing (DON/staff #116) on (MONTH) 3, (YEAR) at 12:05 p.m., she stated the order to change tubing every 24 hours can refer to IV tubing and feeding tubes. She stated when there is an order to change tubing every 24 hours, the nurses are expected to follow the order and document it was performed on the MAR, IV MAR and/or TAR. Further, she stated when there are boxes on the MAR, IV MAR and/or TAR not initialed then it would indicate the tubing change was not performed. The facility policy on Administration of Drugs included medications shall be administered in accordance with the written orders of the attending physician. The facility policy on Physician orders [REDACTED].accurately implement orders in addition to medication orders (treatment, procedures) only upon the written order of a person duly licensed and authorized to do so . The Rules of the Arizona State Board of Nursing included a registered nurse and/or LPN administers prescribed aspects of care including treatment, therapies and medications; and, clarifies orders with health care providers as needed.",2020-09-01
643,LAKE PLEASANT POST ACUTE REHABILITATION CENTER,35111,20625 NORTH LAKE PLEASANT ROAD,PEORIA,AZ,85382,2017-02-03,311,D,0,1,G8OV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and staff interviews, and policy, the facility failed to provide the appropriate treatment and services to maintain or improve one resident's abilities related to bathing, dressing, and grooming for one resident (#8). Findings include: Resident #8 was readmitted on (MONTH) 29, (YEAR) with [DIAGNOSES REDACTED]. Resident #8 discharged to the hospital on (MONTH) 1, (YEAR). Review of a 5 day Minimum Data Set (MDS) assessment dated (MONTH) 5, (YEAR) revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15, which indicated the resident had no cognitive impairment. The MDS also assessed the resident to require supervision with oversight, encouragement, or cueing with hygiene, and required physical help of one person with bathing. Review of a nursing ADL (activities of daily living) care plan revealed the resident was as at risk for self-care deficit related to limited mobility, pain, and amputation of left lower extremity (LLE) with a goal that the resident will maintain current level of function in bed mobility, transfers, eating, dressing, grooming, toilet use, and personal hygiene. Continued review of the care plan revealed the resident was resistive to care as evidenced by requesting pain clinic and dental appointments and then refusing them. The care plan did not address the resident was resistive to care regarding showers/hygiene. Review of the certified nursing assistants (CNAs) ADL notes for (MONTH) and (MONTH) of (YEAR) and (MONTH) of (YEAR) revealed documentation of showers and baths. For the month of (MONTH) (YEAR) two showers and a one-time refusal for a shower was documented. No showers or refusals were documented for the month of (MONTH) (YEAR). For the month of (MONTH) (YEAR) two showers were refused and two showers were documented completed. Review of the shower sheet records for (MONTH) (YEAR) revealed the resident refused two showers. Prior shower sheets were not available. Per the DON (Director of Nursing/staff #116) shower sheets are only retained for one previous month. On (MONTH) 31, (YEAR) at 8:56 a.m. Resident #8 was observed out of bed in a wheelchair and dressed for the day. The resident's long hair was observed not combed and she had a slight odor of urine/feces. The resident's hair remained the same during other observations conducted throughout the day. An interview was conducted with the DON on (MONTH) 2, (YEAR) at 3:09 p.m. The DON stated that the shower sheet record was to be filled out by a CNA each time a resident refused a shower. She stated the CNA is to give the shower sheet record to the nurse responsible for the resident. The nurse discusses the refusal with the resident, signs the form, and places the signed form in the shower sheet book. The DON also stated that resident #8 often refused care, including showers. The DON further stated that the showers should be marked refused in the ADL notes for each refusal. She has no explanation as to why the ADL notes are not being documented in the correct manner. An interview was conducted with a CNA (staff#21) on (MONTH) 3, (YEAR) at 12:37 p.m. regarding documentation on the ADL notes. She stated that the notation N/A on the notes indicated it was determined it was not the resident's shower day. An interview was conducted with another CNA (staff #53) on (MONTH) 3, (YEAR) at 12:43 p.m. The CNA stated that resident #8 refused care many times and the shower sheet should be filled out with the refusal and turned into the nurse. The CNA also had no explanation why this was not done for resident #8. Staff #53 added that showers are done on night shift for this resident and she has never bathed the resident. Another interview was conducted with the DON on (MONTH) 3, (YEAR) at 1:16 p.m. The shower sheets were reviewed with the DON and she agreed there was no documentation that the resident had any showers in (MONTH) (YEAR). A facility policy ADL, services to carry out included: Bathing will be offered at least twice weekly and PRN per resident request.",2020-09-01
644,LAKE PLEASANT POST ACUTE REHABILITATION CENTER,35111,20625 NORTH LAKE PLEASANT ROAD,PEORIA,AZ,85382,2017-02-03,314,D,0,1,G8OV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff and resident interviews, and policy review, the facility failed to ensure a pressure ulcer for one resident (#188) was assessed accurately. Findings include: Resident #188 was admitted at the facility on (MONTH) 17, (YEAR) with [DIAGNOSES REDACTED]. The hospital discharge instructions dated (MONTH) 17, (YEAR) included special instructions for Stage II wound care to the coccyx with [MEDICATION NAME] (foam dressing). Review of the initial nurse admission record dated (MONTH) 17, (YEAR) revealed a Stage II pressure ulcer to the sacrum measuring 4.0 cm (centimeters) x 3.0 cm x 0.2 cm. The additional documentation section revealed stage 2 coccyx Review of the nursing note dated (MONTH) 17, (YEAR) revealed a stage II pressure ulcer to the coccyx measuring 4.0 cm x 3.0 cm x 0.1 cm with no drainage noted with Duoderm applied to the wound. Further review of the nursing note revealed no description of the wound bed. Review of the physician recapitulation orders revealed an order dated (MONTH) 18, (YEAR) to clean the pressure ulcer to the coccyx with normal saline (NS) , pat dry, apply Duoderm dressing on the day shift every other day. However, review of the skin/wound note documented by the wound nurse dated (MONTH) 18, (YEAR) revealed a blanchable, intact skin. Per the documentation, there was redness to the coccyx measuring 2.4 cm x 3.0 cm and treatment orders were in place. Review of the clinical record revealed no documentation of any error in the assessment, identification, staging, and measurement of the resident's pressure ulcer on (MONTH) 17, (YEAR) nor documentation the physician was notified of the absence of a Stage II pressure ulcer to coccyx. The skin care plan dated (MONTH) 18, (YEAR) revealed the resident had potential for pressure ulcer development. Interventions included administration of treatment as ordered. Review of a shower skin assessment dated (MONTH) 20, (YEAR) revealed no [MEDICAL CONDITION]. Continued review of the clinical record revealed daily skilled nursing documentation from (MONTH) 19, (YEAR) through (MONTH) 23, (YEAR) documented the skin was intact. The Admission MDS (Minimum Data Set) assessment dated (MONTH) 24, (YEAR) revealed a BIMS (Brief Interview for Mental Status) score of 15 indicating the resident was cognitively intact. The assessment also assessed the resident had no unhealed pressure ulcer but was at risk for pressure ulcer. The CAA summary revealed pressure ulcer was triggered for care planning. Review of the TAR from (MONTH) 1, (YEAR) through (MONTH) 31, (YEAR) revealed the ordered treatment was performed on (MONTH) 18, 20, 22 and 28, (YEAR) but not performed on (MONTH) 24 and (MONTH) 26, (YEAR). Review of the physician recapitulation orders revealed an order dated (MONTH) 31, (YEAR) to apply a perma foam dressing to the coccyx during the day shift on Monday and Wednesday. The pressure ulcer care plan initiated on (MONTH) 31, (YEAR) included a Stage II pressure ulcer to coccyx and to perform treatments as ordered. Review of the Skin Pressure Ulcer weekly notes dated (MONTH) 31, (YEAR) documented by the wound nurse revealed the resident developed a Stage I pressure ulcer to the coccyx measuring 3.0 cm x 3.0 cm x 0 cm and that a protective dressing would be applied every Monday-Wednesday-Friday. Additional review revealed no description of the wound bed. Review of a Skin/Wound note dated (MONTH) 31, (YEAR) documented by the wound nurse revealed a stage 1 pressure ulcer to the coccyx measuring 3.0 cm x 3.0 cm x 0 cm, with nonblanchable redness with undefined edges. Per the documentation the treatment order was for application of a perma non-adhesive foam dressing every Monday, Wednesday, and Friday. Review of the Daily Skilled Note dated (MONTH) 31, (YEAR) revealed an unstageable pressure ulcer to the coccyx measuring approximately 3.0 cm x 2.5 cm, periwound [DIAGNOSES REDACTED]tous, and the wound bed yellow with scant purulent discharge. The Skin Pressure Ulcer Weekly note documented by the wound nurse dated (MONTH) 3, (YEAR) included an unstageable pressure ulcer to coccyx, measuring 2.5 cm x 2.0 cm x 0 cm, with scant serous exudate, slough, and defined wound edges. An interview with the resident was conducted on (MONTH) 3, (YEAR) at 9:03 a.m. She stated she had a wound to her bottom when she was admitted that she received treatment for. During an interview with the wound nurse (staff #66) conducted on (MONTH) 3, (YEAR) at 10:19 a.m., she stated that the resident developed a Stage II pressure ulcer to the coccyx which was not present when the resident was admitted . In an interview with the clinical service team nurse (staff #105) conducted on (MONTH) 3, (YEAR) at 10:25 a.m., she stated pressure ulcer assessments were identified as an issue and brought to the facility's Quality Assessment (QA) program in (MONTH) (YEAR). A review of the submitted QA documentation included inconsistent assessments and documentation identified by the wound nurse on (MONTH) 12, (YEAR). The causal factors included lack of daily audits, lack of accountability for weekly skin assessments, and lack of understanding of care planning specific wounds. Interventions included conducting in-service training to licensed nurses on importance of completing weekly skin assessments timely and daily audits for missed assessments. Review of the facility's QA documentation of in-services and meeting revealed the following: wound and treatments will be completed by the unit nurse; all documentation is completed on scheduled shifts; and weekly skin assessments by all nurses. Review of the facility's documentation of in-service training conducted to staff did not include ensuring the accuracy of skin assessments and correcting wound assessments when an error is identified. Despite the facility's identification of a problem and implementing a plan of correction by conducting an in-service to all staff to correct the problem, the staff failed to ensure an accurate skin assessment was conducted for resident #188 wound upon admission on (MONTH) 17, (YEAR). A pressure ulcer treatment observation of the pressure ulcer was conducted with staff #66 on (MONTH) 3, (YEAR) at 11:25 a.m. Staff #66 stated the wound was previously measured earlier during the week and did not measure the wound. An interview with the assistant director of nursing (ADON/staff #79) was conducted on (MONTH) 3, (YEAR) at 11:49 a.m. She stated weekly skin checks are conducted by staff. She stated the wound nurse is responsible for identifying, staging, measurement, and treatment of [REDACTED]. She also stated nurses are to notify the wound nurse with any skin conditions. In an interview with the director of nursing (DON/staff #116) conducted on (MONTH) 3, (YEAR) at 12:05 p.m., she stated the nurses do not identify, stage, and measure complex wounds like pressure ulcer, they perform weekly skin assessments and document what they observe. She further stated that the identification, staging, measuring, and treatment of [REDACTED]. The wound nurse documents this information in the clinical record. In another interview with the wound nurse (staff #66) conducted on (MONTH) 3, (YEAR) at 1:26 p.m., she stated her initial observation of the wound on (MONTH) 18, (YEAR) revealed no pressure ulcer. She stated the documentation of the nurse on (MONTH) 17, (YEAR) was an error. She further stated the treatment performed was good for protection of the resident's skin. Staff #66 stated it is the nurses responsibility to notify the physician regarding changing orders. During an interview with the corporate resource nurse (staff #119) conducted on (MONTH) 3, (YEAR) at 2:04 p.m., she stated the resident's wound was assessed, identified, staged, and measured by the registry staff on (MONTH) 17, (YEAR). However, the registry staff was not supposed to do this per facility policy. The facility policy on Wound Management included the nurse is responsible for assessing and evaluating the resident's condition on admission and is expected that once a wound has been identified, assessed, and documented, shall administer treatment as per physician's orders [REDACTED].>",2020-09-01
645,LAKE PLEASANT POST ACUTE REHABILITATION CENTER,35111,20625 NORTH LAKE PLEASANT ROAD,PEORIA,AZ,85382,2017-02-03,323,E,0,1,G8OV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, staff interviews, and policy, the facility failed to ensure that each resident received adequate supervision and assistive devices to prevent accidents in the residents smoking area. Findings include: Resident #8 was originally admitted to the facility on (MONTH) 20, (YEAR) and readmitted on (MONTH) 29, (YEAR), with [DIAGNOSES REDACTED]. A nursing care plan for smoking dated (MONTH) 17, (YEAR) revealed the resident had a potential for injury related to smoking. Interventions for the resident included the following interventions: - Monitor to assess compliance with facility smoking policy/individual plan - Observe smoking while in designated area - Provide 1:1 observation while smoking - Report non-compliance or unsafe smoking habits to MD and responsible party - Utilize smoking apron during smoking activities An additional focus of potential for injury related to lethargy was added to the nursing care plan for smoking on (MONTH) 26, (YEAR). The goal of this focus was that the resident will not be granted an outside pass if any signs of lethargy, restlessness, or sleepiness were displayed. The interventions included that the resident will remain in the facility if any signs of lethargy occur. A resident Smoking Evaluation form was updated on (MONTH) 29, (YEAR). The evaluation identified the following: - Cognition- The resident has no cognitive loss. - Vision- The resident has no visual deficits - Dexterity- This question was not answered. The answer choices include yes, no, and unable to determine - Balance- The resident does not fall forward. The resident does not fall or lean sideways. - Smoking Frequency- The resident likes to smoke morning, afternoon, and evening. - Safety- The resident can light her own cigarette. The resident has no need for adaptive clothing/device/assistance. The plan of care was used to assure the resident is safe while smoking. - Comments- No additional comments were recorded. Review of a Minimum Data Set (MDS) 5 day scheduled assessment dated (MONTH) 25, (YEAR) revealed the resident's cognitive skills were intact with a Brief Interview for Mental Status (BIMS) score of 15. The MDS also revealed that the resident's range of motion in her upper extremities, (shoulder, elbow, wrist, and hands) was not impaired. During a smoking observation conducted Tuesday, (MONTH) 31, (YEAR) at 10:00 a.m., six residents were observed on the smoking patio. A Certified Nursing Assistant (CNA/staff #53) who was in charge of the residents in the smoking area was assisting the residents with lighting their cigarettes. After assisting the residents, the CNA noticed resident #8 approximately 25 feet away from the smoking residents slumped forward in her wheelchair with her head and arms resting on her knees. The CNA shook the resident and loudly called her name three times before the resident indicated any response. The resident appeared to be very drowsy, had delayed movements, and had delayed verbal response time. The CNA then wheeled resident #8 to the smoking area of the patio and assisted her to light a cigarette. The resident immediately dropped the lit cigarette to the concrete flooring. The CNA picked up the cigarette and gave it back to the resident. The resident dropped her cigarette to the ground four times in the time allowed to smoke one cigarette. Each time the CNA picked it up off of the concrete and returned it to the resident. There were no cigarette burn holes present in the resident's clothing or burns present on any skin surfaces. The resident was able to take the cigarette back each time the CNA handed it to her. The resident was able to respond verbally to questions and did not go back to sleep while smoking. An interview was conducted with the CNA during the residents 10:00 a.m. smoke break. When asked where the fire extinguisher was located, the CNA stated she did not know. She stated she had only worked here a couple of weeks and did not know the rules yet. An additional smoking observation was conducted on Tuesday, (MONTH) 31 at 1:00 p.m. Resident #8 was observed sitting straight in her wheelchair making conversation with the other smoking residents. She did not drop her cigarette during this observation, however, the resident was seated at a table made of steel and the lit cigarette tip was observed resting against the steel. No burn holes in her clothing, no ashes present on clothing, and no burns on her body were observed. An additional interview was conducted with the CNA at the 1:00 p.m. smoke break. The CNA stated that normally resident #8 is more alert and the lethargy displayed earlier in the day was not her normal baseline. An interview was conducted with resident #8's licensed practical nurse (LPN/Staff#57) on (MONTH) 31, (YEAR) at 3:18 p.m. The LPN stated she had not been informed of anything unusual with resident #8. The LPN stated that resident #8 was out on the smoking patio and out of her direct observation all day. She stated the last time she had observed resident #8 was when she administered her a.m. medications. Review of the nursing notes for the evening of (MONTH) 31, (YEAR) revealed the following: January 31, (YEAR) 6:17 p.m. Resident had episode of intermittent slow speech and response. She was able to verbalize needs but spoke with the patient in detail regarding holding the afternoon meds due to slow speech and impairment. January 31, (YEAR) 10:24 p.m. Patient is passed out in wheelchair and very hard to arouse, patient pupils are dilated, she is drooling and her speech is slurred. She can barely wheel herself in wheelchair. Patient out on smoke break and can't light her cigarette and passes out every 5 seconds. Lit blanket on fire, burned a hole in it. Has burned her hand several times. Further review of the nurses' notes revealed the resident was discharged to the hospital (MONTH) 1, (YEAR). An additional smoking observation was conducted (MONTH) 3, (YEAR) at 10:05 a.m. The facility administrator (staff#117) and CNA (staff #53) were present in addition to four resident smokers. The administrator was going over the facility policy with the CN[NAME] The CNA then read the entire policy to the residents present and had the residents sign the policy before they could begin smoking. Another facility employee delivered some smoking aprons wrapped in plastic. The CNA asked the other employee What are those? The employee replied smoking aprons. An additional interview was conducted with the CNA on (MONTH) 3, (YEAR) at 10:08 a.m. in the smoking area. She stated she is new, does not know all of the rules, does not know how to apply a smoking apron, and that she did not know what a smoking apron was until now. The CNA stated she read the smoking book (white notebook consisting of smoking assessments and smoking policy), but never knew what a smoking apron was. During an interview conducted with the Director of Nursing (DON/staff#116) on (MONTH) 3, (YEAR) at 11:21 a.m., the DON stated that it is her expectation that the CNA supervising the resident smoking area know the location of the fire extinguisher and the fire blanket. She further stated it is also her expectation that a CNA who is assigned to put a smoking apron on residents know what a smoking apron is. The facility's policy Smoking Policy/Procedure included to provide those residents who choose to smoke, a means in which to do so that does not jeopardize their safety or the safety of others residing in the facility .",2020-09-01
646,LAKE PLEASANT POST ACUTE REHABILITATION CENTER,35111,20625 NORTH LAKE PLEASANT ROAD,PEORIA,AZ,85382,2017-02-03,329,E,0,1,G8OV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, clinical record review, and facility policy review, the facility failed to ensure that pain medication was administered as ordered to one resident (#106). Findings include: Resident #106 was admitted at the facility on (MONTH) 1, (YEAR), (YEAR) with [DIAGNOSES REDACTED]. The Pain care plan dated (MONTH) 8, (YEAR) revealed the resident had potential or actual discomfort related to chronic physical disability and [MEDICAL CONDITION]. Interventions included administration of [MEDICATION NAME] medication as ordered and to follow ordered pain scale. Review of the physician recapitulation orders dated (MONTH) 2, (YEAR) revealed an order to monitor level of pain every shift using the following scale: 0 for no pain; 1-3 for mild pain; 4-6 for moderate pain and 7-10 for severe pain. The quarterly MDS (Minimum Data Set) assessment dated (MONTH) 16, (YEAR) revealed a BIMS (Brief Interview for Mental Status) score of 15 indicating the resident was cognitively intact. It also included that the resident was on scheduled and as needed pain medications and had some pain at some time during the last 5 days of the assessment. The physician recapitulation orders revealed an order dated (MONTH) 13, (YEAR) for: -[MEDICATION NAME]-[MEDICATION NAME] (narcotic [MEDICATION NAME]) 5-325 mg (milligrams)1 tablet via PEG (percutaneous endoscopic gastrostomy) tube every 4 hours as needed for pain of 1-5; and, - [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg 2 tablets via PEG tube every 6 hours as needed for pain of 6-10. Review of the (MONTH) (YEAR) MAR from (MONTH) 13 through 30 revealed the following: - (MONTH) 14, 19 and 20, (YEAR) - pain level of 5 Per the documentation, the resident was administered [MEDICATION NAME]-[MEDICATION NAME] (narcotic [MEDICATION NAME]) 5-325 mg 2 tablets for this pain level. The physician recapitulation orders also included an order dated (MONTH) 30, (YEAR) for: -[MEDICATION NAME] ([MEDICATION NAME]) 325 mg 2 tablets by mouth every 4 hours as needed for pain of 1-3; -[MEDICATION NAME]-[MEDICATION NAME] 5-325 mg 1 tablet via PEG tube every 4 hours as needed for pain of 4-6; and, - [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg 2 tablets via PEG tube every 4 hours as needed for pain of 7-10. Review of the (MONTH) (YEAR) MAR indicated [REDACTED] - (MONTH) 20, (YEAR) - pain level of 5 - (MONTH) 12, 13, 29, 21, 22, and 26, (YEAR) - pain level of 6 Per the documentation, the resident was administered [MEDICATION NAME]-[MEDICATION NAME] (narcotic [MEDICATION NAME]) 5-325 mg 2 tablets for these pain levels. In an interview with the clinical service team nurse (staff #105) conducted on (MONTH) 3, (YEAR) at 10:25 a.m., she stated it was identified in (MONTH) (YEAR) nurses were not following pain scale when administering as needed (PRN) pain medications. Review of the QA documentation revealed the facility identified as a problem nurses were not following pain scale orders when administering as needed pain meds on (MONTH) 12, (YEAR). The causal factors included lack of knowledge and understanding in following pain scales when administering pain medications and lack of audits or monitoring system for PRN pain medication administration. Facility intervention included in-servicing staff on following physician orders [REDACTED]. The QA documentation also revealed that on (MONTH) 15, (YEAR), the staffs were provided an in-service on pain scale and management, ensuring that appropriate pain scale is in place, and ensuring that non-pharmacological interventions are in place for each pain medication. The facility's pain medication audit tool revealed the facility audit is in progress for non-pharmacological pain interventions, effectiveness using pain scale, monitoring of side effects and accurate dosing. Despite the facility's identification of the problem and implementing plan of correction by conducting an in-service on all staff to correct the problem, the staff still failed to ensure that PRN pain medications were administered within the pain parameters it was prescribed for. In an interview with a licensed practical nurse (LPN/staff #57) conducted on (MONTH) 2, (YEAR) at 12:43 p.m., she stated scheduled and/or PRN pain medications are administered as ordered within the pain parameters the medication was prescribed. She stated if the resident's pain is outside of the pain parameters, she will call the physician. An interview with the assistant director of nursing (ADON/staff # 79) was conducted on (MONTH) 2, (YEAR) at 1:06 p.m. She stated nurses are expected to assess the resident's pain, ask for the pain level, and administer the pain medication for the pain that was reported by the resident. She also stated if the pain level is outside the pain parameters, the nurses are to call the physician and implement the orders received. An interview with the director of nursing (DON/staff #116) was conducted on (MONTH) 3, (YEAR) at 12:05 p.m. She stated the nurses are expected to assess the resident's pain and administer medications per physician ordered pain parameters. The facility policy on Administration of Drugs included medications shall be administered in accordance with the written orders of the attending physician. The facility policy on Physician orders [REDACTED].",2020-09-01
647,LAKE PLEASANT POST ACUTE REHABILITATION CENTER,35111,20625 NORTH LAKE PLEASANT ROAD,PEORIA,AZ,85382,2017-02-03,356,D,0,1,G8OV11,"Based on observation, staff interviews, and facility policy review, the facility failed to ensure the staff posting was accurate and posted on a daily basis. Findings include: During the survey entrance on (MONTH) 30, (YEAR) at 10:45 a.m., the Daily Nursing Staff Information was posted on the side wall in the entrance hall to the nurse station. The Daily Nursing Staff posted was dated (MONTH) 20, (YEAR) and it included a resident census of 88. In a later observation conducted on (MONTH) 30, (YEAR) at 11:30 a.m., the Daily Nursing Staff Information posted was dated (MONTH) 30, (YEAR) and included resident census of 85. The Resident Listing Report submitted by the operations manager (staff #117) on (MONTH) 30, (YEAR) at 11:35 a.m. included a current census of 83. In an interview with staff #117 conducted on (MONTH) 30, (YEAR) at 11:45 a.m., he stated the facility was in the process of reconciling the census and will correct the Daily Nurse Staffing Information posted with the correct census. At 11:55 a.m., staff #117 provided a copy of the Daily Nurse Staffing Information dated (MONTH) 30, (YEAR) with resident census of 85 crossed out and replaced with the number 83. At 12:20 a.m., staff #117 stated that the facility had 81 residents at 8:00 a.m. and provided a corrected Daily Nurse Staffing Information dated (MONTH) 30, (YEAR) with resident census of 85 and 83 crossed out and replaced with the number 81. During an interview conducted with the staffing coordinator (staff #94) on (MONTH) 2, (YEAR) at 1:39 p.m., she stated she is responsible for the accuracy of the Daily Nurse Staffing Information posted during the week and the weekend charge nurse is responsible for accurate posting on the weekend. She stated every Friday; she ensures the weekend staffing schedule is in the staffing binder located at the nurse station for the weekend charge nurse to reference to ensure accurate staffing information. She further stated she did not know the posted staffing information for (MONTH) 30, (YEAR) was that outdated nor the reason why it was not accurate. An interview with the Director of Nursing (DON/staff #116) was conducted on (MONTH) 3, (YEAR) at 12:05 p.m. She stated the staffing coordinator (staff #94) is responsible for the accuracy of the Daily Nurse Staffing Information posted. She also stated the posting on (MONTH) 30, (YEAR) was wrong and inaccurate. The facility policy on Posting Staffing Numbers included the facility will post the hours worked by staff working who are directly responsible for resident care to comply with the benefits Improvement and Protection Act (BIPA) of 2000. However, the policy did not include the accuracy of the data posted.",2020-09-01
648,LAKE PLEASANT POST ACUTE REHABILITATION CENTER,35111,20625 NORTH LAKE PLEASANT ROAD,PEORIA,AZ,85382,2018-04-06,600,D,1,1,WTUO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, review of a police report and policies and procedures, the facility failed to ensure that one resident (#224) was free from abuse by a staff member. Findings include: Resident #224 was readmitted to the facility on (MONTH) 5, (YEAR), with [DIAGNOSES REDACTED]. Review of a mood disorder care plan dated (MONTH) 17, (YEAR) revealed the resident had angry outbursts toward staff members. An intervention included to redirect resident when verbal outbursts occur, if not redirectable, ensure resident and others are safe and return when the resident calms down. A Behavior note dated (MONTH) 12, (YEAR) documented Resident continues to interfere with care and is verbally aggressive with staff. Redirected with no change. Will continue to monitor. Review of a Social Services note dated (MONTH) 23, (YEAR) revealed Met with resident and executive director to discuss recent events. Resident has appeared more agitated lately and has been threatening to staff .States will not threaten staff in the future . Review of another Social Services note dated (MONTH) 24, (YEAR) revealed .Informed both parties of current behaviors and threatening of staff. Case manager will attempt to locate another facility that might better meet his needs. Plan: Case manager to follow up with alternate placement. Review of a Nursing note dated (MONTH) 22, (YEAR) at 4:27 a.m. by a licensed practical nurse (LPN/staff #103), revealed the resident was being verbally abusive to staff and running into the nurses with his wheelchair at approximately 12:30 a.m. This nurse attempted to redirect the resident and took him outside in the courtyard. Resident had been drinking alcohol and this nurse could see the empty bottles in his pants. Encouraged resident to go to bed and assisted him to his room. Resident pushed this nurse into the doorway of his room stating well go in. Resident then went into his room and sat by his bed in his wheelchair for a few minutes then came back out and began yelling at the 200 hall nurse (LPN/staff #119). The 200 hall nurse was verbally abusive back to the resident. This nurse walked up the hall to call the 300 hall nurse for assistance and to call the police. As this nurse was walking back, the 200 hall nurse and the resident began throwing items and hitting each other. The resident fell over backward in his wheelchair and the nurse (staff #119) continued to hit him. This nurse pulled the nurse (staff #119) off the resident and had the 400 hall nurse take her away from the situation. The resident was lying on the floor in the door way of his room and the only visible injury was a small cut on his chin. The resident stated that he was okay. The paramedics and the police arrived. Paramedics stated the resident was okay, just intoxicated. Police made a report with no charges, as neither the resident or the nurse wanted to press charges. Resident was assisted back to his wheelchair by medics and the Administrator and Director of Nursing were notified. A Nursing note dated (MONTH) 22, (YEAR) at 4:51 p.m. included Patient transferred to group home . Review of the facility's Investigative Report dated (MONTH) 22, (YEAR) revealed that the Director of Nursing was called on (MONTH) 22, (YEAR) at approximately 1 a.m. by staff #103, who reported that a registry nurse (licensed practicable nurse/staff #119) had a physical altercation with resident #224, who was a paraplegic. The resident had been belligerent and was cursing loudly at the nurses, including yelling at staff #119 and was propelling his wheelchair at her. Staff #119 was verbally abuse back to him and they began throwing items and hitting each other. The resident fell over backward in his wheelchair while the nurse continued to hit him. Staff #103 pulled staff #119 off of the resident. The empty alcohol bottles were lying on the floor beside the resident, as they had fallen out of his pants. The paramedics and police arrived. The resident was okay and no charges or arrests were made. Staff #119 was immediately relieved of her assignment and escorted off of the premises. Review of a police report revealed that on (MONTH) 22, (YEAR) at approximately 12:26 a.m., officers responded to the facility. The report included that per facility staff, the resident had been drinking earlier and was belligerent, and was yelling and cursing at them and was interfering with the nurses performing their duties. The report included that a commotion occurred between the resident and one of the nurses (staff #119). Per the witness (staff #103), the nurse (staff #119) ended up on top of the resident and the nurse was striking him in the face repeatedly, and that she had to physically pull the nurse off of the resident to get her to stop hitting him. Per a statement from the nurse who hit the resident, she reported that the resident pushed her cart, hit her computer, tried to stopped her cart, took a swing at her and that the resident attempted to kick her in the knee. The witness confirmed that the resident is wheelchair bound and is paraplegic and does not have any use of this legs, therefore, he would not be able to kick at someone. The report further included that the resident had several small lacerations around his face and appeared to have been struck several times in the face and cut with someone's fingernails. The officer spoke with the resident who did not want to answer questions and did not want to say how he got injured and refused to cooperate with the investigation. The report further included that the nurse (staff #119) said she did hit the resident in the face, but did not know how many times and that she was defending herself. Per the report, the nurse did not provide a reason why she did not just back away from the resident An interview was conducted with a LPN (staff #103) on (MONTH) 4, (YEAR) at 12:05 p.m. Staff #103 stated that the resident was drunk and harassing the nurses particularly staff #119. Staff #103 stated that staff #119 was ignoring the resident, which made him mad. Staff #103 stated that she heard yelling and saw the resident slapping staff #119's computer and throwing things. She said that staff #119 was cussing at the resident and calling him a woman beater, which escalated his behavior. Staff #103 stated that by the time she got down the hall, staff #119 was hitting the resident in the face with a closed fist, which caused his wheelchair to flip over. Staff #103 stated that once the resident fell , staff #119 continued to hit the resident and she had to pull staff #119 off the resident. An interview was conducted with the registry LPN (staff #119) on (MONTH) 4, (YEAR) at 6:45 p.m. Staff #119 stated that she recalled the incident which occurred between her and the resident, but could not go into details, as a police report had been filled out. When asked if she had any physical contact with the resident, the LPN stated that it's in the police report. When she was told that the police report included that she admitted to hitting the resident in the face, staff #119 stated it was true if that is what the police report said. An interview was conducted with the Administrator (staff #110) on (MONTH) 5, (YEAR) at 7:40 a.m. Staff #110 stated that staff are trained to walk away from residents with aggressive behaviors. The Administrator further stated that the facility was unable to substantiate that abuse had occurred. An interview was conducted with a registered nurse consultant (staff #120) on (MONTH) 5, (YEAR) at 7:45 a.m. Staff #120 stated that the facility was unsure if abuse had occurred, but they reported the incident to the Board of Nursing, police and Adult Protective Services. A review of the facility's Abuse policy revealed It is the policy of this facility that each resident has the right to be free from abuse .Physical Abuse includes but is not limited to hitting, slapping, pinching, and kicking .",2020-09-01
649,LAKE PLEASANT POST ACUTE REHABILITATION CENTER,35111,20625 NORTH LAKE PLEASANT ROAD,PEORIA,AZ,85382,2018-04-06,607,D,1,1,WTUO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, resident and staff interviews, and policies and procedures, the facility failed to ensure that their abuse policy was implemented regarding an allegation of abuse for one resident (#68). Findings include: -Resident #68 was admitted to the facility on (MONTH) 7, (YEAR) and readmitted on (MONTH) 9, (YEAR). [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment dated (MONTH) 16, (YEAR), documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had no cognitive impairment. A quarterly MDS assessment dated (MONTH) 19, (YEAR) included the resident had a BIMS score of 15, which indicated no cognitive impairment. During an interview conducted on (MONTH) 3, (YEAR) at 10:43 a.m., the resident stated that in (MONTH) (YEAR) the wound treatment team rolled her over in bed and in the process they slammed her head in to the siderail of her bed and the right side of her face hurt for days. She stated that although she informed the Administrator (staff #110) and the previous Director of Nursing (DON), she did not know if an investigation occurred. She further stated that even though she asked many times about the investigation, they never responded to her questions. Following this interview, the allegation of staff to resident abuse was reported to staff #110. He stated that he would immediately start an investigation and notify all mandated agencies. On (MONTH) 3, (YEAR) at approximately 2:30 p.m., a corporate registered nurse (staff #120) provided a packet of information and stated that this same staff to resident abuse allegation had been reported and investigated in (MONTH) (YEAR), during their annual survey. She further stated the facility was unable to substantiate the allegation of abuse. On (MONTH) 5, (YEAR) the packet of information provided by staff #120 was reviewed. The information was in regards to a staff to resident abuse allegation, however, it was a different allegation than the allegation of abuse that resident #68 stated had occurred in (MONTH) (YEAR). An interview was conducted with staff #120, the Director of Nursing (staff #111), staff #110 and a corporate registered nurse (staff #121) on (MONTH) 5, (YEAR) at 11:49 a.m. Staff were informed that the investigation they provided was in reference to a (MONTH) (YEAR) allegation of staff to resident abuse, and was not regarding the allegation that the resident stated occurred in (MONTH) (YEAR). Staff #110 stated because he thought it was the same allegation, an investigation regarding the (MONTH) (YEAR) allegation was not initiated, per their policy. An interview was conducted with staff #111 on (MONTH) 6, (YEAR) at 12:21 p.m. She stated that an allegation of staff to resident abuse needed to be reported right away to all required agencies and immediately investigated. She stated the abuse policy was not implemented for this resident. Review of a facility policy regarding Abuse revealed that all identified events are reported to the Administrator immediately. All allegations, inclusive of abuse and injuries of unknown origin, will be promptly and thoroughly investigated. At the conclusion of the investigation, the facility will determine if abuse or an injury of unknown origin occurred. The policy further included that allegations of abuse will be reported to the appropriate state and federal agencies in applicable timeframes, as per this policy and applicable regulations. The policy included to ensure that all alleged violations including injuries of unknown source are immediately reported to the State agency and Adult Protective Services, no later than two hours after the allegation is made.",2020-09-01
650,LAKE PLEASANT POST ACUTE REHABILITATION CENTER,35111,20625 NORTH LAKE PLEASANT ROAD,PEORIA,AZ,85382,2018-04-06,609,D,0,1,WTUO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, resident and staff interviews, and policy review, the facility failed to ensure that an allegation of staff to resident abuse for one resident (#68) were reported to the State agency and/or Adult Protective Services, within the required timeframe. Findings include: -Resident #68 was admitted to the facility on (MONTH) 7, (YEAR) and readmitted on (MONTH) 9, (YEAR). [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment dated (MONTH) 16, (YEAR), documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had no cognitive impairment. A quarterly MDS assessment dated (MONTH) 19, (YEAR) included the resident had a BIMS score of 15, which indicated no cognitive impairment. During an interview conducted on (MONTH) 3, (YEAR) at 10:43 a.m., the resident stated that in (MONTH) (YEAR), the wound treatment team rolled her over in bed and in the process they slammed her head in to the siderail of her bed and the right side of her face hurt for days. She stated that although she informed the Administrator (staff #110) and the previous Director of Nursing (DON), she did not know if an investigation occurred. She further stated that even though she asked many times about the investigation, they never responded to her questions. Following this interview, the allegation of staff to resident abuse was reported to staff #110. He stated that he would immediately start an investigation and notify the State agency and Adult Protective Services. On (MONTH) 3, (YEAR) at approximately 2:30 p.m., a corporate registered nurse (staff #120) provided a packet of information and stated that this same staff to resident abuse allegation had been reported and investigated in (MONTH) (YEAR), during their annual survey. She further stated the facility was unable to substantiate the allegation of abuse. On (MONTH) 5, (YEAR) the packet of information provided by staff #120 was reviewed. The information was in regards to a staff to resident abuse allegation, however, this was a different allegation than the allegation of abuse that resident #68 stated had occurred in (MONTH) (YEAR). An interview was conducted with staff #120, the Director of Nursing (staff #111), staff #110 and a corporate registered nurse (staff #121) on (MONTH) 5, (YEAR) at 11:49 a.m. Staff were informed that the investigation they provided was in reference to a (MONTH) (YEAR) allegation of staff to resident abuse, and was not regarding the allegation that the resident stated occurred in (MONTH) (YEAR). Staff #110 stated because he thought it was the same allegation, an investigation was not completed and the State agency and Adult Protective Services were not notified. An interview was conducted with staff #111 on (MONTH) 6, (YEAR) at 12:21 p.m. She stated that an allegation of staff to resident abuse needed to be reported right away to all required agencies. She stated the abuse policy was not implemented for this resident. According to the facility's policy regarding Abuse revealed that allegations of abuse will be reported to the appropriate state and federal agencies in applicable timeframes, as per this policy and applicable regulations. The policy included to ensure that all alleged violations are immediately reported to the State agency and Adult Protective Services, no later than two hours after the allegation is made.",2020-09-01
651,LAKE PLEASANT POST ACUTE REHABILITATION CENTER,35111,20625 NORTH LAKE PLEASANT ROAD,PEORIA,AZ,85382,2018-04-06,610,D,0,1,WTUO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, resident and staff interviews, and policy review, the facility failed to ensure that an allegation of abuse was investigated for one resident (#68). Findings include: -Resident #68 was admitted to the facility on (MONTH) 7, (YEAR) and readmitted on (MONTH) 9, (YEAR). [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment dated (MONTH) 16, (YEAR), documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had no cognitive impairment. A quarterly MDS assessment dated (MONTH) 19, (YEAR) included the resident had a BIMS score of 15, which indicated no cognitive impairment. During an interview conducted on (MONTH) 3, (YEAR) at 10:43 a.m. the resident stated that in (MONTH) (YEAR), the wound treatment team rolled her over in bed and in the process they slammed her head in to the siderail of her bed and the right side of her face hurt for days. She stated that although she informed the Administrator (staff #110) and the previous Director of Nursing (DON), she did not know if an investigation occurred. She further stated that even though she asked many times about the investigation, they never responded to her questions. Following this interview, the allegation of staff to resident abuse was reported to staff #110. He stated that he would immediately start an investigation and notify all mandated agencies. On (MONTH) 3, (YEAR) at approximately 2:30 p.m., a corporate registered nurse (staff #120) provided a packet of information and stated that this same staff to resident abuse allegation had been reported and investigated in (MONTH) (YEAR), during their annual survey. She further stated the facility was unable to substantiate the allegation of abuse. On (MONTH) 5, (YEAR) the packet of information provided by staff #120 was reviewed. The information was in regards to a staff to resident abuse allegation, however, this was a different allegation than the allegation of abuse that resident #68 stated had occurred in (MONTH) (YEAR). An interview was conducted with staff #120, the Director of Nursing (staff #111), staff #110 and a corporate registered nurse (staff #121) on (MONTH) 5, (YEAR) at 11:49 a.m. Staff were informed that the investigation they provided was in reference to a (MONTH) (YEAR) allegation of staff to resident abuse, and was not regarding the allegation that the resident stated occurred in (MONTH) (YEAR). Staff #110 stated because he thought it was the same allegation, an investigation regarding the (MONTH) (YEAR) allegation was not initiated, per their policy. An interview was conducted with staff #111 on (MONTH) 6, (YEAR) at 12:21 p.m. She stated that an allegation of staff to resident abuse needed to be immediately investigated. Review of a facility policy regarding Abuse revealed that all identified events are reported to the Administrator immediately. All allegations, inclusive of abuse, will be promptly and thoroughly investigated. At the conclusion of the investigation, the facility will determine if abuse or an injury of unknown origin occurred.",2020-09-01
652,LAKE PLEASANT POST ACUTE REHABILITATION CENTER,35111,20625 NORTH LAKE PLEASANT ROAD,PEORIA,AZ,85382,2018-04-06,657,D,0,1,WTUO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and policy review, the facility failed to ensure a care plan was revised for one resident (#31). Findings include: Resident #31 was admitted to the facility on (MONTH) 5, (YEAR), with [DIAGNOSES REDACTED]. An annual Minimum Data Set assessment dated (MONTH) 4, (YEAR) included the resident had severe cognitive impairment. Review of a current care plan revealed the resident was to be seated in a geri chair as tolerated, due to multiple contractures. However, the care plan had a resolved date of (MONTH) 19, (YEAR). Observations were conducted on (MONTH) 3, (YEAR) at 9:09 a.m., (MONTH) 4, (YEAR) at 2:04 p.m., and on (MONTH) 5, (YEAR) at 9:37 a.m., of the resident sitting in a high back wheelchair. Further review of the care plan revealed that it had not been revised to reflect that the resident now utilized a high back wheelchair. An interview was conducted with a Licensed Practical Nurse (staff #102) on (MONTH) 6, (YEAR) at 9:04 a.m. He stated that the resident is currently using a high back wheelchair and not a geri chair. An interview was conducted with a Certified Nursing Assistant (staff #37) on (MONTH) 6, (YEAR) at 9:07 a.m. She stated the resident previously was in a geri chair, but was now utilizing a high back wheelchair. An interview was conducted with a Registered Nurse (staff #95) on (MONTH) 6, (YEAR) at 10:54 a.m. She stated the charge nurse on the unit is responsible for making sure the care plan gets revised, so it reflects what the resident is currently using, such as a change from a geri chair to a high back wheelchair. An interview was conducted with the Director of Nursing (staff #111) on (MONTH) 6, (YEAR) at 12:00 p.m. She stated that resident care plans need to be revised when there are changes regarding what a resident needs and uses. She also stated the current plan does not include the use of the high back wheelchair. A facility policy regarding Care Planning included the following: It is the policy of this facility that the interdisciplinary team shall develop a comprehensive care plan for each resident. The resident's plan of care is reviewed and revised on an ongoing basis and as needed, with changes in condition.",2020-09-01
653,LAKE PLEASANT POST ACUTE REHABILITATION CENTER,35111,20625 NORTH LAKE PLEASANT ROAD,PEORIA,AZ,85382,2018-04-06,684,D,0,1,WTUO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record review, staff interviews, and policy review, the facility failed to ensure a physician's order was consistently implemented for one resident (#330). Findings include: Resident #330 was admitted on (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. Review of the intravenous (IV) antibiotic care plan dated (MONTH) 27, (YEAR) revealed the resident was receiving IV antibiotics related to a [DIAGNOSES REDACTED]. A nursing note dated (MONTH) 1, (YEAR) included the resident continued on IV antibiotic for osteo[DIAGNOSES REDACTED]. Review of the (MONTH) (YEAR) physician order recap revealed to change the central line tubing every 24 hours for intermittent infusion/flow. This order was transcribed onto the IV MAR (Medication Administration Record) for (MONTH) (YEAR). However, further review of the IV MAR revealed that there was no documentation that the IV tubing was changed on (MONTH) 4, 8, 10, 11, 15 and 18, (YEAR). The daily skilled notes for these dates included the resident was receiving IV antibiotic medication for osteo[DIAGNOSES REDACTED]. However, the notes did not include documentation that the IV tubing was changed on these dates. In an interview with a licensed practical nurse (LPN/staff #9) conducted on (MONTH) 6, (YEAR) at 9:43 a.m., she stated that if there is a physician's order to change IV tubing every 24 hours, then this is transcribed in the MAR and must be done as ordered. She stated that the MAR should be initialed to indicate that the tubing was changed. Further, she said that if the boxes in the MAR are blank, then there should be documentation in the clinical record as to why the order was not administered. During an interview with the Director of Nursing (DON/staff #111) conducted on (MONTH) 6, (YEAR) at 11:25 a.m., she stated that all orders including changing IV tubing must be administered as ordered by the physician. She said the orders must be documented as being done in the MAR. She said that if the MAR is not marked, it can either mean that the order was administered but the nurse forgot to sign it off, or the order was not administered. She stated that she noticed this was a problem when she first became the DON of the facility. Review of the policy on Physician Orders revealed that the facility accurately implements orders in addition to medication orders (treatment, procedures) only upon the written order of a person duly licensed and authorized to do so in accordance with the resident's plan of care.",2020-09-01
654,LAKE PLEASANT POST ACUTE REHABILITATION CENTER,35111,20625 NORTH LAKE PLEASANT ROAD,PEORIA,AZ,85382,2018-04-06,761,D,0,1,WTUO11,"Based on observation, staff interviews, review of the manufacturer instructions and policy and procedures, the facility failed to ensure that one medication in a medication cart was labeled, with an open date. Findings include: An observation of the 400 hall medication cart was conducted with a Licensed Practical Nurse (staff #86) on (MONTH) 5, (YEAR) at 1:01 p.m. Inside of the medication cart was one 10 milliliter (ml) vial of Humalog insulin, with no date of when it was opened. An interview was conducted on (MONTH) 5, (YEAR) at 2:58 p.m. with staff #86, who stated that the insulin should have been dated when it was opened. She said that she would throw away any vial of insulin that did not have an open date on it. An interview was conducted on (MONTH) 5, (YEAR) at 3:12 p.m., with the Director of Nursing (staff #111). She stated that it is their policy as recommended by the manufacturer's instructions to date all insulin vials after opening them. She said they have 28 days to use the vial of insulin after opening it. Staff #111 stated that they would dispose of any insulin vials which did not have an open date on them. According to the Humalog insulin manufacturer's instructions, insulin can be used up to 28 days after opening. The facility's policy regarding Medication Access and Storage included that any opened vial without an open date will be discarded immediately, and replaced with a new vial. Any medication that cannot be verified as to the expiration date, either due to not being dated when opened or unclear shelf life, shall be discarded immediately and replaced.",2020-09-01
655,LAKE PLEASANT POST ACUTE REHABILITATION CENTER,35111,20625 NORTH LAKE PLEASANT ROAD,PEORIA,AZ,85382,2018-04-06,880,J,0,1,WTUO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, facility documentation, review of the Center for Disease Control (CDC) guidelines and policies and procedures, the facility failed to maintain an effective infection control program, by failing to ensure that contact precautions were followed for one resident (#376) with active [MEDICAL CONDITIONS]. As a result, the Condition of Immediate Jeopardy (IJ) was identified. Findings include: On (MONTH) 3, (YEAR) at 11:11 a.m., the Condition of Immediate Jeopardy (IJ) was identified. The Administrator was informed of the facility's failure to implement infection control procedures for one resident (#376), who was on contact precautions for [MEDICAL CONDITION]. A visitor was observed in the resident's room sitting in a chair and was not wearing a gown or gloves. The visitor was also observed leaving the resident's room carrying a briefcase into the hallway. The Administrator presented a plan of correction on (MONTH) 3, (YEAR) at 12:50 p.m. At 1:27 p.m. the Administrator was informed that the plan of correction needed to address additional areas. A revised plan of correction was presented on (MONTH) 3, (YEAR) at 1:52 p.m. The Administrator was informed that the plan of correction needed to address how visitors would be monitored for compliance with isolation precautions between the hours of 6:00 p.m. to 6:00 a.m. A revised plan of correction was presented on (MONTH) 3, (YEAR) at 2:24 p.m. and was accepted. The plan of correction included the following: all staff were to be provided in-service education regarding visitor compliance with isolation policies and procedures; visitors will be educated regarding wearing protective equipment in the isolation room and hand washing, and as an interim measure staff will monitor visitors to ensure they comply with wearing a gown, gloves and handwashing procedures. Multiple observations were conducted on (MONTH) 3 and 4, (YEAR) of the facility implementing their plan of correction. Staff in-services were being completed and staff interviewed were knowledgeable of infection control procedures, including contact precautions for visitors and staff. In addition, there were no observations of staff or visitors entering the resident's room, without donning a gown and gloves. As the facility was implementing their plan of correction and there were no new concerns identified, the Condition of Immediate Jeopardy was abated on (MONTH) 4, (YEAR) at 11:48 a.m. Resident #376 was admitted on (MONTH) 18, (YEAR), with [DIAGNOSES REDACTED]. A physician's progress note dated (MONTH) 19, (YEAR), included the resident was admitted from the hospital with an infected pressure ulcer of the sacrum, and had been transferred to the facility for continued wound care and IV antibiotics. A bowel movement (BM) report dated (MONTH) 20, (YEAR), included that the resident had an episode of loose/diarrhea stool. A change of condition note dated (MONTH) 20, (YEAR) at 3:50 p.m. included the resident had diarrhea which started on (MONTH) 19, and the physician was notified, and stool softeners were held. A change of condition note dated (MONTH) 21, (YEAR) at 9:45 a.m., revealed the diarrhea had stopped since holding the laxatives. Review of the BM reports revealed the resident had episodes of loose/diarrhea stools on (MONTH) 22, 24, 25, 27, 28 and 29, (YEAR). Review of a dietary note dated (MONTH) 29, (YEAR), revealed the resident had a history of [REDACTED]. A BM report dated (MONTH) 30, (YEAR) included the resident had two episodes of loose/diarrhea stools. A physician's orders [REDACTED]. Per the clinical record, a stool specimen was obtained on (MONTH) 30, (YEAR) and the laboratory test results dated (MONTH) 30, confirmed that the resident was positive for [MEDICAL CONDITION] toxin. A physician's orders [REDACTED]. A care plan initiated on (MONTH) 31, (YEAR) included the resident had [MEDICAL CONDITION] related to IV antibiotic therapy. A goal was for the resident to not have symptoms of dehydration related to [MEDICAL CONDITION]. Interventions included for contact isolation, educate the resident, family and staff regarding preventive measures to contain the infection, and to monitor the resident's family who visits to assure compliance with isolation precautions. The care plan also included that the resident's family member had been educated, but was forgetful. A physician's progress note dated (MONTH) 31, (YEAR) revealed documentation that the resident had reported having diarrhea one week prior to admission to the facility. Also, that a (stool) culture was positive for [MEDICAL CONDITION] and the resident was prescribed [MEDICATION NAME]. A BM report dated (MONTH) 31, (YEAR) included the resident had two episodes of loose/diarrhea stools. A BM report dated (MONTH) 1, (YEAR) included the resident had three episodes of loose/diarrhea stools. A daily skilled note dated (MONTH) 1, (YEAR) at 11:44 p.m. included the resident was on isolation for an infectious disease. The note stated that the resident had [MEDICAL CONDITION] and was on contact precautions. A BM report dated (MONTH) 2, (YEAR) included the resident had three episodes of loose/diarrhea stools. An observation was conducted on (MONTH) 3, (YEAR) at 9:25 a.m., outside of the resident's room. An orange sign was posted on the door frame which read, Stop check with nurse before entering. A small cart was located under the sign next to the door, which contained Personal Protective Equipment (PPE-disposable gowns, gloves, and shoe covers). At this time, the door to the room was open and a visitor was observed in the room and the visitor was not wearing a gown or gloves. The visitor then closed the door and remained in the room. An observation was conducted on (MONTH) 3, (YEAR) at 9:35 a.m., of a Licensed Nursing Assistant (staff #17), who donned a gown, gloves and shoe covers and entered the resident's room. When staff #17 exited the room at 9:38 a.m., the visitor was observed in the resident's room, sitting in a chair next to the resident's bed. The visitor was not wearing a gown or gloves. An interview was conducted on (MONTH) 3, (YEAR) at 9:40 a.m., with the Assistant Director of Nursing (ADON/staff #7). At this time, the ADON was in the hallway near the resident's room and was passing medications. Staff #7 stated that the resident's visitor was a family member, who had been educated on isolation precautions and wearing protective equipment due to the resident having [MEDICAL CONDITION]. Staff #7 stated that although the visitor had been educated regarding wearing a gown and gloves, the visitor refused to wear the protective items. Staff #7 further stated that the resident had multiple loose stools the day before and was considered to have an active [MEDICAL CONDITION] infection. An observation was conducted on (MONTH) 3, (YEAR) at 10:20 a.m., of the visitor exiting the room of resident #376. The visitor was carrying a briefcase out of the room and then stopped and spoke with the Administrator (#110) and two other administrative staff members. An interview was conducted on (MONTH) 3, (YEAR), at 11:11 a.m. with the Administrator (#110). The Administrator stated that the family member who visits the resident puts protective equipment on prior to entering the room, but removes it after entering the resident's room. Continued review of the clinical record revealed that the care plan for [MEDICAL CONDITION] had been revised on (MONTH) 3, (YEAR), to include an intervention that the (family member) of the resident must be banned from visiting immediately, if non-compliant. An interview was conducted on (MONTH) 4, (YEAR) at 8:31 a.m., with a Licensed Practical Nurse (LPN/staff #8). Staff #8 stated that before a visitor enters an isolation room, she would educate them on the protocol for PPE. She stated that visitors are required to wear PPE each time they enter an isolation room. Staff #8 stated that if a visitor refuses to wear PPE, she would contact the Director of Nursing to speak with the visitor, and if the visitor continued to refuse to wear PPE, the visitor would probably be refused entry into the isolation room. Staff #8 further stated that if a visitor brings personal property into the facility, they must leave it outside the isolation room. An interview was conducted on (MONTH) 4, (YEAR) at 8:45 a.m., with a Certified Nursing Assistant (CNA/staff #37). Staff #37 stated that if a visitor approached an isolation room and was not wearing PPE, she would stop the visitor and instruct them regarding the requirement for PPE. She said if the visitor was resistant to wearing PPE, she would tell the visitor that they cannot enter the room without wearing it, and notify the supervisor. She said if a visitor was found inside an isolation room without wearing PPE, she would instruct the visitor to exit the room and she would notify the supervisor. Review of a sample admission packet revealed it contained a policy titled, Visitation Policy Isolation and Prevention, which included that Visitors must observe the facilities policies for isolation practices and barrier precautions. If visitors are not observing isolation practices and barrier precautions, the facility reserves the right to restrict visitation. Review of a policy and procedure titled, Isolation and Prevention revealed that it is the policy of this facility to prevent transmission of infection to residents and visitors. The policy included that Visitors will observe the facility's policies for isolation practices and barrier precautions. In the event that a visitor fails to comply with the facility's isolation protocols, the right to visit will be denied. An infection control policy titled, Contact Precautions for [MEDICAL CONDITION] Infection included that all visitors must comply with isolation precautions, i.e. donning and doffing gowns and gloves, and with handwashing requirements. Visitors will be called and notified when the resident is placed on isolation precautions, and a time will be set up to be in-serviced on isolation precautions. The policy included that visitors will be informed that non-compliance with facility's isolation and handwashing procedures will result in visitation being denied. Review of the CDC guidelines revealed that [MEDICAL CONDITION] is a spore forming bacterium that causes inflammation of the colon known as [MEDICAL CONDITION]. [MEDICAL CONDITION] spores are shed in feces and transferred to patients mainly via the hands of people who have touched a contaminated surface or item. For prevention of transmission of [MEDICAL CONDITION] in healthcare settings, use contact precautions for patients with known or suspected [MEDICAL CONDITION]. The guidelines included to use gloves and gowns when entering patient rooms and during care and for all interactions that may involve contact with patient or potentially contaminated areas in the patients environment. The policy also stated that before exiting the patient room, discard gowns and gloves, and wash hands to contain the [MEDICAL CONDITION] pathogens.",2020-09-01
656,LAKE PLEASANT POST ACUTE REHABILITATION CENTER,35111,20625 NORTH LAKE PLEASANT ROAD,PEORIA,AZ,85382,2019-06-13,641,B,0,1,ZMVX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, policy review, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure a Minimum Data Set (MDS) assessment accurately reflected the discharge status of one of 3 sampled residents (#80). The deficient practice has the potential to affect continuity of care. Findings include: Resident #80 was admitted to the facility on (MONTH) 27, 2019 with [DIAGNOSES REDACTED]. The discharge care plan revealed that the resident's discharge goal was to return to the community. Review of the physician's orders [REDACTED]. A discharge summary progress note dated (MONTH) 19, 2019 revealed resident #80's health had improved sufficiently and the resident no longer needed the services of the facility. The note stated the post discharge plan of care was the resident was being discharged to the community. Review of the clinical record revealed the resident discharged from the facility to the community on (MONTH) 21, 2019. However, review of the resident's discharge MDS assessment dated (MONTH) 21, 2019, revealed the resident was coded as having been discharged to an acute hospital. An interview was conducted on (MONTH) 13, 2019 at 8:58 a.m. with the MDS coordinator (staff #118). She stated that it was an accuracy issue and the MDS was not coded correctly. She said she strives to be accurate all the time, and was still in the window to modify the information. An interview was conducted on (MONTH) 13, 2019 at 9:04 a.m. with the Director of Nursing (DON/staff #115). She noted the error and stated they would fix it right away. The facility policy titled Resident Assessment (MDS 3.0) stated it is the policy of the facility to ensure that the assessment accurately reflects the resident's status. The RAI manual for the MDS included that the importance of accurately completing and submitting the MDS cannot be over-emphasized. Further, Federal regulations require that the assessment accurately reflects the resident's status. When coding for discharge location, the RAI manual instructs to review the medical record including the discharge plan and discharge orders for documentation of discharge location.",2020-09-01
657,LAKE PLEASANT POST ACUTE REHABILITATION CENTER,35111,20625 NORTH LAKE PLEASANT ROAD,PEORIA,AZ,85382,2019-06-13,684,D,0,1,ZMVX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff and resident interviews, observations, and policy review, the facility failed to ensure that physician's orders for a wheelchair cushion were implemented for one of 18 sampled residents (#47). The deficient practice has the potential to cause the resident unnecessary discomfort and potential skin breakdown. Findings include: Resident #47 was admitted on (MONTH) 18, 2019 with [DIAGNOSES REDACTED]. On (MONTH) 19, 2019, two physician's orders were noted: One was for a wheelchair cushion and the other for monitoring the wheelchair cushion every shift. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 1, 2019 revealed that the resident was coded as being at risk for pressure ulcers. The resident's pressure ulcer care plan noted that the resident was at risk for skin breakdown related to impaired mobility. Risk factors included [MEDICAL CONDITIONS], and fragile skin. One of the interventions included utilizing a wheelchair cushion. Review of the Treatment Administration Record (TAR) for (MONTH) 1 through 10, 2019 revealed that the resident was coded as having had the wheelchair cushion on her wheelchair during all shifts except on the day shift on (MONTH) 3 and (MONTH) 7. For these dates, the MAR indicated [REDACTED]. The nursing notes were reviewed from (MONTH) 1 through 10, 2019. There was no indication as to what happened with the wheelchair cushion on (MONTH) 3 or (MONTH) 7. There was no further documentation concerning the wheelchair cushion in the nursing notes. On (MONTH) 10, 2019 at 11:12 a.m., an interview was conducted with resident #47. She stated her bottom hurt really, really bad from sitting in her wheelchair. She said she thought a wheelchair cushion would help a lot. An observation of the resident was conducted on (MONTH) 10, 2019 at 1:02 p.m The resident was in her wheelchair with no wheelchair cushion present. On (MONTH) 11, 2019, the resident was observed at 9:00 a.m., 10:59 a.m., 12:51 p.m., and 3:24 p.m. in her wheelchair with no wheelchair cushion present. The TAR was reviewed for (MONTH) 11, 2019 and it indicated that the wheelchair cushion was in place during the day shift. On (MONTH) 11, 2019 at 1:30 p.m., an interview was conducted with a Certified Nursing Assistant (CNA/staff #33). She stated the resident does have a wheelchair cushion, but that sometimes she puts it away in her closet and then forgets it is there. Staff #33 said she helps the resident find her things sometimes, and that she usually finds them in the resident's closet. However, she stated she hasn't seen the resident's wheelchair cushion for a while. On (MONTH) 11, 2019 at 3:16 p.m., an interview was conducted with a Registered Nurse (RN/staff #28). She stated that monitoring of the resident's wheelchair cushion pops up on the MAR (Medication Administration Record) on a twice daily basis and that it's the nurses' responsibility to ensure/document that the cushion is there. She said if it's not in the resident's chair, staff look for it in the resident's room. If the cushion still can't be found, there are extra cushions in the back of the therapy room and staff can get her another one since it's not a specialty item. An interview was conducted on (MONTH) 12, 2019 at 8:36 a.m. with the Physical Therapy Assistant (PTA/staff #94). She stated there are extra wheelchair cushions in the therapy room and in central supply. She said that if a resident's cushion is misplaced, staff can come and get another one as they have extra. She said that since this resident does not require a specialty cushion, a new one can be obtained at any time if hers is misplaced. On (MONTH) 12, 2019 at 8:54 a.m., an interview was conducted with the Director of Nursing (DON/staff #115). She stated her expectation is for nursing to follow the physician's orders. The facility policy titled Physician's Orders stated it is the policy of the facility to accurately implement orders in accordance with the resident's plan of care. The policy further noted that medication, treatment or related procedure orders are transcribed in the TAR accordingly.",2020-09-01
658,LAKE PLEASANT POST ACUTE REHABILITATION CENTER,35111,20625 NORTH LAKE PLEASANT ROAD,PEORIA,AZ,85382,2019-06-13,757,E,1,1,ZMVX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews, and policy review, the facility failed to ensure 2 of 6 sampled residents (#23 and #179) were free from unnecessary drugs, by failing to administer drugs according to the physician ordered parameters. The deficient practice could result in low blood pressures and residents receiving drugs which may not be necessary. Findings include: -Resident #23 was admitted on (MONTH) 2, 2019 with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The resident's hypertension care plan, dated (MONTH) 3, 2019, noted that the resident had [MEDICAL CONDITION]. The goal for the care plan was that the resident was to be free from signs or symptoms of complications of cardiac problems. Interventions included to give medications for hypertension and document the response to medication. The admission Minimum Data Set (MDS) assessment dated (MONTH) 12, 2019 included that the resident had a Brief Interview for Mental Status (BIMS) score of 12, which indicated mild cognitive impairment. Review of the Medication Administration Record (MAR) for (MONTH) 3, 2019 through (MONTH) 16, 2019 revealed the resident received the carvedilol when his SBP was below physician ordered parameters on nine occasions: -April 3 for a SBP of 105 mmHg -April 4 for a SBP of 91 mmHg -April 6 for a SBP of 91 mmHg -Twice on (MONTH) 7 both SBPs of 107 mmHg -April 9 for a SBP of 92 mmHg -April 10 for a SBP of 99 mmHg -April 11 for a SBP of 85 mmHg -April 14 for a SBP of 93 mmHg Review of the nursing notes for (MONTH) 3, (YEAR) through (MONTH) 16, 2019 revealed no documentation to show the medication had been held when the SBP was below the physician ordered parameters. On (MONTH) 16, 2019, the physician's orders [REDACTED]. Review of the MAR for (MONTH) 16, 2019 through (MONTH) 31, 2019 revealed the resident received the carvedilol when his SBP was below the physician ordered parameters on two occasions: -April 27 for a SBP of 90 mmHg -May 8 for a SBP of 92 mmHg Review of the nursing notes for (MONTH) 16, 2019 through (MONTH) 31, 2019 revealed no documentation to show the medication had been held when the SBP was below the physician ordered parameters. An interview was conducted on (MONTH) 12, 2019 at 2:13 p.m. with a Licensed Practical Nurse (LPN/staff #72). She stated that before she administers a blood pressure medication, she makes sure the resident's BP is within the ordered parameters and if it's too low, she holds the medication. An interview was conducted on (MONTH) 13, 2019 at 9:06 a.m. with the Director of Nursing (DON/staff 115). She stated it was rare to have parameters on a medication, but she expects the nurses to follow them. She agreed that the resident had received a blood pressure medication outside of the physician ordered parameters. -Resident #179 was admitted on (MONTH) 30, (YEAR) with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated (MONTH) 6, (YEAR) included that resident #179 had a BIMS (Brief Interview for Mental Status) score of 15, which indicated she was cognitively intact. An Initial Admission Record dated (MONTH) 30, (YEAR) included that the resident had [MEDICAL CONDITION]. A physician's progress note dated (MONTH) 6, (YEAR) included that the resident had gained 7 pounds (lbs) and the resident felt that she was swollen. The note included that the resident had mild/moderate bilateral lower extremity [MEDICAL CONDITION], and [MEDICATION NAME] (a diuretic medication) was to be started. A physician's orders [REDACTED]. A written care plan dated (MONTH) 6, (YEAR) included that the resident was on diuretic therapy related to [MEDICAL CONDITION]. Interventions documented in the care plan included to administer medication as ordered, and (MONTH) cause dizziness, postural [MEDICAL CONDITION], fatigue, and an increased risk for falls. Review of the Medication Administration Record (MAR) for (MONTH) (YEAR) revealed the [MEDICATION NAME] was given outside of the physician's orders [REDACTED]. -November 8, (YEAR) for SBP of 86 mmHg -November 12, (YEAR) for SBP of 87 mmHg Continued review of the clinical record did not reveal any additional documentation that [MEDICATION NAME] had been held on (MONTH) 8, and 12, (YEAR). An interview was conducted on (MONTH) 11, 2019 at 12:53 p.m. with a LPN (Licensed Practical Nurse/staff #20). The nurse stated that when blood pressure parameters are ordered for the use of a medication (including [MEDICATION NAME]) the nurse checks the resident's blood pressure prior to administering the medication and if the blood pressure is too low, the medication is not given and the physician is notified. An interview was conducted on (MONTH) 12, 2019 at 10:35 a.m. with the Director of Nursing (DON/staff #115). The Director stated that when a nurse is providing a medication with a physician's orders [REDACTED]. The Director stated that the nurse should not have given the [MEDICATION NAME] 20 mg to resident #179 on (MONTH) 8, and 12, (YEAR). A policy and procedure titled Administration of Medication included a statement that medications shall be administered as prescribed by the attending physician and medications must be administered in accordance with the written orders of the attending physician including following parameter orders for blood pressure.",2020-09-01
659,APACHE JUNCTION HLTH CENTER,35112,2012 WEST SOUTHERN AVE,APACHE JUNCTION,AZ,85120,2020-01-16,582,D,0,1,CSRN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and the Form Instructions for the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN), the facility failed to ensure one resident (#56) received the SNFABN when his skilled services ended. The deficient practice could result in residents not being informed of their potential liability for payment. Findings include: Resident #56 was admitted on [DATE] with a [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident scored a 14 on the Brief Interview for Mental Status (BI[CONDITION]) indicating that he was cognitively intact. Review of the clinical record revealed that the resident's stay was being billed to Medicare and that he was receiving skilled therapy to increase his strength. The facility determined that the resident's stay would not longer be billable to Medicare after 1/3/19 as he was to be discharged from skilled therapy. The resident remained in the facility after 1/3/19. There was no documentation that the resident was informed of the liability change or that a SNFABN had been completed. During an interview with the resident on 1/16/20 at 10:00 a.m., he stated he didn't remember getting a form telling him how much services would cost when the funding source changed. In an interview with the interim administrator (staff #158) on 1/16/20 at 11:00 a.m., she stated resident #56 was not given a SNFABN and should have been informed of facility service costs when being discharged from skilled services and remaining in the facility. She further stated that the facility does not have a specific policy for the SNFABN. Review of the form instruction for the SNFABN revealed that Medicare requires skilled nursing facilities to issue the SNFABN to Medicare beneficiaries prior to providing care that Medicare usually covers but may not pay for when the care is not medically necessary. The SNFABN provides information to the beneficiary so that he can decide whether or not to get the care that may not be paid for by Medicare and assume financially responsibility.",2020-09-01
660,APACHE JUNCTION HLTH CENTER,35112,2012 WEST SOUTHERN AVE,APACHE JUNCTION,AZ,85120,2020-01-16,689,D,1,1,CSRN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interview, facility documentation and policy review, the facility failed to ensure that fall safety interventions were consistently documented and implemented for one of three sampled residents (#258), who was identified to be at high risk for falls. The deficient practice resulted in a lack of interventions to prevent falls and the resident sustained [REDACTED]. Findings include: Resident #258 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the admission nursing note dated August 22, 2019 at 2:30 p.m. revealed the resident had arrived from the hospital with left hip pain related to a fall at home. Per the note, the resident was oriented to person only. Review of a fall risk assessment dated [DATE] revealed the resident had intermittent confusion, had 1-2 falls in the past 3 months and had decreased muscular coordination. Per the fall risk assessment, the resident was a high fall risk. A care plan initiated on August 22, 2019 included the resident had decreased abilities with activities of daily living (ADL) related to [MEDICAL CONDITION], anxiety and a previous ground level fall. The goal was that the resident would have participation in performance of ADL's to the greatest potential. Interventions included to encourage the resident to be out of bed as tolerated, encourage independence, allow time for task performance before offering assistance, assist of one person for toileting and a grab bar for bed mobility, repositioning and transfers. A nursing note dated August 23, 2019 included the resident was very confused and unable to follow directions. The resident had refused to go to bed or sleep, had been sitting in her wheelchair the entire night shift, and had required 1:1 supervision, as she would attempt to stand and ambulate every minute. Per the note, the resident was unsteady, was unable to be redirected and displayed moods ranging from tearful to pleasantly confused within minutes. The note included that the next shift was made aware of the resident's behavior and fall risk. Further review of the clinical record revealed there was no documentation of the rationale for discontinuing the 1:1 supervision or when it was discontinued, nor was there documentation of any additional safety interventions which were implemented to prevent falls after discontinuing the 1:1 supervision, despite the resident being at high risk for falls. A nursing note dated August 24, 2019 at 1:20 a.m., included that a loud noise was heard and the resident was found in her room on the floor, near the right side of her bed. The note included that the resident was asked what happened and replied I got up to get a glass of water, but I fell . Per the note, the resident was alert and oriented x 3; however; it also included that the resident was able to answer simple questions, but thought she was at home. The note further included the resident was sent out to the hospital for complaints of severe pain to the left hip. The note did not include a description of any fall interventions which were in place, prior to the fall. Another nursing note dated August 24 2019, included the resident was admitted to the hospital for a left femoral neck fracture. Review of an interdisciplinary fall note dated August 29, 2019, which was five days after the fall incident revealed that on the first night in the facility, the resident had been agitated/restless and needed close supervision from staff. The fall note included that per staff interviews, the resident had been calm and cooperative on the evening prior to the fall, and the resident had been educated to use the call light and wait for assistance. The note included that around 9:00 p.m., the nurse had administered medication to the resident while she was watching television, and around 10:30 p.m. the resident was in bed sleeping, with the bed in a low position at about knee level. At midnight the resident was observed to be sleeping, while the nurse aide changed the resident's pitcher of ice water and placed it on the bedside table. The bedside table, water pitcher and call light were all noted to be within the resident's reach. The note included that the floor was free of clutter with adequate lighting, and at the time of the fall the resident was wearing non-skid socks. The facility's fall investigation report was requested on January 14, 2020 at 11:00 a.m., however the fall investigation report was not provided. An interview was conducted with the Director of Nursing (DON/staff #98) on January 15, 2020 at 12:00 p.m. She said that some factors, such as a fall at home or a [DIAGNOSES REDACTED]. She said typical interventions for new resident's who are at risk for falls would include a low bed position, a fall mat and instructions/re-education to use the call light. She said a baseline care plan would be initiated for residents on admission, and additional care areas and interventions would be added to the baseline care plan until the comprehensive care plans were created. She stated that if a resident had a fall, either she or the charge nurse would conduct an investigation. She said the fall review progress note contained the details of the fall investigation, however the actual fall investigation report was an internal document and would not be provided. She said that her understanding of the situation for this resident was that on the first night the resident was adjusting to the facility, but by the next afternoon the resident was calm. She said the resident went to bed early and did not need one on one supervision. She said the reason there was not specific documentation of supervision or interventions on the night the resident fell was because the resident had been so calm. During a follow-up interview on January 15, 2020 at 1:16 p.m., staff #98 stated the resident did not have a care plan for fall risk. Review of the Fall Prevention policy revealed that a fall prevention program will be maintained that provides ongoing assessment of each resident's risk potential for falls. The goal of a fall prevention program is to identify and eliminate or modify risk factors and thereby, reduce the likelihood of an accident occurring or re-occurring. Per the policy, a fall risk assessment would be completed within 24 hours following admission, and an interim care plan would be instituted for residents determined to be at risk for falls.",2020-09-01
661,APACHE JUNCTION HLTH CENTER,35112,2012 WEST SOUTHERN AVE,APACHE JUNCTION,AZ,85120,2020-01-16,695,D,0,1,CSRN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, staff interviews and policy and procedure, the facility failed to ensure that a physician's order was obtained for one of two sampled residents (#[AGE]) who was receiving oxygen. The deficient practice could result in adverse clinical outcomes. Findings include: Resident #[AGE] was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the admission physician's orders revealed no evidence of an order for [REDACTED].>A physician's progress note dated December 20, 2019, included that the resident had a history of [REDACTED]. The note included that upon examination, the resident was receiving oxygen at 2 LPM. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BI[CONDITION]) score of 15, which indicated that the resident was cognitively intact. The assessment included that the resident had received oxygen, but not while he was a resident at the facility. The baseline careplan did not include that the resident was receiving oxygen. Review of a skilled nursing note dated January 6, 2020, revealed the resident had an oxygen saturation of 91% while breathing room air. However, the note also included that the resident had received oxygen while in the facility. A care plan initiated January 8, 2020, included for the potential for difficulty breathing related to chronic conditions of [MEDICAL CONDITION], valley fever, cardiac status, and [MEDICAL CONDITION]. The goal included to minimize risks for respiratory distress, with interventions to administer and monitor the effectiveness of drugs affecting respiratory status, remind the resident to breathe slowly and deeply when short of breath, and report changes in respiratory status to the physician. Review of the physician's orders for January 2020, revealed no evidence of an order for [REDACTED].>An observation of the resident was conducted on January 13, 2020 at 10:26 a.m. The resident was receiving oxygen at 3 LPM via nasal cannula. During an observation of the resident on January 15, 2020 at 3:00 p.m., the resident was seated in his bed in his room. He was receiving oxygen at 3 LPM via nasal cannula. An observation was conducted on January 16, 2020 at 9:51 a.m. The resident was receiving oxygen at 3 LPM via nasal cannula. An interview was conducted on January 16, 2020 at 10:49 a.m. with a Licensed Practical Nurse (LPN/staff #110). She stated that in order for a resident to receive oxygen, there should be a physician's order and a care plan created. She said a resident could receive oxygen without an order if the situation was emergent, however the physician would be notified and an order would be obtained as soon as possible. She said residents receiving oxygen would also have documentation in the clinical record every shift of the oxygen rate, method of delivery, and saturation levels. She said she did not know why this resident did not have an order for [REDACTED].>An interview was conducted on January 16, 2020 with the Director of Nursing (DON/staff #98). She stated her expectation is that oxygen would be administered with a physician's order. She said in an emergency the nurse could administer oxygen and then notify the physician as soon as possible. Review of the facility's policy for oxygen administration revealed that the purpose of administering oxygen is to improve tissue oxygenation for the treatment of [REDACTED]. Oxygen would only be administered by physician's order, except in an emergency. The policy included that in an emergency situation, oxygen could be administered without a physician's order, but the order must be obtained immediately after the crisis was under control.",2020-09-01
662,APACHE JUNCTION HLTH CENTER,35112,2012 WEST SOUTHERN AVE,APACHE JUNCTION,AZ,85120,2018-11-16,607,D,1,1,DIHF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interviews, review of clinical records, facility records, and review of policies and procedures, the facility failed to implement their abuse policy by failing to ensure that an allegation of abuse involving two residents (#141 and #22) was reported in a timely manner to the State Survey Agency, by failing to thoroughly investigate the allegation of abuse that involved the two residents, and by failing to prevent further potential abuse while the investigation was in progress for one resident (#76). Findings include: -Resident #141 was admitted on (MONTH) 24, (YEAR), with [DIAGNOSES REDACTED]. An admission MDS (Minimum Data Set) assessment dated (MONTH) 1, (YEAR) included a BIMS (Brief Interview for Mental Status) score of 4, which indicated the resident had severely impaired cognition. The assessment also included the resident was delusional, had verbal and physical behavioral symptoms directed at others, and that the resident's behavioral symptoms put the resident and others at significant risk for physical injury. The assessment further included that resident #141 used a wheelchair and had wandering behaviors which significantly intruded on the activity of others. A nurse's note dated (MONTH) 4, (YEAR) revealed that on (MONTH) 1, (YEAR) at 10:15 p.m. a CNA (Certified Nursing Assistant) informed the nurse that after dinner resident #141 ran his wheelchair into the wheelchair of resident #22, and then struck resident #22 on her left upper arm. The note also included that resident #141 had no safety awareness, wandered in the hallway, and was redirected multiple times by staff. -Resident #22 was admitted on (MONTH) 12, 2012, with [DIAGNOSES REDACTED]. A quarterly MDS assessment dated (MONTH) 21, (YEAR) revealed a BIMS score of 15 which indicated the resident was cognitively intact. The assessment also revealed the resident used a wheelchair. Review of the facility's investigation record dated (MONTH) 6, (YEAR) revealed that on (MONTH) 1, (YEAR) at 5:30 p.m. a CNA observed resident #22 propelling down the hallway in her wheelchair when she was bumped by the wheelchair of resident #141. Resident #22 told resident #141 not to do that again. Resident #141 then struck resident #22 on the upper left arm. Further review of the investigative report revealed that although the incident occurred on (MONTH) 1, (YEAR) at 5:30 p.m., it was not reported to the State Survey Agency until (MONTH) 4, (YEAR) at 4:20 p.m. Additional review of the investigative record did not reveal documented evidence that any additional staff, residents, or possible witness interviews had been conducted. An interview was conducted on (MONTH) 15, (YEAR) at 11:28 a.m. with the Administrator (staff #108). The Administrator stated that when there is an allegation of abuse, the staff will notify him or the Director of Nursing immediately. He stated that staff are aware that they have two hours to phone in allegations to the State Survey Agency. The Administrator stated that when they conduct an investigation, they interview all the residents involved, any residents who may have been in the area, and any additional staff who may have been in the area. He further stated that the interviews are documented. Review of the facility's policy titled Abuse Prevention Policy and Procedure included that the facility will ensure that all alleged violations that involve mistreatment and abuse are reported immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse. The policy also included that the investigation may include interviews of employees, visitors, and/or residents who may have knowledge of the alleged incident. -Resident #76 was admitted [DATE], discharged to the hospital on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the 14-day MDS assessment dated [DATE], revealed a BIMS score of 12 which indicated the resident had moderate cognitive impairment. During an interview conducted with resident #76 on 11/13/18 at 10:26 AM, the resident stated that about a month ago before being admitted to the hospital, she did not want to take a pill. She stated the Registered Nurse (RN/staff #143) stuffed the pill in her mouth and put his fingers in her mouth. Resident #76 stated that she reported the incident to the social worker or director of nursing and that she was interviewed by staff. No self-report was made to the State Agency regarding the allegation of abuse. The Administrator/Abuse Prohibition Officer (staff #108) was notified of the incident on 11/13/18 at approximately 11:20 AM. A review of payroll time punches for staff member #143 revealed staff #143 punched in to work at 6:13 AM on 11/13/18 and punched out at 2:39 PM. In a follow-up interview conducted with resident #76 on 11/15/18 at 11:12 AM, resident #76 stated that staff #143 took his middle, index, and ring fingers and shoved the pills in her mouth. Resident #76 stated that another nurse (Licensed Practical Nurse/staff #134) was present and that the two nurses kept saying she had to take the pill the doctor ordered. She told the nurses that she did not want to take the pill. She stated that she reported the incident to the Social Worker (staff #24) the next day. During an interview conducted on 11/15/18 at 12:19 PM with staff #143, he stated that a resident has the right to refuse to take medications and that he has never forced anybody to take a medication. He stated that this alleged allegation of abuse was brought to his attention on 11/13/18 after he had finished his shift. Staff #143 stated that he was placed on suspension after he had signed his statement. An interview was conducted on 11/15/18 at 01:58 PM with the Administrator (staff #108), who stated that if someone observes any type of abuse, the expectation is for them to safely intervene or immediately call for help, stop the abuse, and make sure the residents are safe. Staff #108 stated that if the allegation involves a staff member, a statement is obtained and the staff member is placed on suspension within the hour. In an interview conducted on 11/15/18 at 02:25 PM with the Director of Social Work (staff #24), staff #24 stated that when she is made aware of an allegation of abuse she initiates an investigation right away and the staff member's supervisor places the staff member on suspension. A review of the facility's policy titled Abuse Prevention Policy and procedure included If the suspected perpetrator is an employee: the Administrator/Designee places the employee on immediate investigatory suspension while completing the investigation.",2020-09-01
663,APACHE JUNCTION HLTH CENTER,35112,2012 WEST SOUTHERN AVE,APACHE JUNCTION,AZ,85120,2018-11-16,609,D,1,1,DIHF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interviews, review of clinical records, facility records, policies and procedures, and the State Survey Agency data base, the facility failed to ensure that an allegation of abuse that involved two residents (#141 and #22) was reported within 2 hours to the State Survey Agency. Findings include: Resident #141 was admitted on (MONTH) 24, (YEAR) with [DIAGNOSES REDACTED]. A nurse's note dated (MONTH) 4, (YEAR) revealed that on (MONTH) 1, (YEAR) at 10:15 p.m. a CNA (Certified Nursing Assistant) informed the nurse that after dinner resident #141 ran his wheelchair into the wheelchair of resident #22, and then struck resident #22 on her left upper arm. The note also included that resident #141 had no safety awareness, wandered in the hallway, and was redirected multiple times by staff. -Resident #22 was admitted on (MONTH) 12, 2012 with [DIAGNOSES REDACTED]. Review of the facility's investigation record dated (MONTH) 6, (YEAR) revealed that on (MONTH) 1, (YEAR) at 5:30 p.m. a CNA observed resident #22 propelling down the hallway in her wheelchair when she was bumped by the wheelchair of resident #141. Resident #22 told resident #141 not to do that again. Resident #141 then struck resident #22 on the upper left arm. Review of the State Survey Agency data base revealed that the incident that occurred on (MONTH) 1, (YEAR) at 5:30 p.m. was not phoned in to the State Survey Agency until (MONTH) 4, (YEAR) at 4:20 p.m. An interview was conducted on (MONTH) 14, (YEAR) at 12:24 p.m. with the Director of Nursing (staff #39) and the social worker (staff #124). Staff #124 stated that the LPN (Licensed Practical Nurse/staff #137) had been informed of the allegation by a CNA late on a Friday and that the nurse had stated to a manager that she did not report the allegation to management until Monday (MONTH) 4, (YEAR) because it was so late in the evening. Staff #39 stated that the LPN had worked at the facility for more than a year and had received in-service education regarding the reporting requirements for allegations of abuse. During an interview conducted on (MONTH) 14, (YEAR) at 1:18 p.m. with a CNA (staff #131), the CNA stated that she had been the witness to the allegation of abuse on (MONTH) 1, (YEAR) at 5:30 p.m. and that she had reported the incident immediately to the LPN (staff #137). An interview was conducted on (MONTH) 14, (YEAR) at 1:44 p.m. with staff #137. Staff #137 stated that although she did not remember the allegation of abuse that occurred on (MONTH) 1, (YEAR) at 5:30 p.m., she would report any allegation of abuse to her supervisor immediately. An interview was conducted on (MONTH) 15, (YEAR) at 11:28 am with the Administrator (staff #108). The Administrator stated that when there is an allegation of abuse, the staff will notify him or the Director of Nursing immediately. He stated that staff are aware that they have two hours to phone in allegations to the State Survey Agency. Review of the personnel record for staff #137 revealed that staff #137 had received in-service education regarding abuse, assault and the Elder Justice Act on (MONTH) 23, (YEAR), (MONTH) 22, (YEAR), (MONTH) 22, (YEAR) and (MONTH) 25, (YEAR). Review of the facility's policy titled Abuse Prevention Policy and Procedure included that it is the responsibility of all employees to immediately report a suspected or alleged violation of abuse. The policy included the facility will ensure that all allegations of abuse are reported to State Agencies in accordance with existing State law, and that all suspected violations that involve mistreatment and abuse are reported immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse.",2020-09-01
664,APACHE JUNCTION HLTH CENTER,35112,2012 WEST SOUTHERN AVE,APACHE JUNCTION,AZ,85120,2018-11-16,610,D,1,1,DIHF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interviews, review of clinical records, facility records, and review of policies and procedures, the facility failed to have evidence that an allegation of abuse that involved two residents (#141 and #22) was thoroughly investigated and failed to prevent further potential abuse while the investigation was in progress for one resident (#76). Findings include: -Resident #141 was admitted on (MONTH) 24, (YEAR) with [DIAGNOSES REDACTED]. A nurse's note dated (MONTH) 4, (YEAR) revealed that on (MONTH) 1, (YEAR) at 10:15 p.m. a CNA (Certified Nursing Assistant) informed the nurse that after dinner resident #141 ran his wheelchair into the wheelchair of resident #22, and then struck resident #22 on her left upper arm. The note also included that resident #141 had no safety awareness, wandered in the hallway, and was redirected multiple times by staff. -Resident #22 was admitted on (MONTH) 12, 2012 with [DIAGNOSES REDACTED]. Review of the facility's investigation record dated (MONTH) 6, (YEAR) revealed that on (MONTH) 1, (YEAR) at 5:30 p.m. a CNA observed resident #22 propelling down the hallway in her wheelchair when she was bumped by the wheelchair of resident #141. Resident #22 told resident #141 not to do that again. Resident #141 then struck resident #22 on the upper left arm. However, the investigative record did not include documented evidence that any additional staff, residents, or any additional possible witness interviews had been obtained. An interview was conducted on (MONTH) 14, (YEAR) at 12:24 p.m. with the Director of Nursing (staff #39) and the social worker (staff #124). The social worker stated that the investigation included viewing of a hallway surveillance video that recorded the incident in the hallway on (MONTH) 1, (YEAR) at 5:30 p.m. The social worker stated that the surveillance video showed that resident #141 bumped his wheelchair into the wheelchair of resident #22, but did not show that resident #141 struck resident #22. The social worker stated that the CNA (staff #131) who reported seeing the incident heard a noise turned around and saw the residents next to each other and assumed that resident #141 had struck resident #22. The social worker stated that based on the surveillance video, the allegation that resident #141 struck resident #22 on the arm never happened, so additional staff and resident interviews were not obtained. Both the social worker and the Director stated that the surveillance video had been taped over and was not available. The social worker stated that she thought she had interviewed staff #131 whom she believed was the only staff member who had been in the area. However, she was unable to locate the witness statement from staff #131. During an interview conducted on (MONTH) 14, (YEAR) at 1:18 p.m. with the CNA (staff #131), the CNA stated that on (MONTH) 1, (YEAR) at 5:30 p.m. as she was walking down the hallway, she heard resident #22 state repeatedly He hit me. She stated that when she looked, she observed resident #141 seated next to resident #22. The CNA stated that she did not actually observed resident #141 strike resident #22. She stated that she immediately separated the residents and reported the incident to the nurse. The CNA also stated that there was an additional CNA who was working in the area who may have witnessed the incident. An interview was conducted on (MONTH) 15, (YEAR) at 11:28 am with the Administrator (staff #108). The Administrator stated that when there is an investigation regarding an allegation of abuse, the investigation is started immediately and that the investigating staff member immediately obtains interviews with additional staff and residents who may have been in the area. He stated that the interviews are documented. The Administrator stated that the viewing of a surveillance video is only a part of the investigation, and that the investigation also involves interviews with witnesses. Review of the facility's policy titled Abuse Prevention Policy and Procedure included that the facility investigates each alleged violation of abuse thoroughly, and that the investigation may include interviews of employees, visitors, and/or residents who may have knowledge of the alleged incident. -Resident #76 was admitted [DATE], discharged to the hospital on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. During an interview conducted with resident #76 on 11/13/18 at 10:26 AM, the resident stated that about a month ago before being admitted to the hospital, she did not want to take a pill. She stated the Registered Nurse (RN/staff #143) stuffed the pill in her mouth and put his fingers in her mouth. Resident #76 stated that she reported the incident to the social worker or director of nursing and that she was interviewed by staff. The Administrator/Abuse Prohibition Officer (staff #108) was notified of the incident on 11/13/18 at approximately 11:20 AM. A review of payroll time punches for staff member #143 revealed staff #143 punched in to work at 6:13 AM on 11/13/18 and punched out at 2:39 PM. During an interview conducted on 11/15/18 at 12:19 PM with staff #143, he stated that a resident has the right to refuse to take medications and that he has never forced anybody to take a medication. He stated that this alleged allegation of abuse was brought to his attention on 11/13/18 after he had finished his shift. Staff #143 stated that he was placed on suspension after he had signed his statement. An interview was conducted on 11/15/18 at 01:58 PM with the Administrator (staff #108), who stated that if someone observes any type of abuse, the expectation is for them to safely intervene or immediately call for help, stop the abuse, and make sure the residents are safe. Staff #108 stated that if the allegation involves a staff member, a statement is obtained and the staff member is placed on suspension within the hour. In an interview conducted on 11/15/18 at 02:25 PM with the Director of Social Work (staff #24), staff #24 stated that when she is made aware of an allegation of abuse she initiates an investigation right away and the staff member's supervisor places the staff member on suspension. A review of the facility's policy titled Abuse Prevention Policy and procedure included If the suspected perpetrator is an employee: the Administrator/Designee places the employee on immediate investigatory suspension while completing the investigation.",2020-09-01
665,APACHE JUNCTION HLTH CENTER,35112,2012 WEST SOUTHERN AVE,APACHE JUNCTION,AZ,85120,2018-11-16,692,E,0,1,DIHF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, clinical record review, and review of policy, the facility failed to ensure one resident's (#76) weight was obtained and adequately monitored. Findings include: Resident #76 was admitted [DATE] with [DIAGNOSES REDACTED]. The care plan initiated 03/23/18 revealed the resident was at risk for complications associated with hyper or hypoglycemic. Interventions included monitoring and reviewing weights per protocol/as ordered and notifying the physician and RD (Registered Dietician) of any significant weight gain or loss. Review of the clinical record revealed the following weights: 03/06/18 - 224 lbs., 03/24/18 - 211 lbs., 04/02/18 - 214 lbs., 05/01/18 - 214.8 lbs., 06/04/18 - 213 lbs., 07/01/18 - 217.4 lbs., and 08/02/18 - 226.8 lbs. The resident was discharged [DATE] and readmitted [DATE]. Review of the clinical record revealed the following weights: 08/27/08 - 230 lbs. and 09/03/18 - 227 lbs. The resident was discharged [DATE] and readmitted [DATE]. Review of the clinical record revealed the following weight: 10/03/18 - 223.8 lbs. The resident was discharged on [DATE] and readmitted on [DATE]. Review of the clinical record revealed the following weights: 10/18/18 - 205 lbs., 10/21/18 - 205.6 lbs., and 11/04/18 - 201 lbs. Nutritional Risk Assessments dated 09/21/18, 10/03/18, and 10/22/18 identified the resident as a high risk for nutrition and weight problems. Review of the 14-day Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderate cognitive impairment. The MDS assessment also included the resident was independent with eating and only required set-up assistance and was not on a physician-prescribed weight loss regimen. The resident was discharged on [DATE] and readmitted on [DATE]. Review of the clinical record revealed the following weight: 11/13/18 - 199.4 lbs. Additional review of the clinical record did not reveal documentation that the initial weights were consistently obtained upon admission and did not reveal documentation that weekly weights were consistently obtained for 4 weeks after admission and did not reveal documentation that the resident had refused a weight. A dietician's progress note dated 11/6/2018 revealed the resident's current body weight was at 201 lbs., down 10.2% x 1 month and 11.4% x 3 months. The resident has increased nutrient needs related to wound healing as evidence by stage 3 pressure ulcer on left buttocks. The resident is consuming mostly 50-75% of meals and refusing all supplements. The note included the resident is on intravenous antibiotics which can affect weight and appetite. The note also included monitoring weight trend and oral intake of meals and skin condition will continue. During an interview conducted with resident #76 on 11/13/18 at 10:37 AM, the resident stated that she had lost a lot of weight since arriving at the facility. An interview was conducted on 11/15/18 at 10:29 AM with the RD (staff #159), who stated weight monitoring and management includes monthly weights unless the resident triggers for weight loss. The RD stated that if the resident triggers for weight loss then weights are obtained on a weekly basis. Staff #159 stated that when a resident is admitted an initial weight should be obtained within 24 hours of admission and weights should be obtained weekly for 4 weeks. The RD stated that weights are being obtained more consistently since more staff has been hired. During an interview conducted on 11/15/18 at 11:47 AM with a Licensed Practical Nurse (LPN/staff #148), the LPN stated that the nurse should ensure the resident's weight is obtained upon admission. Staff #148 also stated that there is no mechanism to alert staff that a weight was not obtained. An interview was conducted on 11/15/18 at 11:59 AM with a Restorative Nursing Assistant (RNA/staff #81) who stated that residents are weighed initially when admitted , then two more times by her for the next two days, then weekly for 4 weeks. Staff #81 stated that if a resident is admitted to the hospital and readmitted to the facility, she starts the weight process all over again. An interview was conducted on 11/15/18 at 01:12 PM with the Director of Nursing (DON/staff #39) who stated an initial weight is obtained when a resident is admitted , weights are obtained daily for 2 more day for a total of three days, then the resident is weighed weekly for 4 weeks. The DON stated that when residents are admitted to the hospital, they are discharged and not on the facility roster anymore, so when they are readmitted they are a new admission again. The DON stated that they lost a RNA and that it came to her attention about 3 months ago that they did not have anyone to obtain the weights. A review of the facility's policy titled Obtaining Accurate Weight included that each individual's weight will be determined and documented upon admission to the facility. The policy included, The Customer Service Assistants, who are CNAs, will be responsible for the initial determination of each individual's weight. This will be completed during their portion of the admission process. The CNA will submit the initial weight to the admitting nurse for inclusion in the admission assessment documentation. Nursing will be responsible for subsequent measurements for weights per policy and will document for appropriate tracking .Weight will be obtained weekly for 4 weeks after admission. Subsequent weights will be obtained monthly, unless physician's orders [REDACTED].",2020-09-01
666,MOUNTAIN VIEW MANOR,35114,1045 SANDRETTO DRIVE,PRESCOTT,AZ,86305,2017-03-31,157,D,0,1,EMQW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews and policy and procedures, the facility failed to ensure that the resident's responsible party was promptly notified when one resident (#41) experienced a change in condition, and failed to notify one resident's (#9) physician when an indwelling urinary catheter was removed without an order. Findings include: -Resident #41 was admitted on (MONTH) 20, (YEAR) and discharged to the hospital on (MONTH) 25, (YEAR). [DIAGNOSES REDACTED]. A physician's order dated (MONTH) 21, (YEAR), included to obtain a chest x-ray and to administer [MEDICATION NAME] (an antibiotic) daily for 7 days. A nursing note also dated (MONTH) 21, (YEAR) included the following: right mid to lower lung field and left basilar infiltrates were present. Another nursing note dated (MONTH) 23, (YEAR), included the resident had been prescribed antibiotic therapy for pneumonia. However, a review of the clinical record revealed no documentation of any attempts to notify the resident's family member regarding the pneumonia and the subsequent antibiotic therapy, until three days later on (MONTH) 24. An interview was conducted on (MONTH) 28, (YEAR) at 1:30 p.m. with the Director of Nursing (DON/staff #43). The DON stated that notification to a resident's family member should be made within 24 hours of a change of condition. She also stated that if the family was unable to be contacted, the notification process would continue to be part of the nursing 24 hour report, until notification was able to be made. -Resident # 9 was admitted to the facility on (MONTH) 8, (YEAR), with [DIAGNOSES REDACTED]. Review of the admission nursing assessment dated (MONTH) 8, (YEAR), revealed the resident had a Foley catheter present on admission. An interim care plan dated (MONTH) 8, (YEAR), included the presence of a Foley catheter. In a review of the nursing notes from (MONTH) 9 through 27, (YEAR), revealed there were multiple entries that a Foley catheter was in place. Review of the clinical record revealed there were no physician orders to remove the catheter. An interview was conducted on (MONTH) 29, (YEAR) at 8:19 a.m., with a Licensed Practical Nurse (LPN/staff #61). She stated that she was the nurse assigned to provide care to the resident. She stated that the resident no longer has a catheter, as she removed the catheter on (MONTH) 28. She said that she removed the catheter, because the resident no longer wanted the catheter. Staff #61 stated there was no physician's order to remove the catheter and that she did not think she needed an order to remove it. She further stated that she should have notified the physician that she had removed the catheter. An interview was conducted with the Director of Nursing (staff #43) on (MONTH) 30, (YEAR) at 1:03 p.m. She stated that it would be standard nursing practice to have a physician's order before removing a Foley catheter and to notify the physician if a catheter was removed. Further review of the clinical record revealed there was no documentation that the physician was notified after the catheter was removed. A facility policy titled, Change in a Resident's Condition or Status included Our facility shall promptly notify the resident, his or her physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care .) The policy also included the following: 2. Unless otherwise instructed by the resident, the nurse supervisor/charge nurse will notify the resident's next-of-kin or representative (sponsor) when: b. There is a significant change in the resident's physical, mental, or psychosocial status. 3. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status.",2020-09-01
667,MOUNTAIN VIEW MANOR,35114,1045 SANDRETTO DRIVE,PRESCOTT,AZ,86305,2017-03-31,241,E,0,1,EMQW11,"Based on observations, staff interviews and policy and procedures, the facility failed to promote an environment which maintained each resident's privacy and dignity, by posting multiple resident's confidential information, in an area that was accessible to the public and other residents. Findings include: Observations were conducted on (MONTH) 29, (YEAR) of multiple resident bathrooms. Observed on the inside of the bathroom doors were Individual Resident Care Plans, which were taped to the doors. These care plans contained the following information: the resident's name, cognitive status, skin risk, bowel/bladder status, toilet plan, dental status, oral hygiene, mobility, splints, ambulation, vision, communication, pain control, fall risk, dehydration risk, activity pursuits, behavior/mood/safety, bathing, dressing, grooming, nutrition status and meal assistance. On each resident's care plan there were multiple areas with a check mark to indicate the problem areas for each resident. Further observations revealed that when the bathroom doors were open, the care plans were visible from the hallway. An observation was conducted on (MONTH) 29, (YEAR) of one of the resident's rooms, with a Licensed Practical Nurse (LPN/staff #90). She stated there were many rooms with two residents residing in each room and the care plans included the name of the resident and all of the care areas. She stated the care plans are placed on the bathroom doors so the Certified Nursing Assistants (CNAs) know what the resident's needs are and what care to provide. She further stated the bathroom doors are not always closed, so visitors and other residents could see the information which was posted. She stated the information on the forms would be considered private and would violate confidentiality and would be a dignity issue, as the information was specific to each resident's needs. An interview was conducted with a Registered Nurse (RN/staff #94) and a Certified Nursing Assistant (CNA/staff #74) on (MONTH) 30, (YEAR) at 8:28 a.m. Staff #94 stated that the information posted on the bathroom door of each resident's room includes a great deal of private and sensitive information. She stated this is a dignity issue, as the information is so specific to each resident. She further stated that the bathroom doors may be open at times and other people, including visitors, could easily see it. Staff #74 stated that she thought the information listed on the form was private and agreed she would not want that information in an area where other people could read it. An interview was conducted with the Director of Nursing (DON/staff #43) on (MONTH) 30, (YEAR) at 8:28 a.m. She stated the individual resident care plans are on every resident bathroom door. The DON stated this is a privacy issue and potential dignity concerns, as the resident information is specific to many care areas. A facility policy regarding resident rights included the facility shall protect and promote the rights of each resident. The policy further noted that the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance and enhancement of his/her quality of life, recognizing each resident's individuality. The resident has a right to privacy and confidentiality of personal records.",2020-09-01
668,MOUNTAIN VIEW MANOR,35114,1045 SANDRETTO DRIVE,PRESCOTT,AZ,86305,2017-03-31,279,D,0,1,EMQW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews and policy and procedures, the facility failed to develop a comprehensive care plan regarding one resident's (#14) diabetic needs and failed to develop a care plan for one resident (#123) who was receiving psychoactive medication. Findings include: -Resident #14 was readmitted to the facility on (MONTH) 13, (YEAR), with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. A physician's orders [REDACTED]. A review of the Medication Administration Records for (MONTH) and (MONTH) (YEAR), revealed the resident was frequently refusing to allow staff to do accuchecks and was also refusing insulin injections. A review of the physician's orders [REDACTED]. A review of the quarterly Minimum Date Set (MDS) assessment dated (MONTH) 13, (YEAR), revealed the Brief Interview for Mental Status (BIMS) score of 7. A score of 7 indicates the resident's cognitive status is severely impaired. The quarterly MDS assessment also revealed the resident had received insulin injections on 5 days during the 7 day look back period. A review of the comprehensive care plan in the clinical record revealed no care plan was developed to address the resident's use of insulin. At 11:45 a.m. on (MONTH) 29, (YEAR), an interview was conducted with three members of the interdisciplinary team (IDT) the Assistant Director of Nursing ADON/MDS Coordinator, (staff #72,) the Social Services and Admission Assistant (staff #57), and the Activity Director (staff #53.) The three members of the IDT stated that a resident receiving insulin injections should have a care plan to reflect the resident care needs. After the ADON reviewed the clinical record she stated that she was unable to find any care plan addressing the use of insulin. -Resident #123 was admitted on (MONTH) 6, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident was receiving hospice care, prior to admission. Review of a hospice Nurse Visit Note which was prior to admitted d (MONTH) 27, (YEAR), revealed the resident stated that he was anxious, was very tearful, and was taking [MEDICATION NAME] (antianxiety medication) twice daily and as needed. A hospice admission physician's orders [REDACTED]. The order stated that if the resident's anxiety was not resolved within 3 doses, contact hospice. Review of a Daily Skilled Nursing note dated (MONTH) 6, (YEAR) revealed the resident had short and long term memory problems, was independent with bed mobility, required supervision with transfers and eating, and had little interest or pleasure in doing things. According to the admission Minimum Data Set (MDS) assessment dated (MONTH) 13, (YEAR), the resident had a Brief Interview for Mental Status score of 12, which indicated moderate cognitive impairment. Under the mood section, the resident was assessed with [REDACTED]. The MDS also included the resident was on antidepressant medication and was on hospice. In the Section titled, Care Area Assessment Summary, the documentation included the care area for psychoactive drug use triggered and was to be addressed in a care plan. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. However, there was no clinical record documentation that a care plan had been developed to address the resident's needs related to anxiety/restlessness and the use of a psychoactive medication. An interview was conducted with a Licensed Practical Nurse (LPN/staff #90) on (MONTH) 30, (YEAR) at 12:34 p.m. She stated that for this resident, staff monitor for anxiety, restlessness and depression. She stated if a resident was on hospice and was on any antianxiety medication, this should be care planned. An interview was conducted with the Director of Nursing (DON/staff #43) on (MONTH) 30, (YEAR) at 1:15 p.m. She stated that any resident on [MEDICAL CONDITION] medication should have a care plan, which includes specifics for that resident. She stated that since the resident was receiving PRN [MEDICATION NAME], he should have a care plan. An interview was conducted with the Assistant Director of Nursing (ADON/staff #72) on (MONTH) 31, (YEAR) at 10:00 a.m. She stated that no care plan was developed before (MONTH) 30, for the use of [MEDICATION NAME] and that one should have been developed. Review of the comprehensive care plan policy revealed that an individualized, comprehensive care plan should be developed for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs.",2020-09-01
669,MOUNTAIN VIEW MANOR,35114,1045 SANDRETTO DRIVE,PRESCOTT,AZ,86305,2017-03-31,280,D,0,1,EMQW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews and policy and procedures, the facility failed to ensure that a pressure ulcer care plan was revised for two residents (#'s 10 and 32). Findings include: -Resident #32 was admitted to the facility on (MONTH) 11, 2014, with [DIAGNOSES REDACTED]. Review of the MDS quarterly assessment dated (MONTH) 13, (YEAR), revealed the resident was rarely or never understood. The MDS documented the resident was totally dependent with bed mobility and transfers and that the resident did not have any pressure ulcers. Review of a weekly pressure ulcer assessment dated (MONTH) 15, (YEAR) revealed the onset of a new stage II pressure ulcer, which measured 3 x 1.8 x 0.1 centimeters (cm). A physician's orders [REDACTED]. Review of a comprehensive care plan revealed the resident was at risk for pressure ulcers. The goal included the resident would have no skin breakdown. Interventions included to check and toilet the resident every 2 hours and anticipate needs regarding incontinence episodes, keep pressure reducing mattress in place at all times, use a two person extensive assist with repositioning to avoid skin friction/shearing, daily observation of skin with routine care, full skin evaluation weekly with bath or showers and use of supportive/protective devices to assist with positioning. Further review of this care plan revealed it was reviewed on (MONTH) 21, (YEAR) by a registered nurse (RN/staff #6). However, there was no documentation that the care plan had been revised to reflect the development of a new pressure ulcer, nor were there any additional interventions which were implemented to prevent further breakdown. According to the weekly pressure ulcer healing assessment dated (MONTH) 22, (YEAR), the sacrum/coccyx pressure ulcer was now unstageable and measured 3 x 1.8 x 0.1 cm. Review of the wound documentation dated (MONTH) 29, (YEAR), revealed the sacrum/coccyx pressure ulcer was unstageable and measured 7.7 x 5.5 x 1.5 cm and that the wound had deteriorated. Further review of the resident's care plans revealed they were not revised to reflect that the pressure ulcer had deteriorated and was an unstageable, nor were there any additional interventions to prevent further breakdown. An interview was conducted with a registered nurse (RN/staff #22) on (MONTH) 31, (YEAR) at 8:45 a.m. She stated the wound was discovered on (MONTH) 15, (YEAR), and that it deteriorated quickly. She stated that the resident's care plan should have updated, after the development of the pressure ulcer. An interview was conducted with the Director of Nursing (DON/staff #43) on (MONTH) 31, (YEAR) at 10:04 a.m. She stated that if a nurse identifies a new pressure ulcer, they should initiate a care plan. She stated that it is expected that care plans are updated with the development or progression of a pressure ulcer. -Resident #10 was admitted on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. A review of the clinical record revealed the resident had been admitted to the facility with a stage 3 pressure ulcer on the sacrum. A pressure ulcer care plan which was developed on (MONTH) 22, (YEAR), included that a stage 3 pressure ulcer was present on the resident's sacrum. Further review of the clinical record revealed that according to the wound care center documentation dated (MONTH) 10, (YEAR), the pressure ulcer had worsened and was now a stage 4. The wound documentation dated (MONTH) 24, (YEAR) and (MONTH) 10, (YEAR) also included the coccyx wound was a stage 4 pressure ulcer. Review of the pressure ulcer care plan revealed it was reviewed by nursing on (MONTH) 10, (YEAR). However, the care plan was not revised to reflect that the pressure ulcer had deteriorated and was now a stage 4, nor was the care plan revised to include any additional interventions, despite the deterioration of the pressure ulcer. An interview was conducted on (MONTH) 30, (YEAR) at 10:40 a.m., with the Director of Nursing (staff #43). Following a review of the clinical record, she confirmed that the care plan had not been revised to reflect the pressure ulcer was now a stage 4. Staff #43 stated the licensed staff, as well as the MDS staff were responsible to revise care plans as necessary, and at the time of the MDS care conferences. An interview was conducted on (MONTH) 30, (YEAR) at 1:50 p.m., with the MDS staff (staff #72). Staff #72 stated that the pressure ulcer care plan should have been revised when it was reviewed on (MONTH) 10. A facility policy titled, Comprehensive Care Plans included: 8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. 9. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans.",2020-09-01
670,MOUNTAIN VIEW MANOR,35114,1045 SANDRETTO DRIVE,PRESCOTT,AZ,86305,2017-03-31,281,D,0,1,EMQW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to ensure an interim care plan was developed for one resident (#85) regarding hospice services. Findings include: Resident #85 was readmitted to the facility on (MONTH) 16, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed admission physician orders [REDACTED]. A nurse's note dated (MONTH) 18, (YEAR) included that the hospice nurse was called regarding medication orders. A nurse's note dated (MONTH) 24, (YEAR) included the hospice nurse was in to see the resident. Further review of the clinical record revealed there was no evidence that an interim care plan had been developed regarding the resident's needs related to hospice services. An interview was conducted with a Registered Nurse (staff #22) on (MONTH) 30, (YEAR) at 11:02 a.m. She stated that she thought the nurse who completed the Minimum Data Set assessments was responsible for the development of the care plan. However, she acknowledged that until the comprehensive care plan was completed she, or the other unit nurses could develop a care plan for the resident regarding hospice. She stated that an interim care plan was not completed for this resident regarding hospice. Staff #22 further stated that a care plan needed to be developed to identify what interventions should be completed for the resident. An interview was conducted with the Director of Nursing (DON/staff #43) on (MONTH) 30, (YEAR) at 1:03 p.m. She stated it was necessary and standard nursing practice to develop an interim care plan, when a resident is being provided hospice services. According to the Administrator (staff #54), the facility did not have a policy regarding the development of interim care plans or for developing care plans on admission.",2020-09-01
671,MOUNTAIN VIEW MANOR,35114,1045 SANDRETTO DRIVE,PRESCOTT,AZ,86305,2017-03-31,309,E,0,1,EMQW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of facility documentation, the facility failed to ensure there was coordination of care and services between the facility and hospice services for one resident (#85). Findings include: Resident #85 was readmitted to the facility on (MONTH) 16, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed admission physician orders [REDACTED]. A nurse's note dated (MONTH) 18, (YEAR) included the hospice nurse was called regarding medication orders. A nurse's note dated (MONTH) 24, (YEAR) included the hospice nurse was in to see the resident. Review of the hospice binder revealed a calendar which included a Certified Nursing Assistant (CNA) visit was scheduled for (MONTH) 22, and a Registered Nurse visit was scheduled for (MONTH) 28 and 29, (YEAR). Continued review of the clinical record and the hospice binder revealed there were no hospice visist notes, no evidence of any plans of care, inclusive of how and when hospice services would be provided or any coordination of care between the care provided by the facility and the care being provided by hospice. An interview was conducted with a Registered Nurse (staff #22) on (MONTH) 30, (YEAR) at 11:02 a.m. She stated there was no plan of care related to hospice services, however, there is a binder that contains the individualized information from the hospice agency for the care and services for the resident. After reviewing the hospice binder, she stated it only contained a calendar of hospice visits for a CNA on (MONTH) 22 and a Registered Nurse on (MONTH) 28 and 29. She stated she did not know what the calendar actually meant. Staff #22 stated there was no documentation of a hospice care plan, schedule of visits, or how the hospice agency would coordinate care with the facility. She stated it was the responsibility of facility staff to contact the hospice nurse for ordering medications, regarding a change of condition, and other related services. She stated that typically the hospice CNA's would provide additional baths/showers and other personal hygiene measures, however, she did not know what scheduled days and times that might be. She stated she was not sure when the hospice nurses were scheduled to come. An interview was conducted with the Director of Nursing (staff #43) on (MONTH) 30, (YEAR) at 1:03 p.m. She stated she would expect that hospice care be coordinated and that the facility staff has the responsibility to make sure the care is coordinated and documented. According to the Administrator (staff #54) the faciliy did not have a policy regarding the coordination of care and services between the facility and the hospice agency.",2020-09-01
672,MOUNTAIN VIEW MANOR,35114,1045 SANDRETTO DRIVE,PRESCOTT,AZ,86305,2017-03-31,314,E,0,1,EMQW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, staff interviews and facility policy and procedures, the facility failed to provide treatments and services to promote healing on of a pressure ulcer for one resident (#10). The facility also failed to ensure thorough wound assessments were conducted and that wound treatment were provided as ordered for one resident (#32). Findings include: -Resident #10 was admitted on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. The nursing admission evaluation dated (MONTH) 9, (YEAR) included the resident had stage 3 sacral pressure ulcer, which measured 3.25 by 2 by 2 cm (centimeters). A physician's treatment order was obtained upon admission and treatments were provided. A pressure ulcer care plan dated (MONTH) 22, (YEAR) included the resident was admitted with a stage 3 pressure ulcer on the coccyx. Goals included that the pressure ulcer would heal and skin would remain intact. Interventions were as follows: weekly and as needed skin checks, wound care treatments, including measurements, encourage resident to weight shift and keep pressure off coccyx, and if wound gets worse or is not responding to current treatment, contact the physician for updated orders. According to the wound care center documentation completed by a FNP (family nurse practitioner) dated (MONTH) 4, (YEAR), the resident had a stage 3 pressure ulcer on the coccyx, which measured 1.6 by 1.6 by 1.9 cm and the wound bed had 1-25% slough present, with undermining from 12:00 o'clock to 6:00 o'clock, with a maximum distance of 1.4 cm. The documentation also included the wound had a moderate amount of serosanguineous drainage with a mild odor. The pressure ulcer was not assessed again until 17 days later on (MONTH) 18, (YEAR). Per the Weekly Pressure Ulcer assessment (completed by a facility nurse) dated (MONTH) 18, (YEAR), the stage 3 pressure ulcer measured 1.4 by 1.5 by 1 cm., with serosanguineous drainage. Although this assessment included that undermining was present, the documentation did not include where the undermining was located or any measurements of the undermining, nor was there a description of the wound bed. The resident was seen at the wound care center on (MONTH) 18, (YEAR). However, the wound care center documentation did not include a description of the wound or any measurements. The (MONTH) 22, (YEAR) Weekly Pressure Ulcer assessment (by a facility nurse) included the wound measured 1.4 by 1.5 by 1.0, with undermining and serosanguineous drainage. The assessment lacked a description of the wound bed and surrounding skin, and there were no measurements of the undermining. The next pressure ulcer assessment was completed ten days later on (MONTH) 2, (YEAR). Per the wound care center documentation (by the FNP) dated (MONTH) 2, (YEAR), the stage 3 pressure ulcer measured 1.5 by 1.5 by 1.5 cm, with a moderate amount of serosanguinous drainage with a mild odor, no undermining, and the wound bed had 1-25% slough. According to the documentation, the wound was deteriorating. Review of a quarterly Minimum Data Set (MDS) assessment dated (MONTH) 13, (YEAR), revealed the resident had a Brief Interview for Mental Status score of 13, which indicated the resident was cognitively intact. The MDS assessed the resident as being independent with bed mobility and transfers, and required limited assistance with toileting. The MDS further included the resident was at risk for pressure ulcer development and was admitted with a stage 3 pressure ulcer, which measured 1.5 by 1.5 by 1.5 cm, with granulation tissue present. The coccyx pressure ulcer was assessed next on (MONTH) 15, (YEAR), which was 13 days after the last assessment. Review of the Weekly Pressure Ulcer assessment (by a facility nurse) dated (MONTH) 15, (YEAR), revealed the stage 3 pressure ulcer measured 1.5 by 1.5 by 1.5, with serosanguineous drainage and no undermining. The wound bed was described as having granulation and slough, however, the percent of granulation and slough was not documented. Review of the wound care center documentation (by the FNP) dated (MONTH) 23, (YEAR), revealed the coccyx pressure ulcer measured 1.5 by 1.5 by 2 cm, had a moderate amount of serosanguineous drainage with mild odor, had 1-25 % slough and 76-100% red granulation tissue and that no eschar was present. A Wound care center treatment order dated (MONTH) 23, (YEAR) included the following: Cleanse coccyx wound with normal saline or wound wash, primary dressing-Biostep Ag and Alginate ([MEDICATION NAME] Ag gently packed into wound if Biostep was not available), cover and secure with foam dressing and tape or adhesive foam dressing and change dressing every two days. According to the Weekly Pressure Ulcer assessment (by a facility nurse) dated (MONTH) 27, (YEAR), the stage 3 pressure ulcer measured 1.5 by 1.5 by 2.0, with no undermining and had granulation and slough present (no percent was documented), with serosanguineous drainage. A review of the (MONTH) (YEAR) TAR (Treatment Administration Record) revealed that the treatment order (from (MONTH) 23) had been transcribed incorrectly. The TAR included to apply Biostep Ag and excluded the Alginate. Therefore; the prescribed treatment was not administered from (MONTH) 23, through 31, (YEAR). The next pressure ulcer assessment was completed 15 days after the last assessment. Per the Weekly Pressure Ulcer assessment (by a facility nurse) dated (MONTH) 11, (YEAR), the stage 3 pressure ulcer on the coccyx measured 1.5 by 1.5 by 2 cm, with no undermining, had serosanguineous drainage and the surrounding skin was swollen. The wound bed was described as having granulation and slough present. However, this assessment did not include the amount of granulation and slough, nor a description of the wound edges. The wound care center documentation (by the FNP) dated (MONTH) 13, (YEAR), included the stage 3 pressure ulcer on the coccyx measured 2 by 2 by 2 cm, with undermining present at 12:00 o'clock and ending at 12:00 o'clock, with a maximum distance of 2.5 cm. The wound bed was described as having 1-25% slough and 76-100% bright red granulation tissue, with eschar present (the amount of eschar was not documented) and had a moderate amount of serosanguineous drainage, with a mild odor. The note further included that the pressure ulcer had deteriorated. A wound care center treatment order dated (MONTH) 13, (YEAR) included the following: Cleanse the coccyx wound with normal saline or wound wash, primary dressing-[MEDICATION NAME] Ag gently packed into the wound, cover and secure with foam dressing and tape or adhesive foam dressing and change dressing every 2 days. Review of the (MONTH) 20, (YEAR) Weekly Pressure Ulcer assessment revealed the stage 3 pressure ulcer measured 2 by 2 by 2 cm. The assessment also included that serosanguineous drainage was present, that the wound edges and surrounding skin were intact, and that undermining and slough were present. However, the location and the amount of undermining and the percent of slough was not documented. Review of the (MONTH) 27, (YEAR) wound care center documentation and the Weekly Pressure Ulcer assessment revealed the pressure ulcer had worsened since last week. The wound was now described as having exposed bone at the base. The pressure ulcer measured 2 by 2 by 2.0 cm, with granulation, slough, and undermining, however, there were no percentages of each. A wound care center treatment order dated (MONTH) 27, (YEAR) (which is the same order from (MONTH) 13) included the following: Cleanse the wound with normal saline or wound wash, primary dressing-[MEDICATION NAME] Ag and gently packed into the wound, cover and secure with foam and tape or adhesive foam dressing and change dressing every two days. Review of the (MONTH) (YEAR) TAR revealed that the treatment orders from (MONTH) 13 and (MONTH) 27, for [MEDICATION NAME] Ag were not included on the TAR. The documentation showed that Biostep Ag continued to be provided from (MONTH) 1 through 31. The Weekly Pressure Ulcer assessment (by a facility nurse) dated (MONTH) 3, (YEAR), included the stage 3 sacral pressure ulcer measured 2 by 2 by 2 cm with undermining, the wound edges and surrounding skin were intact, and the wound bed had granulation and slough present. However, the amount of the granulation and slough, and the location and measurements of the undermining were not documented. Review of the (MONTH) (YEAR) TAR revealed that the Biostep Ag continued to be administered from (MONTH) 1 through 9, and not the [MEDICATION NAME] Ag as ordered. Per the wound care center assessment (by the FNP) dated (MONTH) 10, (YEAR), the coccyx pressure ulcer was now a stage 4 and was deteriorating. The wound measured 2.2 by 2.2 by 1.8 cm, with undermining at 10:00 o'clock and ending at 12:00 o'clock, with a maximum distance of 2.3 cm, and had a moderate amount of serosanguineous drainage, with a mild odor. The wound bed was described as having 1-25% slough and 76-100% bright red granulation tissue, with no [MEDICATION NAME] and eschar present. Per the documentation, the pressure ulcer was deteriorating. Review of the wound care center treatment order dated (MONTH) 10, (YEAR) revealed a change in treatment as follows: cleanse with normal saline or wound wash, primary dressing-[MEDICATION NAME] Ag gently packed into wound, add Alginate, cover and secure with foam and tape or adhesive foam dressing every 2 days. Despite the wound care center documentation (by the FNP) that the pressure ulcer was a stage 4, the Weekly Pressure Ulcer assessment (completed by a facility nurse) dated (MONTH) 10, (YEAR), included the pressure ulcer was a stage 3. Review of the (MONTH) 16, (YEAR) Weekly Pressure Ulcer assessment (by a facility nurse) revealed the wound was identified as a stage 3 and measured 2 by 2 by 2 cm, with serous drainage, intact wound edges, and the wound bed had granulation and slough, with undermining. However, the assessment did not include the location or measurements of the undermining, nor the amount of granulation tissue and slough. The (MONTH) 23, (YEAR) Weekly Pressure Ulcer assessment (by a facility nurse) included that the coccyx wound was a stage 3 pressure ulcer, which measured 2 by 2 by 2 cm, had serosanguineous drainage, the wound edges and surrounding skin were intact, and the wound bed had epithelium present. Although undermining was present, the assessment did not include the location or measurements of the undermining. The wound care center assessment (by the FNP) dated (MONTH) 24, (YEAR) included the coccyx wound was a stage 4 pressure ulcer which measured 2.7 by 2.2 by 2 cm. The documentation also included that muscle and adipose tissue were exposed and that tunneling was present at 12:00 o'clock and ending at 12:00 o'clock, with a maximum distance of 1.8 cm. The wound base was described as having 1-25% slough and 76-100% bright red granulation tissue, and had no epithelization, but eschar was present (no percent of eschar was documented). Again, the documentation included that the wound was deteriorating. The documentation also included the following wound treatment was in place: cleanse with normal saline or wound wash, apply [MEDICATION NAME] Ag gently pack into wound, add Alginate, cover and secure with foam and tape or adhesive foam dressing and to change every two days. Further review of the (MONTH) TAR revealed that the order from (MONTH) 10, to cleanse the coccyx with normal saline or wound wash, apply [MEDICATION NAME] Ag gently packed into wound, add Alginate, cover and secure with foam and tape or adhesive foam dressing every 2 days, was not included on the TAR. The TAR continued to include the treatment for [REDACTED]. There was no documentation that the [MEDICATION NAME] Ag and the Alginate were administered from (MONTH) 10 through 28. A review of the nursing weekly pressure ulcer assessment (by a facility nurse) dated (MONTH) 1, (YEAR), revealed the stage 3 pressure ulcer measured 2 by 2 by 2 cm with serosanguineous drainage, the wound edges and surrounding skin were intact and epithelium was present in the wound bed. A review of the annual MDS assessment dated (MONTH) 6, (YEAR), included the resident was cognitively intact. The MDS also included the resident was at risk for pressure ulcer development and had a stage 4 pressure ulcer, which was not present on admission. The next pressure ulcer assessment was completed 10 days after the last assessment. Review of the wound care center assessment (by the FNP) dated (MONTH) 10, (YEAR), revealed the stage 4 coccyx pressure ulcer measured 2.5 by 2 by 3 cm depth, muscle and adipose tissue were exposed, and that undermining was present from 3 o'clock to 7 o'clock, with a maximum distance of 2.8 cm. The wound bed was described as having 1-25% slough, 76-100% bright red granulation tissue, and that eschar was present, with a moderate amount of serosanguineous drainage with no odor and the peri wound was excoriated with [MEDICAL CONDITION]. Per the note, the wound was smaller, but the undermining had increased. The documentation also included there were no changes in the treatment orders and the following wound treatment was in place: cleanse with normal saline or wound wash, apply [MEDICATION NAME] Ag gently packed into wound, add Alginate, cover and secure with foam and tape or adhesive foam dressing and to change every two days. Per the Weekly Pressure Ulcer assessment (by a facility nurse) dated (MONTH) 10, (YEAR), the coccyx pressure ulcer continued to be documented as a stage 3. Review of the Weekly Pressure Ulcer assessment (by a facility nurse) dated (MONTH) 15, (YEAR) revealed the stage 3 pressure ulcer measured 2 by 2 by 2 cm, with serosanguineous drainage, surrounding skin was intact and the wound bed was described as having epithelium tissue. A review of the (MONTH) (YEAR) TAR revealed that the prescribed treatment from (MONTH) 10, (YEAR) to cleanse the coccyx with normal saline or wound wash, apply [MEDICATION NAME] Ag gently packed into wound, add Alginate, cover and secure with foam and tape or adhesive foam dressing every 2 days, was not included on the TAR. The TAR included for Biostep Ag cover and secure with foam and tape every 2 days and as needed. There was no documentation that the [MEDICATION NAME] Ag and the Alginate were administered from (MONTH) 10 through (MONTH) 23. Review of the wound care center documentation (by the FNP) dated (MONTH) 24, (YEAR) revealed the stage 4 coccyx pressure ulcer measured 2.5 by 1.5 by 1.7 cm, with undermining at 3 o'clock and ending at 7 o'clock with a maximum distance of 1.7 cm. The wound bed was described as having 1-25% slough and 76-100% granulation tissue, with exposed muscle and adipose tissue present. The periwound had [MEDICAL CONDITION] and excoriation. A wound care center treatment order dated (MONTH) 24, (YEAR) (which is the same order from (MONTH) 10) included to cleanse the wound with normal saline or wound wash, primary dressing-[MEDICATION NAME] Ag gently packed into wound, add Alginate, cover and secure with foam and tape or adhesive foam dressing and change every two days. The Weekly Pressure Ulcer assessment (by a facility nurse) dated (MONTH) 24, (YEAR), continued to document that the pressure ulcer was a stage 3. Review of the (MONTH) (YEAR) TARs revealed that the physician's orders [REDACTED]. The TAR documentation included the following: cleanse with wound cleanser, apply primary dressing of Calcium Alginate, apply foam adhesive dressing and secure with [MEDICATION NAME] every day. The TAR showed that this treatment was provided on (MONTH) 25, 27, 28 and 29. The TAR did not include the (MONTH) 24 order. In addition, the treatment was scheduled and provided daily and not every two days as ordered. A pressure ulcer treatment observation was conducted on (MONTH) 28, (YEAR) at 10:00 a.m., with a Registered Nurse (staff #15). Staff #15 stated that the resident had a stage 3 pressure ulcer on the coccyx. During the observation, undermining was determined to be present by staff #15, however, the location and the amount of undermining was not measured. According to staff #15, the wound measured 1.5 by 2.5 by 2 cm, however, staff #15 was not observed to properly measure the depth. Staff #15 was observed to place the end of the plastic ruler at the base of the wound bed and measure to the surface of the pressure ulcer. An interview was conducted on (MONTH) 28, (YEAR) at 11:30 a.m. with the DON (Director of Nursing/staff #43). Following a review of the pressure ulcer assessments, she stated the assessments were not consistently completed. She stated the assessments were incomplete and inaccurate (regarding the description of the pressure ulcer). Staff #43 stated that the site and distance of the undermining of the pressure ulcer was suppose to be assessed and documented. The DON also reviewed the prescribed pressure ulcer treatment orders and the corresponding TARs and stated the incorrect pressure ulcer treatment had been administered for several months. Review of the Weekly Pressure Ulcer assessment (MONTH) 29, (YEAR), revealed the coccyx pressure ulcer was a stage 3, which measured 1.5 by 2.5 by 2.0 cm with undermining present, and that slough and granulation tissue were present, however, the amount of undermining, slough and granulation tissue were not documented. Another interview was conducted on (MONTH) 30, (YEAR) at 10:40 a.m., with staff #43. At this time, she stated that the resident's non compliance and the fact that the wrong treatment had been done worked against the resident and it could have lead to the increased size of the pressure ulcer to a stage 4. Review of the clinical record revealed documentation that at times the resident refused care, however, the resident was not care planned for any concerns related to non compliance with care. On (MONTH) 30, (YEAR) at 12:30 p.m., another interview was conducted with staff #15, who had administered the pressure ulcer treatment on (MONTH) 28. In regards to the measuring of the undermining in the wound, staff #15 stated that she just checks the box on the assessment that undermining was present, and that measuring and documenting the amount of undermining was not part of the routine practice. Staff #15 agreed that she had not properly measured the depth of the pressure ulcer and stated that she should have used a sterile q-tip in order to obtain an accurate measurement of the depth of the pressure ulcer. She stated that she was in a hurry to get the treatment done, because the resident was getting tired of standing (resident's preference to stand for the treatment) and had forgotten to bring a sterile q-tip into the room. Staff #15 further stated that the licensed staff were suppose to review the wound care center's documentation for any new orders and they were not usually focused on the assessment of the pressure ulcer. -Resident #32 was admitted on (MONTH) 11, 2014, with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident was receiving hospice services. A Braden Scale for Predicting Pressure Ulcer risk dated (MONTH) 8, (YEAR), identified that the resident was at mild risk for developing pressure sores. Review of the Minimum Data Set (MDS) quarterly assessment completed on (MONTH) 13, (YEAR) revealed the resident was rarely or never understood. The MDS included the resident was totally dependent on staff for bed mobility and transfers and that the resident did not have any pressure ulcers at the time of assessment. Review of the weekly pressure ulcer healing assessment dated (MONTH) 15, (YEAR) revealed the onset of a new stage II pressure ulcer to the coccyx/sacrum. However, a physician's orders [REDACTED]. A comprehensive care plan identified that the resident was at risk for pressure ulcers. This care plan was reviewed on (MONTH) 21, (YEAR) by a registered nurse (RN/staff #6). The goal was for the resident to have no further skin breakdown. Interventions included for a pressure reducing mattress in place at all times, use a two person extensive assist with repositioning to avoid skin friction/shearing, encourage good nutritional intake, daily observation of skin with routine care and for a full skin evaluation weekly. Review of the weekly pressure ulcer healing assessment dated (MONTH) 22, (YEAR) revealed the pressure ulcer was unstageable, however, there was no description of the wound bed. Review of the (MONTH) (YEAR) treatment administration record (TAR) revealed the treatments were being administered as ordered. A hospice physician's orders [REDACTED]. The orders included that after cleansing the wound and applying [MEDICATION NAME] or Alginate, apply an odor reducing pad, apply a thin duoderm and change weekly and as needed. Review of the weekly pressure ulcer healing assessment dated (MONTH) 17, (YEAR) revealed there was no staging of the pressure ulcer, and the section to indicate if undermining and tunneling were present was left blank. A weekly pressure ulcer healing assessment dated (MONTH) 22, (YEAR) revealed the wound was a stage 3 pressure ulcer. A physician's telephone order dated (MONTH) 29, (YEAR) included that staff may use an allevyn foam dressing if duoderm was unavailable. An observation of pressure ulcer care was conducted on (MONTH) 29, (YEAR) at 9: 29 a.m., with a registered nurse (RN/staff #15). She stated the resident is repositioned every 2 hrs for offloading and staff try to get her up for meals. She stated the resident has been using an alternating air loss mattress. At this time, the wound bed was observed to have approximately 60% slough and a small amount of drainage, with a foul odor. The RN cleansed the wound as ordered and applied an allevyn foam dressing, however, the RN did not apply the odor reducing pad as ordered. Another interview was conducted with staff #15 was on (MONTH) 30, (YEAR) at 1:13 p.m. She stated that the odor-reducing pads had not been available for treatment for [REDACTED]. She stated the hospice nurse said that they had to order more odor reducing pads, since they were also out of them. An interview was conducted with another RN (staff #22) on (MONTH) 31, (YEAR) at 8:45 a.m. She stated that hospice gives the orders for wound treatment. She stated that for assessments which are missing information, the assessments should have been filled out completely and the wound should always be staged. An interview was conducted with the Director of Nursing (DON/staff #43) on (MONTH) 31, (YEAR) at 10:04 a.m. She stated that it is expected that nurses completely fill out the weekly pressure ulcer healing sheets every time they do an assessment of a wound, and that the blank areas on the assessments should have been completed. She stated the wound should always have a stage documented. A facility policy titled, Wound Assessment and Documentation included All wounds are thoroughly assessed upon admission of the resident to the facility, or upon occurrence of the wound. All wounds are assessed for changes with each dressing change. A weekly assessment, including measurements is complete. The policy also included that assessment with each dressing change should include drainage, odor, peri-wound description and wound bed description. The presence of the wound and significant findings in the nurses notes should be charted daily. Regarding the Weekly Assessments, the policy included that the day shift nurse does a weekly assessment every Wednesday which includes: wound measurements (in centimeters); any odor; periwound and wound bed. Chart the assessment on the back of the treatment wound healing assessment sheet. Review of the Pressure Ulcer Treatment policy revealed that the dressing/treatment should be administered according to the manufacturer's direction, care plan and physician orders.",2020-09-01
673,MOUNTAIN VIEW MANOR,35114,1045 SANDRETTO DRIVE,PRESCOTT,AZ,86305,2017-03-31,315,E,0,1,EMQW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, and review of policies and procedures, the facility failed to ensure there was medical justification for the use of an indwelling urinary catheter for one resident (#9) and that physician orders were obtained for it's use, and failed to ensure there was medical justification for the use of an indwelling urinary catheter for one resident (#85). Findings include: -Resident #9 was admitted to the facility on (MONTH) 8, (YEAR) and readmitted on (MONTH) 16, (YEAR), with [DIAGNOSES REDACTED]. Review of the admission nursing assessment dated (MONTH) 8, (YEAR), revealed the resident had a Foley catheter present on admission. An interim care plan dated (MONTH) 8, (YEAR), included the presence of a Foley catheter. In a review of the nursing notes from (MONTH) 9 through 27, (YEAR), revealed there were multiple entries that a Foley catheter was in place. However, review of the clinical record revealed there were no physician orders for the Foley catheter, nor any orders for catheter care or how often to change the catheter. There was also no medical justification for the use of an indwelling urinary catheter and there were no orders to remove the catheter. An interview was conducted on (MONTH) 29, (YEAR) at 8:19 a.m., with a Licensed Practical Nurse (LPN/staff #61). She stated that she was the nurse assigned to provide care to the resident. She stated that the resident no longer has a catheter, as she removed the catheter on (MONTH) 28. She said that she removed the catheter, because the resident no longer wanted the catheter. Staff #61 stated there was no physician's order to remove the catheter and that she did not think she needed an order to remove it. A later interview was conducted at 9:58 a.m., with staff #61. She stated there needs to be admission physician orders and a [DIAGNOSES REDACTED]. She stated that she did not know how she and other staff did not notice there were no admission orders [REDACTED]. Staff #61 stated the facility does not do 24 hour chart checks to ensure there are physician orders on admission. An interview was conducted with the Director of Nursing (staff #43) on (MONTH) 30, (YEAR) at 1:03 p.m. She stated it is necessary and is standard nursing practice to obtain physician orders and a [DIAGNOSES REDACTED]. She also stated that it would be standard nursing practice to have a physician's order before removing a Foley catheter. -Resident #85 was readmitted to the facility on (MONTH) 16, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident was receiving hospice services. Admission physician orders included for an indwelling urinary catheter and for catheter care to be done every shift. A nurse's note dated (MONTH) 16, (YEAR) included the resident had a Foley catheter in place. A nurse's note dated (MONTH) 19, (YEAR) included that a Foley catheter was in place. However, review of the clinical record revealed there was no documentation of the medical justification for the use of the catheter. In addition, the (MONTH) (YEAR) Treatment Administration Record (TAR) included that catheter care was to be provided every shift. However, from (MONTH) 17 through 30, there were seven occasions with no documentation that catheter care had been provided. An interview was conducted with a Registered Nurse (staff #22) on (MONTH) 30, (YEAR) at 11:02 a.m. She stated that any resident on admission needs to have a [DIAGNOSES REDACTED]. She stated that on (MONTH) 28, the hospice nurse was notified and a [DIAGNOSES REDACTED].#22 also stated the procedure was to document on the TAR when catheter care is done, and if there are no staff initials then it looks as if the care was not provided. An interview was conducted with the Director of Nursing (staff #43) on (MONTH) 30, (YEAR) at 1:03 p.m. She stated it was expected that nurses follow the standard of practice and make sure there are physician orders for catheters. She also stated that catheter care needed to be done as ordered and documented on the TAR. According to the Administrator (staff #54), the facility did not have a policy regarding the need for physician orders upon admission for a catheter or a policy that addressed the need for documentation in the clinical record regarding medical justification for the use of a catheter. A facility policy regarding catheters included the following: Objective: To insure all residents with indwelling catheters receive catheter care at least daily for prevention of infection. Do catheter care at least daily and as needed. The policy did not address the need for physician orders for a urinary catheter, including orders for the removal of a catheter, nor of the need for medical justification for the use of a catheter. According to the Administrator, the facility had no additional policies regarding catheters.",2020-09-01
674,MOUNTAIN VIEW MANOR,35114,1045 SANDRETTO DRIVE,PRESCOTT,AZ,86305,2017-03-31,323,E,0,1,EMQW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview and review of facility documents, the facility failed to ensure safe hot water temperatures were maintained in multiple resident rooms. Findings include: Random observations of hot water temperatures in nine residents' rooms were conducted between 1:11 p.m. and 2:30 p.m. on (MONTH) 27, (YEAR), and revealed the following: -In room #101, the hot water temperature was 129 degrees Fahrenheit (F). -In room #103, the hot water temperature was 128 degrees F. -In room #104, the hot water temperature was 131 degrees F. -In room #110, the hot water temperature was 124 degrees F. -In room #202, the hot water temperature was 130 degrees F. -In room #204, the hot water temperature was 130 degrees F. -In room #207, the hot water temperature was 125 degrees F. -In room #208, the hot water temperature was 128 degrees F. -In room #210, the hot water temperature was 126 degrees F. At 2:30 p.m. on (MONTH) 27, (YEAR), the Maintenance Director (staff #81) who had a digital probe thermometer and the two surveyor's digital probe thermometers were tested in a glass of ice water. All three thermometers displayed temperatures between 32-33 degrees F. Staff #81 also had an infrared thermometer. Following this, additional resident room temperatures were then taken as follows: -In room #103, the hot water temperature using two surveyor's thermometers were 131.4 degrees F and 131.9 degrees F. The Maintenance Director's digital thermometer read 132.2 degrees F. -In room #104 the hot water temperature using two surveyor's thermometers were 129.4 degrees F and 130 degrees F. The Maintenance Director's digital thermometer read 129.6 degrees F. -In room #204, the hot water temperature using two surveyor's thermometers were 127.0 degrees F and 127.0 degrees F. The Maintenance Director's digital thermometer read 127.0 degrees F. -In room #203, the hot water temperature using two surveyor's thermometers were 126 degrees F and 126 degrees F. The Maintenance Director's digital thermometer read 126 degrees F. During the observation, the Maintenance Director stated that he usually uses his infrared thermometer to test the hot water in resident rooms. He then used the infrared thermometer to check the hot water in room #203. The thermometer read 105 degrees F. The Maintenance Director stated he had not realized the infrared thermometer did not accurately reflect the temperature of the hot water. The Maintenance Director also stated that he never received any training on how to check the hot water temperatures. During an interview conducted at 3:11 p.m. on (MONTH) 27, (YEAR), the Maintenance Director stated he has used the infrared thermometer for the past [AGE] years and did not have any instruction manual or manufacturer's instructions for the use of the infrared thermometer. A review of the Water Temperature Logs revealed hot water temperatures were monitored in multiple resident rooms weekly. The water temperatures were documented between (MONTH) 6, (YEAR) and (MONTH) 20, (YEAR), and ranged between 101 to 120 degrees F. During an interview conducted at 3:53 p.m. on (MONTH) 27, (YEAR), the Maintenance Director stated the hot water heaters had been set at 135 degrees F. A copy of the facility's water temperature policy and procedure was requested. The Maintenance Director provided a written statement dated (MONTH) 28, (YEAR), which included We do not have a policy regarding water temps. We follow industry regs (regulations) and standards.",2020-09-01
675,MOUNTAIN VIEW MANOR,35114,1045 SANDRETTO DRIVE,PRESCOTT,AZ,86305,2017-03-31,371,E,0,1,EMQW11,"Based on observations, staff interviews, facility documentation and policy review, the facility failed to ensure that proper sanitation levels were maintained in the dishwasher, and failed to ensure that food was kept at a safe temperature in the kitchen reach in refrigerator. Findings include: An observation was conducted on (MONTH) 27, (YEAR) at 10:30 a.m. of the kitchen, with the Food Service Manager (staff #8) present. At this time, staff #8 stated the facility uses a low temperature dishwasher and that they use strips to check the sanitation level of the dishwasher. She stated that the sanitation levels should be between 50-100 parts per million (PPM). Staff #8 then checked the sanitation level with a test strip and stated, This is too low, there is not enough sanitizer in here. She further stated that she had checked the sanitation level last night and it was appropriate. She stated the sanitation level of the dishwasher is to be checked daily. Review of the dish machine temperature log for (MONTH) (YEAR) revealed the dishwasher sanitation level should be maintained between 50-100 PPM. On the log, there were areas to document the sanitation level three times a day (breakfast, lunch and dinner). Per the log, the sanitation level was 150 PPM on two occasions for the dinner meal and there were eight occasions when the sanitation level ranged from 0-40 PPM for the dinner meal. There was no documentation regarding any corrective action which was taken for the low/high sanitation levels. Review of the dish machine temperature log policy revealed that staff will be trained to report any problems with the dish machine to the food service manager, as soon as they occur. The policy included that for a low temperature dishwasher, the final sanitation level should reach 50 PPM hypochlorite. During this same observation, the outside thermometer on the reach-in refrigerator showed a temperature of 47 degrees Fahrenheit (F). An observation was then conducted of the inside of the refrigerator and there was no internal thermometer present. At this time, staff #8 stated there is normally an internal thermometer inside each refrigerator. She then placed an internal thermometer inside the reach-in refrigerator. After approximately five minutes, she stated the internal thermometer showed a temperature of 47 degrees F. After reviewing the temperature log for the reach-in refrigerator, she stated the temperature log showed that the refrigerator temperature was within normal range the previous night, but the temperature had not been checked today. She stated the food is not safe for residents to consume, because there is no way of knowing how long the refrigerator has been at 47 degrees. She stated the refrigerator temperature should be between 32 and 42 degrees, and since this food was unsafe, she would throw the food away immediately. Review of the food storage policy revealed that food is stored, prepared and transported at appropriate temperatures to prevent contamination. The policy included that all refrigerator units must be in good working condition at all times. The policy further included that temperatures for refrigerators should be between 35-39 degrees Fahrenheit, that thermometers should be checked at least two times per day, and that every refrigerator must be equipped with an internal thermometer. Review of the (MONTH) (YEAR) temperature logs for the reach-in refrigerator revealed instructions that the temperature should be below 41 degrees. The log showed temperatures were to be checked in the a.m. and the p.m. There were 17 times (7 times for the a.m. and 10 times for the p.m. temp) when the temperatures were out of the 35-39 range, per their policy.",2020-09-01
676,MOUNTAIN VIEW MANOR,35114,1045 SANDRETTO DRIVE,PRESCOTT,AZ,86305,2017-03-31,431,E,0,1,EMQW11,"Based on observations, staff interviews, manufacturers instructions and policy and procedures, the facility failed to discard six bottles of blood glucose control solutions which had expired. Findings include: -During a Medication Storage observation conducted at 2:00 p.m. on (MONTH) 30, (YEAR), of the 200 hall medication cart, two bottles of glucometer control solutions had opened dates written on the bottles of (MONTH) 21, (YEAR), and had discard dates of (MONTH) 21, (YEAR). The manufacturer's instructions on the bottles included that the solutions should be discarded within 90 days of the opened date. During an interview at this time, a Licensed Practical Nurse (LPN/staff #90) stated the glucometer is tested daily by the night shift and had been checked with these control solutions for eight days after the discard date. The LPN also stated that she had checked the 200 hall medication cart for expired medications, but had not checked the bottles of glucometer control solutions for expiration dates. -A Medication Storage observation was conducted at 2:10 p.m. on (MONTH) 30, (YEAR), of the 100 hall medication cart. Inside the cart were four bottles of glucometer control solutions. Two of the bottles had opened dates of (MONTH) 18, (YEAR). The manufacturer's instructions written on the bottles stated Use within 90 days of opening. The two bottles also had manufacturer's expiration dates of (MONTH) 31, (YEAR). In addition, the other two bottles of control solution were opened, however, there was no date when the bottles were opened. Per the instructions on the bottles, the solution should be discarded on the expiration date or within 90 days of the opened date. Review of the Blood Glucose Testing Log for (MONTH) (YEAR) revealed no documentation that the glucometer had been tested on 18 days during the month. During an interview conducted at 2:24 p.m. on (MONTH) 30, (YEAR), a Registered Nurse (RN/staff #94) stated she could not be sure the blood sugar test results were accurate, if using the glucometer in the 200 hall medication cart. She also stated that all nurses were responsible for checking drugs and biologicals for expiration dates. An interview was conducted at 9:00 a.m. on (MONTH) 31, (YEAR) with the Director of Nursing (staff #43). She stated the facility did not have a policy regarding the calibration of the glucometers. She said their protocol was for the night nurses to use the bottle of glucometer control solutions to calibrate the glucometers daily. She stated the manufacturer's guidelines included that the glucometers should be calibrated whenever a new bottle of test strips were opened, or when the batteries were changed or if the monitor was dropped. She stated that since no record was being kept regarding those conditions, the best practice and what she expected was for the glucometers to be checked every night by the nurses. She further stated that she had checked the medication carts for expired medications, but failed to check the glucometer control solutions to see if they were expired. A review of the manufactures Performing A Control Solution Test instructions revealed Perform a control solution test: Before testing the system for the first time; when you open a new bottle of test strips; and wherever you suspect the meter or test strips may not be functioning properly; if the test strip bottle has been left open or has been exposed to light or temperatures below 39 degrees F (Fahrenheit) or above 86 degrees F, or humidity levels above 80%. To check your technique; when the meter has been dropped or stored below 32 degrees F or above 122 degrees F and each time the batteries are changed. A review of the manufacturer's Glucose Control Instructions for Use insert revealed to use the Control solutions to make sure your system is working the way it should. If test results displayed in Meter falls within range of Control values given on Test Strip vial label, testing technique and System performance are acceptable. The Test Procedure: If opening the Control bottle for first time, write date opened on the bottle; check expiration dates on Control bottle and Test Strip vial label. Discard Control if 3 months past written opened date or past printed label expiration date. Use new Control and/or Test Strips if either date has passed.",2020-09-01
677,MOUNTAIN VIEW MANOR,35114,1045 SANDRETTO DRIVE,PRESCOTT,AZ,86305,2018-05-29,563,D,0,1,JGXN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, interviews and policy and procedures, the facility failed to ensure that a hospice provider had reasonable access to one resident (#22) and that one resident's (#45) responsible party had immediate access to the resident. Findings include: -Resident #22 was admitted on (MONTH) 13, (YEAR), with [DIAGNOSES REDACTED]. A physician's note dated (MONTH) 31, (YEAR) included for the resident to be admitted to hospice services. A nurses note dated (MONTH) 20, (YEAR) at 10:30 a.m., included that a nurse had called the resident's hospice provider to report that the resident was seeing snakes, refusing to leave the bathroom and was constantly scratching at herself. The note included that she spoke with a hospice nurse who said that they would follow-up with the resident's physician. The nurses note was signed by a LPN (Licensed Practical Nurse/staff #18). On (MONTH) 22, (YEAR) at 2:23 p.m., an interview was conducted with staff #18 who stated that on the weekend, the resident had been seeing snakes and centipedes and was cutting up toilet paper rolls and was refusing to leave the bathroom and wasn't sleeping well. Staff #18 stated she had contacted the on-call hospice nurse (registered nurse/staff #84) and told him that she wanted someone to see the resident. Staff #18 stated that another hospice nurse (staff #82) told her that staff #84 had come to see the resident on Sunday (May 20) and rang the doorbells and called by phone, but did not get an answer. Staff #18 further stated that she worked on (MONTH) 20, until 7:00 p.m., but did not receive a call from hospice staff #84. A telephone interview was conducted with hospice staff #82 on (MONTH) 23, (YEAR) at 9:28 a.m. Staff #82 stated that she had spoken to staff #18 on (MONTH) 22, regarding staff #84 not being able to get into the building to see the resident on (MONTH) 20. On (MONTH) 23, (YEAR) at 1:24 p.m., a telephone interview was conducted with hospice staff #84. Staff #84 stated he was the on-call nurse supervisor for the weekend. Staff #84 stated that early on (MONTH) 20, (YEAR), he had received a telephone call from staff #18 regarding resident #22's behaviors. Staff #84 stated that he told staff #18 that he would follow up with the resident's physician. He said later in the afternoon on (MONTH) 20, he wanted to see resident #22 and speak with staff #18 about resident 22's behaviors and review the resident's chart. Staff #84 stated he arrived at the building and rang the doorbell and called the number which was posted, but got no response so he could not get into the building. -Resident #45 was admitted on (MONTH) 16, (YEAR), with [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed the resident had a friend, who was documented as the resident's responsible party/POA (Power of Attorney). On (MONTH) 21, (YEAR) at 2:50 p.m., a telephone interview was conducted with resident #45's responsible party/POA, who stated that he came to visit the resident on Sunday (MONTH) 20, (YEAR), and was unable to get anyone to answer the door to let him in to see the resident. During an interview conducted with staff #18 on (MONTH) 22, (YEAR) at 2:23 p.m., staff #18 stated that when visitors or providers visit the facility after hours or on weekends, they are to ring the bell and/or call the telephone number posted on the door. She stated that the telephone rings throughout the building for staff to answer so visitors and providers can enter the building. She further stated that when there are staff in the office by the lobby, they let visitors and providers in. On (MONTH) 23, (YEAR) at 1:24 p.m., an interview was conducted with the Administrator (staff #81) regarding access to the building during non-business hours. The Administrator stated it was his understanding that families/responsible parties were given the code for the lobby and the number to call for staff to open the door. He stated that the telephone rings at the nurses' stations. He further stated that the information he had received from staff was that the code numbers were not being given to providers and that they were to call the telephone number listed at the door to have staff let them in or ring the doorbells. A sign posted at the front door included the following: All visitors must enter and exit through the main entrance and to sign in at the front desk. If you are a regular visitor, you may request the code to enter and exit the main lobby during business hours by completing the agreement. Business hours are 8:30 a.m., to 4:30 p.m. Monday through Friday. The sign further stated that there were no set visiting hours and listed a telephone number to call after hours and on the weekends and that visitors could ring the doorbells at doors 1, 2, or 6 for staff assistance. Review of the facility policy regarding Visitation revealed documentation that the facility provides 24-hour access to all individuals visiting with the consent of the resident. The policy stated that visitors may include but are not limited to spouses, domestic partners, other family members, and friends. Per the policy, residents are permitted to visit with representatives from Federal and State survey agencies, resident advocates, the State Long-Term Care Ombudsman, protection and advocacy agencies, clergy and personal physicians at any time.",2020-09-01
678,MOUNTAIN VIEW MANOR,35114,1045 SANDRETTO DRIVE,PRESCOTT,AZ,86305,2018-05-29,578,E,0,1,JGXN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews and policy review, the facility failed to ensure that advance directives for three residents (#3, #22 and #35) were accurately documented in their clinical record. Findings include: -Resident #35 was admitted on (MONTH) 6, (YEAR), with [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed a Do Not Resuscitate (DNR) medical care directive dated (MONTH) 16, (YEAR), which was signed by the resident's family member and a licensed health care provider. However, review of a recapitulation of physicians' orders for (MONTH) (YEAR) which were signed by the resident's physician, documented that the resident's code status was a Full Code. On (MONTH) 24, (YEAR) at 2:47 p.m., an interview was conduced with the Social Worker (staff #32). Staff #32 stated that he was aware of the conflict between the Advance Directive and the physician's orders [REDACTED]. -Resident #3 was admitted to the facility on (MONTH) 28, 2013 and readmitted on (MONTH) 21, (YEAR), with [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed an Advanced Directive form dated (MONTH) 14, (YEAR), which was signed by the resident, a nurse and the physician. This form contained a section to indicate I do want or I do NOT want specific life saving measures, such as cardiopulmonary resuscitation, hydration, nutrition, ventilators/respirators, blood transfusion and hospital transfer. Further review of this form revealed that it was difficult to determine what the resident's wishes were regarding these measures, because in the space to indicate if the resident wanted these life saving measures, there was what appeared to be hand written initials or a check mark with a line through it. The documentation was not clear as to what the resident's wishes were. Review of the recapitulation of physicians' orders for (MONTH) (YEAR) through (MONTH) (YEAR) which were signed by the resident's physician, revealed that the resident's code status was a DNR, meaning the resident would not be resuscitated if cardiac or respiratory arrest occurred. -Resident #22 was readmitted to the facility on (MONTH) 13, 2007, with [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed a medical care directive dated (MONTH) 3, (YEAR), which was signed by the resident's POA, a licensed health care provider and a Social Worker. The documentation included that the resident was a DNR status. However, according to the recapitulation of physician's orders [REDACTED]. The recapitulation of physicians' orders were signed by the resident's physician. Review of the recapitulation of physician's orders [REDACTED]. On (MONTH) 22, (YEAR) at 11:47 a.m., an interview was conducted with a Licensed Practical Nurse (LPN/staff #58). Staff #58 stated that when a resident is admitted , the admission nurse (or occasionally the social worker) will review the advanced directives with the resident and get the signatures. Staff #58 stated that the pharmacy transcribes the orders into the electronic system and returns the recapitulation of physician's orders [REDACTED].#58 stated that one copy will remain in the resident's chart for use, one copy is reviewed by the nurse and any corrections are made and returned to the pharmacy to update the recapitulation of physician's orders [REDACTED]. Staff #58 stated that once the white copy is signed it is placed in the resident's clinical record. On (MONTH) 23, (YEAR) at 12:18 p.m., an interview was conducted with the Director of Nursing (staff #5). Staff #5 stated when a resident is admitted the documents explaining the advance directive options are read to the resident and thoroughly explained. Staff #5 said they ensure that all questions are answered and the resident or representative understand the choices that are made. Staff #5 stated that a telephone order is created for the resident's preferences and faxed to the pharmacy. Staff #5 stated when they get the recapitulation back, the orders are reviewed to ensure that the correct code status is reflected on the orders. Review of a facility policy titled, Advanced Directives revealed that a resident's advanced directives will be respected in accordance with state law and facility policy. The policy also included that the DON or designee will notify the Attending Physician of advanced directives so that appropriate orders can be documented in the resident's medical record and plan of care.",2020-09-01
679,MOUNTAIN VIEW MANOR,35114,1045 SANDRETTO DRIVE,PRESCOTT,AZ,86305,2018-05-29,607,D,1,1,JGXN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, facility documentation, staff interviews and policy and procedures, the facility failed to follow their abuse policy for one resident (#38). Findings include: Resident #38 was admitted to the facility on (MONTH) 21, (YEAR), with [DIAGNOSES REDACTED]. A significant change of condition Minimum Data Set (MDS) assessment dated (MONTH) 27, (YEAR) revealed that staff assessed the resident as having moderate cognitive impairment and had memory problems. Review of a facility report revealed that bruising of an unknown origin was identified between and under the resident's eyes on (MONTH) 23, (YEAR). The report included a list of staff names, along with their speculations, as to how the injury of unknown origin may have occurred. The list included possible causes such as: -Could have happened during a transfer to or from bed -Resident is in constant movement -Can be combative or resistive when clothing is removed -Arms and hands fly all around -Bedside table was right next to the mattress The report included that the bruising may have occurred as early as (MONTH) 19, (YEAR). The report also included a list of six residents with the following comment: No concerns with direct care staff handing roughly, feeling unsafe, or fearful. No history of complaints of this nature in the 400 hall or the facility. Further review of the facility's investigative documentation revealed it was not thorough, as there were no interviews with staff who had worked around the time that the bruising occurred. A telephonic interview was conducted with a Resident Services Assistant (staff #41) on (MONTH) 24, (YEAR) at 9:10 a.m. Staff #41 stated that on a Friday in (MONTH) (a week or two after her start date of (MONTH) 5, (YEAR)) she witnessed abuse, but did not come forward because she was scared. Staff #41 said a resident yelled out in the dining room, because another resident was falling, so staff #86 (registered nurse) came over and grabbed the resident under her arms and lifted her up into the geri-chair. She stated that staff #86 then slammed the back of the geri-chair down three times and the resident bounced hard three times. She said that staff #86 was having a bad day and was very emotional and was crying on and off, because she thought the work was too hard. She said later the resident was found to have black eyes. Staff #41 said that she told a co-worker about it on the way home, and told the social worker when she punched out, but she did not tell the administrator until around (MONTH) 25, (YEAR). A telephonic interview was conducted with the former Administrator (staff #87) on (MONTH) 24, (YEAR) at 1:37 p.m. Staff #87 stated the staff interviews were done as a group, and they speculated as to how the injuries may have occurred. Staff #87 stated that she didn't know who to interview so she just asked for ideas from the group. Staff #87 further stated that on her last day at the facility maybe 10-20 minutes before she left, staff #41 called her and said she had an idea of how the bruising under the resident's eyes may have occurred, but nothing else was done at that time and the nurse no longer worked at the facility. An interview was conducted with the Director of Admissions (staff #40) on (MONTH) 25, (YEAR) at 9:00 a.m. Staff #40 stated that if abuse is witnessed or if there is a suspicion of abuse, it needs to be reported immediately to the Administrator. Staff #40 stated if the perpetrator is an employee they would be suspended, so they can't do the same thing to another resident. Staff #40 stated that staff #41 told her she was in the dining area and saw staff #86 respond to a resident who was sliding out of a chair and did something to the chair and it popped and jerked the resident 3-4 times. Staff #40 further stated that staff #86 was completely burned out and couldn't cope with admissions and would cry, because she wasn't able to handle that. An interview was conducted with the Director of Nursing (staff #5) on (MONTH) 25, (YEAR) at 12:04 p.m. Staff #5 stated that staff #86 was a new nurse and had a lot going on in her personal life. Staff #5 stated that staff #86 came in to her office and cried at least twice and once said that if they took any more residents she would quit. Staff #5 stated that staff #86 just called and quit one day. Staff #5 stated that she heard about the event with staff #86 much later and was aware that staff #41 told staff #40 about the incident, but staff #40 never reported it. Review of the facility policy titled Abuse Investigations and Reporting included that All reports of resident abuse .and/or injuries of unknown source shall be promptly reported to local, state and federal agencies .and thoroughly investigated by facility management . The Role of the Administrator section documented that The Administrator will suspend immediately any employee who has been accused of abuse, pending the outcome of the investigation. The Role of the Investigator section documented that the individual conducting the investigation will at a minimum: a. Review the completed documentation forms; b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident (as medically appropriate); f. Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition; g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family members, and visitors; i. Interview other residents to whom the accused employee provides care or services The policy also revealed guidelines to be used when conducting interviews which included that each interview will be conducted separately and in a private location and witness reports will be obtained in writing and will be signed and dated. Review of the facility's Abuse Prevention Program policy revealed that the objectives of the program were zero tolerance for all types of abuse, establish an atmosphere conducive to reporting, and develop a system for identifying, investigating, preventing, and reporting an incident or suspected incident of abuse. The Post-Employment section of the program documented that all employees will be informed of what constitutes abuse, reporting indications, take all comments of abuse seriously and report to the DON or Administrator immediately upon discovery, and that employees will be .instructed on stress and job burnout, which can put the employee at higher risk of impulsivity reacting to a resident in a manner which could be construed as mistreatment.",2020-09-01
680,MOUNTAIN VIEW MANOR,35114,1045 SANDRETTO DRIVE,PRESCOTT,AZ,86305,2018-05-29,609,D,1,1,JGXN11,"> Based on facility documentation, staff interviews and policy review, the facility failed to ensure an allegation of abuse was reported immediately to the Administrator for one resident (#38). Findings include: Review of a facility report revealed that bruising of an unknown origin was identified between and under the resident's eyes on (MONTH) 23, (YEAR). The report included a list of staff names, along with their speculations, as to how the injury of unknown origin may have occurred. The list included possible causes such as: -Could have happened during a transfer to or from bed -Resident is in constant movement -Can be combative or resistive when clothing is removed -Arms and hands fly all around -Bedside table was right next to the mattress The report included that the bruising may have occurred as early as (MONTH) 19, (YEAR). The report also included a list of six residents with the following comment: No concerns with direct care staff handing roughly, feeling unsafe, or fearful. No history of complaints of this nature in the 400 hall or the facility. A telephonic interview was conducted with a Resident Services Assistant (staff #41) on (MONTH) 24, (YEAR) at 9:10 a.m. Staff #41 stated that on a Friday in (MONTH) (a week or two after her start date of (MONTH) 5, (YEAR)) she witnessed abuse, but did not come forward because she was scared. Staff #41 said a resident yelled out in the dining room, because another resident was falling, so staff #86 (registered nurse) came over and grabbed the resident under her arms and lifted her up into the geri-chair. She stated that staff #86 then slammed the back of the geri-chair down three times and the resident bounced hard three times. She said that staff #86 was having a bad day and was very emotional and was crying on and off, because she thought the work was too hard. She said later the resident was found to have black eyes. Staff #41 said that she told a co-worker about it on the way home, and told the social worker when she punched out, but she did not tell the administrator until around (MONTH) 25, (YEAR). A telephonic interview was conducted with the former Administrator (staff #87) on (MONTH) 24, (YEAR) at 1:37 p.m. Staff #87 stated that on her last day at the facility maybe 10-20 minutes before she left, staff #41 called her and said she had an idea of how the bruising under the resident's eyes may have occurred, but nothing else was done at that time and the nurse no longer worked at the facility. An interview was conducted with the Director of Admissions (staff #40) on (MONTH) 25, (YEAR) at 9:00 a.m. Staff #40 stated that if abuse is witnessed or if there is a suspicion of abuse, it needs to be reported immediately to the Administrator. Staff #40 stated if the perpetrator is an employee they would be suspended, so they can't do the same thing to another resident. Staff #40 stated that staff #41 told her she was in the dining area and saw staff #86 respond to a resident, who was sliding out of a chair and then did something to the chair and it popped and jerked the resident 3-4 times. Staff #40 further stated that staff #86 was completely burned out and couldn't cope with admissions and would cry, because she wasn't able to handle that. An interview was conducted with the Director of Nursing (staff #5) on (MONTH) 25, (YEAR) at 12:04 p.m. Staff #5 stated that she heard about the event with staff #86 much later and was aware that staff #41 told staff #40 about the incident, but staff #40 never reported it. Review of the facility policy titled Abuse Investigations and Reporting included that All reports of resident abuse .and/or injuries of unknown source shall be promptly reported to local, state and federal agencies .and thoroughly investigated by facility management . Review of the facility's Abuse Prevention Program policy revealed that the objectives of the program were zero tolerance for all types of abuse, establish an atmosphere conducive to reporting, and develop a system for identifying, investigating, preventing, and reporting an incident or suspected incident of abuse. The Post-Employment section of the program documented that all employees will be informed of what constitutes abuse, reporting indications, take all comments of abuse seriously and report to the DON or Administrator immediately upon discovery.",2020-09-01
681,MOUNTAIN VIEW MANOR,35114,1045 SANDRETTO DRIVE,PRESCOTT,AZ,86305,2018-05-29,610,D,1,1,JGXN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, facility documentation, staff interviews, and policy and procedures, the facility failed to thoroughly investigate an injury of unknown origin for one resident (#38). Findings include: Resident #38 was admitted to the facility on (MONTH) 21, (YEAR), with [DIAGNOSES REDACTED]. Review of a facility report revealed that bruising of an unknown origin was identified between and under the resident's eyes on (MONTH) 23, (YEAR). The report included a list of staff names, along with their speculations, as to how the injury of unknown origin may have occurred. The list included possible causes such as: -Could have happened during a transfer to or from bed -Resident is in constant movement -Can be combative or resistive when clothing is removed -Arms and hands fly all around -Bedside table was right next to the mattress The report included that the bruising may have occurred as early as (MONTH) 19, (YEAR). The report also included a list of six residents with the following comment: No concerns with direct care staff handing roughly, feeling unsafe, or fearful. No history of complaints of this nature in the 400 hall or the facility. Further review of the facility's investigative documentation revealed it was not thorough, as there were no interviews with staff who had worked around the time that the bruising occurred. A telephonic interview was conducted with a Resident Services Assistant (staff #41) on (MONTH) 24, (YEAR) at 9:10 a.m. Staff #41 stated that on a Friday in (MONTH) (a week or two after her start date of (MONTH) 5, (YEAR)) she witnessed abuse, but did not come forward because she was scared. Staff #41 said a resident yelled out in the dining room, because another resident was falling, so staff #86 (registered nurse) came over and grabbed the resident under her arms and lifted her up into the geri-chair. She stated that staff #86 then slammed the back of the geri-chair down three times and the resident bounced hard three times. She said that staff #86 was having a bad day and was very emotional and was crying on and off, because she thought the work was too hard. She said later the resident was found to have black eyes. Staff #41 said that she told a co-worker about it on the way home, and told the social worker when she punched out, but did not tell the administrator until around (MONTH) 25, (YEAR). A telephonic interview was conducted with the former Administrator (staff #87) on (MONTH) 24, (YEAR) at 1:37 p.m. Staff #87 stated the staff interviews were done as a group, and they speculated as to how the injuries may have occurred. Staff #87 stated that she didn't know who to interview so she just asked for ideas from the group. Staff #87 further stated that on her last day at the facility maybe 10-20 minutes before she left, staff #41 called her and said she had an idea of how the bruising under the resident's eyes may have occurred, but nothing else was done at that time and the nurse no longer worked at the facility. Review of the facility policy titled Abuse Investigations and Reporting included that All reports of resident abuse .and/or injuries of unknown source shall be promptly reported to local, state and federal agencies .and thoroughly investigated by facility management . The Role of the Administrator section documented that The Administrator will suspend immediately any employee who has been accused of abuse, pending the outcome of the investigation. The Role of the Investigator section documented that the individual conducting the investigation will, as a minimum: a. Review the completed documentation forms; b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident (as medically appropriate); f. Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition; g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family members, and visitors; i. Interview other residents to whom the accused employee provides care or services The policy also revealed guidelines to be used when conducting interviews which included that each interview will be conducted separately and in a private location and witness reports will be obtained in writing and will be signed and dated. Review of the facility's Abuse Prevention Program policy revealed that the objectives of the program were zero tolerance for all types of abuse, establish an atmosphere conducive to reporting, and develop a system for identifying, investigating, preventing, and reporting an incident or suspected incident of abuse.",2020-09-01
682,MOUNTAIN VIEW MANOR,35114,1045 SANDRETTO DRIVE,PRESCOTT,AZ,86305,2018-05-29,637,D,0,1,JGXN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and policy review, the facility failed to ensure that a significant change of condition MDS (Minimum Data Set) assessment was completed for one resident (#22), who was admitted on hospice services. Findings include: Resident #22 was admitted to the facility on (MONTH) 13, (YEAR), with [DIAGNOSES REDACTED]. According to a change of condition MDS assessment dated (MONTH) 9, (YEAR), the resident was not receiving hospice services at this time. A physician's orders [REDACTED]. However, there was no change of condition MDS assessment which was completed within 14 days of the resident having been admitted to hospice services. Review of the clinical record revealed that the next MDS assessment which was completed was a quarterly assessment dated (MONTH) 9, (YEAR). This MDS included the resident was receiving hospice services. During an interview with a LPN (Licensed Practical Nurse/MDS coordinator/staff #3) on (MONTH) 24, (YEAR) at 9:40 a.m., staff #3 stated that a change of condition MDS should have been initiated within 14 days of the physician's orders [REDACTED]. Review of the MDS Completion and Submission Timeframe policy revealed documentation that a significant change in status assessment should be completed no later than 14 days after determination of a significant change. The policy further documented that the MDS assessment coordinator or designee shall be responsible for ensuring that resident assessments are submitted in accordance with current Federal and State guidelines.",2020-09-01
683,MOUNTAIN VIEW MANOR,35114,1045 SANDRETTO DRIVE,PRESCOTT,AZ,86305,2018-05-29,656,D,0,1,JGXN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility failed to ensure that comprehensive care plans were developed to address problem areas as identified in the Minimum Data Set (MDS) assessment for one resident (#49). Findings include: Resident #49 was readmitted to the facility on (MONTH) 2, (YEAR), with [DIAGNOSES REDACTED]. Review of the admission MDS assessment dated (MONTH) 9, (YEAR) revealed the following problem areas triggered: cognitive loss/dementia, urinary incontinence, indwelling catheter, behavioral symptoms, pressure ulcers, [MEDICAL CONDITION] drug use and pain. The MDS also included to proceed to care planning for these areas. However, review of the resident's comprehensive care plans revealed there were no care plans which were developed to address cognitive loss/dementia, urinary incontinence, indwelling catheter, behavioral symptoms, pressure ulcers, [MEDICAL CONDITION] drug use and pain. During an interview conducted at 9:01 a.m. on (MONTH) 25, (YEAR), the MDS Coordinator (staff #3) stated that the comprehensive care plans should have been completed within 7 days after the completion of the MDS assessment (May 16, (YEAR)), and that the comprehensive care plans have not been completed as of (MONTH) 25.",2020-09-01
684,MOUNTAIN VIEW MANOR,35114,1045 SANDRETTO DRIVE,PRESCOTT,AZ,86305,2018-05-29,657,D,0,1,JGXN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure one resident (#19) was invited to participate in the development of his care plan. Findings include Resident #19 was readmitted to the facility on (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. According to an admission Minimum Data Set (MDS) assessment dated (MONTH) 27, (YEAR), the resident was assessed to have a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderate cognitive impairment. Review of the care plan conference summary dated (MONTH) 3, (YEAR) revealed the resident was alert and oriented times two, and was usually able to make needs known. Further review revealed the resident's fiduciary was invited to attend the care plan conference on (MONTH) 27, (YEAR), and that the fiduciary was present via phone for the care plan conference. However, there was no evidence that the resident was invited to attend or participated in his care plan conference. Review of a quarterly MDS assessment dated (MONTH) 19, (YEAR), revealed the resident had a BIMS score of 9, which indicated the resident had moderate cognitive impairment. Review of the care plan conference summary dated (MONTH) 28, (YEAR), revealed the resident was alert and oriented times two and makes needs known. Further review revealed the resident's fiduciary was invited to attend the care plan conference and attended via phone. However, there was no evidence that the resident was invited to attend or participated in his care plan conference. An interview was conducted on (MONTH) 21, (YEAR) at 12:59 p.m., with resident #1. He stated that he has not been invited, nor has he participated in a care plan conference. An interview was conducted on (MONTH) 23, (YEAR) at 10:09 a.m., with a registered nurse (RN/staff #30). She stated the resident is alert and oriented times two and has occasional confusion, due to dementia. She stated that family and residents are invited to attend their care plan conferences. An interview was conducted on (MONTH) 23, (YEAR) at 11:53 a.m., with Social Services (staff #32). He stated that care plan conferences are based on the MDS assessments and that family and residents are invited a week prior to the care plan conference. He stated care plan conference notes are completed and should include if the resident was invited. At this time, he reviewed the clinical record and stated there is no documentation that the resident was invited to participate in his care plan conferences. An interview was conducted on (MONTH) 24, (YEAR) at 1:42 p.m. with the Director of Nursing (DON/staff #5) and the Assistant Director of Nursing (ADON/staff #3). Staff #3 stated that care plan conferences are held with the resident and the family, within 7-14 days after the MDS assessment is completed. Staff #3 stated social services is responsible for inviting the resident and family. Staff #3 stated the resident and family invitations and participation are documented under the care plan conference summary, and there is no other place to document this. At this time, staff #3 and staff #5 reviewed the resident's clinical record and stated there is no evidence that the resident was invited to participate in his care plan conference. Review of the facility's policy titled Care plans, Comprehensive Person Centered revealed that an interdisciplinary team (IDT) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. Further, an explanation will be included in the resident's medical record if the participation of the resident and his/her representative for developing the resident's care plan is determined to not be practicable or the resident refuses to participate. According to a policy titled, Resident/Family participation-assessment/care plans revealed each resident and his/her family members are encouraged to participate in the development of the resident's comprehensive assessment and care plan. The policy included that a seven day advance notice of the care planning conference is provided to the resident.",2020-09-01
685,MOUNTAIN VIEW MANOR,35114,1045 SANDRETTO DRIVE,PRESCOTT,AZ,86305,2018-05-29,658,E,0,1,JGXN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, facility documentation and policy review, the facility failed to ensure that physician's orders for two residents (#21 and #24) were followed. Findings include: -Resident #21 was admitted to the facility on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. Review of the dietary progress notes dated (MONTH) 13, (YEAR) revealed a recommendation for med pass, twice a day between meals. A physician's order dated (MONTH) 14, (YEAR) included for four ounces of med pass twice a day between meals. Review of the Minimum Data Set (MDS) admission assessment completed on (MONTH) 22, (YEAR), revealed a Brief Interview for Mental Status (BIMS) score of 5, which indicated that the resident had severe cognitive impairment and required limited assistance with activities of daily living. According to the Medication Administration Record [REDACTED]. However, review of the clinical record including the MAR for (MONTH) and (MONTH) (YEAR), revealed no documentation that the resident received the med pass twice a day between meals as ordered. Further review of the clinical record revealed there was no physician's order to discontinue the med pass. During an interview conducted on (MONTH) 24, (YEAR) at 10:38 a.m. with a licensed practical nurse (staff #58), she stated that the resident receives med pass, but was unable to locate the administration records for the months of (MONTH) and (MONTH) (YEAR). She stated that she was the staff member responsible to transcribe the orders from month to month and that it must have been overlooked. She stated that the resident was receiving the med pass, but could not produce any documentation which would confirm it's administration. During an interview conducted on (MONTH) 24, (YEAR) at 10:56 a.m. with the Dietary Manager (staff #7) and the Registered Dietician (staff #85), they stated that the resident should be continuing to receive the med pass supplement and that there was no order to discontinue it. An interview was conducted on (MONTH) 24, (YEAR) at 11:18 a.m., with the Director of Nursing (staff #5). She stated that the expectation is for the orders to be transcribed correctly. Staff #58 said that staff #58 was responsible for transcribing the orders and the recaps for the 100 and 200 halls, and verifying that all orders were present. -Resident #24 was admitted on (MONTH) 8, (YEAR), with [DIAGNOSES REDACTED]. A review of the (MONTH) (YEAR) physician's orders revealed the following medication orders [REDACTED] [MEDICATION NAME] (a mood stabilizer) 250 mg (milligrams) po (by mouth) every night at bedtime for unspecified dementia with behavioral disturbances; [MEDICATION NAME]-R (insulin) per sliding scale subcutaneous four times a day for diabetes mellitus; [MEDICATION NAME] 500 mg every a.m. and with dinner for diabetes mellitus; Alfuzosin 10 mg daily for [MEDICAL CONDITION]; [MEDICATION NAME] 20 mg at bedtime for high cholesterol; and [MEDICATION NAME] 75 mg daily for [MEDICAL CONDITION]. Review of the MAR for (MONTH) (YEAR) revealed no documentation that the following medications were administered: Alfuzosin was missing 11 doses; [MEDICATION NAME]-R per sliding scale was missing one dose at 11:00 a.m. and seven doses at 10:00 p.m.; [MEDICATION NAME] was missing two doses at 6:00 p.m.; and [MEDICATION NAME] was missing one dose at 8:00 a.m. According to the (MONTH) (YEAR) MAR, there was no documentation that the following medications were administered: Divoloprex was missing one dose at 10:00 p.m.; [MEDICATION NAME] was missing three doses at 10:00 p.m.; Alfuzosin was missing seven doses at 6:00 p.m.; and [MEDICATION NAME]-R per sliding scale was missing three doses at 8:00 p.m. An interview was conducted with a LPN (Licensed Practical Nurse/staff #18) on (MONTH) 25, (YEAR) at 11:25 a.m. Staff #18 stated that when a nurse administers a medication, the nurse should put their initial in the box on the MAR for the corresponding date and time that the medication was given. Staff #18 further stated that she was unaware if anyone was auditing the MARs for completion, but the nurses should be making sure they have completed their documentation. A facility job description for Registered Nurse's and LPN's included that the nurse should prepare and administer medications, as ordered by the physician. A policy for medication administration revealed documentation that the MAR indicated [REDACTED]. Initials on each MAR indicated [REDACTED]. The MAR indicated [REDACTED].",2020-09-01
686,MOUNTAIN VIEW MANOR,35114,1045 SANDRETTO DRIVE,PRESCOTT,AZ,86305,2018-05-29,677,E,0,1,JGXN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff and resident interviews, facility documentation, and policy review, the facility failed to ensure one resident (#27) received adequate showers. Findings include: Resident #27 was admitted to the facility on (MONTH) 5, (YEAR), with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 9, (YEAR), revealed the resident had a Brief Interview for Mental Status score of 14, which indicated the resident was cognitively intact. The MDS included the resident required extensive assistance of one person for personal hygiene and required total assistance of one person for bathing. An interview was conducted with resident #27 on (MONTH) 21, (YEAR) at 11:33 a.m. The resident stated that she was lucky if she ever got a shower. The resident stated if she was not ready for her shower at the moment the Certified Nursing Assistants (CNAs) come in, they leave and say I refused, and I never refuse a shower. She stated her shower days are Sundays and Thursdays. Review of the resident's electronic shower documentation and the daily CNA staffing sheets revealed the following: -Week of (MONTH) 18-24, (YEAR): the resident did not receive any showers -Week of (MONTH) 25-March 3: the resident received only one shower -Week of (MONTH) 4-10, (YEAR): the resident received only one shower -Week of (MONTH) 11-17: the resident received only one shower -Week of (MONTH) 18-24: the resident did not receive any showers -Week of (MONTH) 25-31: the resident received only one shower -Week of (MONTH) 1-7, (YEAR): the resident did not receive any showers -Week of (MONTH) 8-14: the resident did not receive any showers -Week of (MONTH) 22-28: the resident received only one shower -Week of (MONTH) 6-12, (YEAR): the resident received only one shower -Week of (MONTH) 13-19: the resident received only one shower -Week of (MONTH) 20-26: the resident received only one shower Further review revealed that there was no documentation that the resident had refused any showers during these time frames. In an interview conducted with a Licensed Practical Nurse (LPN/staff #58) on (MONTH) 22, (YEAR) at 11:47 a.m., staff #58 stated that if staffing is short, the showers don't get done. Staff #58 stated if a shower is missed we might try a bed bath if we can or move the shower to the next shift or the next day. In an interview conducted with a Certified Nursing Assistant (CNA/staff #36) on (MONTH) 22, (YEAR) at 12:10 p.m., staff #36 stated that lately over the past few months, we have been short staffed and the resident's showers are the things that probably don't get done. An interview was conducted with the Director of Nursing (staff #5) on (MONTH) 22, (YEAR) at 1:05 p.m. Staff #5 stated that they have been short a lot, and evening shift is the worst. Staff #5 said when they are short, the baths and showers don't get done. Staff #5 stated that the staff will try and provide the bath or shower the next day, but it has been hard and sometimes we messed up. A facility policy titled, Shower/Tub Bath included the purpose was to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. The policy included that the following information should be reported and/or recorded in the resident's medical record: -the date and time of the shower or bath -the name and title of the individual who assisted the resident -all assessment data obtained during the shower or bath -how the resident tolerated the shower/bath -if the resident refused, the reason why and the intervention taken -the signature and title of the person recording the data The policy further noted that the supervisor should be notified if the resident refuses a shower or bath.",2020-09-01
687,MOUNTAIN VIEW MANOR,35114,1045 SANDRETTO DRIVE,PRESCOTT,AZ,86305,2018-05-29,695,D,0,1,JGXN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, resident and staff interviews, and policy and procedures, the facility failed to ensure one resident (#47) was provided oxygen, per the physician's orders and plan of care, and failed to ensure one resident (#49) had physician orders for oxygen. Findings include: -Resident #47 was admitted to the facility on (MONTH) 29, (YEAR), with [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment completed on (MONTH) 11, (YEAR), revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS also identified that the resident was receiving oxygen prior to admission and while a resident. According to the clinical record documentation, the resident was hospitalized with pneumonia and [MEDICAL CONDITION] on (MONTH) 7, (YEAR), and was readmitted to the facility on (MONTH) 15, (YEAR). Review of the resident's comprehensive care plan revealed the resident required the use of oxygen therapy. An intervention included to Provide me with humidification. Review of the re-admission physician orders dated (MONTH) 15, (YEAR) revealed for oxygen at 2 liters/minute via nasal cannula as needed for SOB (shortness of breath). Review of the recapitulation of physician's orders for (MONTH) (YEAR) revealed an order for [REDACTED]. A review of the Vital Signs Record for (YEAR) revealed the resident was receiving oxygen at 2 liters on (MONTH) 22, 23, 24, 26, and on (MONTH) 6. The documentation also included the resident received 3 liters of oxygen on (MONTH) 26, 30, and on (MONTH) 9. However, the clinical record documentation did not include any evidence that the resident was short of breath or experienced any wheezing during the above time frames. During an observation conducted at 12:32 p.m. on (MONTH) 21, (YEAR), the resident was observed receiving oxygen at two liters per minute. Also, the humidifier on the oxygen concentrator was not connected. At this time, an interview with the resident was conducted. The resident stated that a nurse disconnected the humidifier, because it was blocking the air flow to the nasal cannula. Additional observations were conducted at 1:03 p.m. on (MONTH) 22, and at 11:18 a.m. on (MONTH) 23, (YEAR). During both of these observations, the resident was observed to be receiving oxygen at 3 liters per minute. Also, the humidifier on the oxygen concentrator was not connected. Another observation was conducted at 1:20 p.m. on (MONTH) 23, (YEAR), with a licensed practical nurse (staff #58) present. The resident was observed to be receiving oxygen at 3 liters per minute. Also, the humidifier on the oxygen concentrator was not connected. At this time, staff #58 stated that she was not aware of what the physician's order was for the oxygen flow rate. Staff #58 also stated that she was not aware of the care plan approach for the use of humidified oxygen and was unaware that the humidifier was not connected to the oxygen concentrator. Following the observation, staff #58 stated that the physician's order was for 2 liters of oxygen as needed for shortness or breath or wheezing. She stated that prior to using 3 liters of oxygen, the physician should have been called and new orders received. Further review of the clinical record revealed the resident was receiving oxygen on (MONTH) 21, 22 and 23, (YEAR). However, there was no documentation that the resident was short of breath or had any wheezing, nor was there an explanation as to why the resident needed the oxygen. -Resident #49 was readmitted to the facility on (MONTH) 2, (YEAR), with [DIAGNOSES REDACTED]. A nurses note dated (MONTH) 3, (YEAR) revealed the resident's oxygen saturation levels were at 88%, so oxygen was applied via nasal cannula (N/C) at three liters per minute, and then the oxygen saturation level increased to 98%. The note further included that the resident needs to be reminded to keep the nasal cannula on to prevent a drop in oxygen saturations, related to narcotic respiratory depression. A nurses note dated (MONTH) 4, (YEAR) included to remind the resident to keep the oxygen on via nasal cannula at 3 liters/minute to prevent oxygen saturations from decreasing. Review of the admission MDS assessment dated (MONTH) 9, (YEAR), revealed the resident was receiving oxygen while a resident. A review of the Vital Signs Record revealed the resident utilized oxygen at two/three liters on (MONTH) 2, 7, 9, 10, 11, 13, 14, 15 and 21, (YEAR). However, further review of the physician orders revealed there were no orders for the resident to receive oxygen. During an observation conducted at 1:42 p.m. on (MONTH) 21, (YEAR), the resident was observed with oxygen on via nasal cannula, and the oxygen concentrator was set at two liters per minute. At this time, the resident stated that she uses oxygen as needed. During an interview conducted at 10:21 a.m. on (MONTH) 25, (YEAR), a licensed practical nurse (staff #58) stated the resident was not receiving oxygen and did not have a physician's order for oxygen. Review of the Oxygen Administration policy revealed the purpose was to provide guidelines for safe oxygen administration. The policy included to verify that there is a physician's order for this procedure. The policy also included to check the tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles, as oxygen flows through. The policy stated to include the reason for as needed administration and all assessment data obtained before, during and after the procedure.",2020-09-01
688,MOUNTAIN VIEW MANOR,35114,1045 SANDRETTO DRIVE,PRESCOTT,AZ,86305,2018-05-29,725,E,1,1,JGXN11,"> Based on resident and staff interviews, facility documentation and policy review, the facility failed to ensure sufficient staff were available on a 24-hour basis to provide nursing care to residents in a timely manner. Findings include: During the initial phase of the survey, 8 out of 19 residents identified concerns of not having enough staff, as they had to wait anywhere from 45 minutes to over an hour for call lights to be responded to during the night shift, resulting in incontinence, leaving residents on the toilet for 40 minutes or longer, and residents becoming agitated due to the long call light response times. Another concern was that residents were not being fed in a timely manner. In addition, there was also a complaint that there were not enough staff available on the 2nd shift, and that residents were not getting showers because of this. As a result, the facility's staffing documentation and a random selection of payroll records were reviewed and revealed the following: February 5, (YEAR): there were 3.5 CNAs who worked the day shift and the resident census was 58. February 8, (YEAR): there were 2 CNAs who worked the night shift and the resident census was 61. February 21, (YEAR): there were 3 CNAs who worked on the evening shift and the resident census was 59. An interview was conducted with a Licensed Practical Nurse (LPN/staff #58) on (MONTH) 22, (YEAR) at 11:47 a.m. Staff #58 stated that staffing has been short and when staffing is short, the things that don't get done are the resident's showers. Staff #58 stated they try and provide a bed bath, or they may give the shower the next shift or next day. Staff #58 also stated that residents may not be able to get to bed or get out of bed when they want, especially if help is needed with a mechanical lift. An interview was conducted with a Certified Nursing Assistant (CNA/staff #36) on (MONTH) 22, (YEAR) at 12:10 p.m. Staff #36 stated that lately there have been only 2 CNAs on the floor during the day and before it was 3. She stated currently there are 6 residents on 300-400 hall and 2 residents on the 100-200 hall that require a Hoyer lift, with 2 staff for transfers. Staff #36 said that when staffing is short, the showers do not get done. Staff #36 stated the CNAs focus on feeding residents and making sure everyone is dry. Staff #36 stated the night shift has been much lower staffed and as a result, the night shift is not able to assist in getting residents up in the morning and that falls to the day shift, which is also lower staffed than in the past. An interview was conducted with the Director of Nursing (DON/staff #5) on (MONTH) 22, (YEAR) at 1:05 p.m. Staff #5 stated the facility is divided into the 100-200 hall (total 46 beds) and the 300-400 hall (total 55 beds), and that all but one staff member work 8-hour shifts. The DON stated the normal staffing levels for the facility included the following: 1 nurse (LPN or RN) on the 100-200 hall and one on the 300-400 hall for each shift; 2 to 4 CNAs for the 100-200 for the day shift and 1-3 for the evening and night shifts; and 2 to 4 CNAs for the 300-400 hall for the day shift and 1-3 for the evening and night shifts. The DON further stated that the workload on the 300-400 hall is heavier, so she staffs that hall higher, with 2 CNAs being the normal. The DON stated much of the discrepancy related to how many CNAs were on duty had to do with the practice of the CNAs being allowed to make their own schedules. The DON stated that the provision of resident care is first and foremost, and that the amount of assistance needed and resident's needs are used to make determinations for staffing. The DON stated we have been short-staffed a lot and the evening shift is the worst. The DON stated when staffing is short, sometimes residents do not get moved and sometimes the baths/showers are not completed, but they try to do it the next day. The DON stated that staffing has been hard and sometimes we messed up. The DON also stated that on occasion she will go into a room during the day or evening and push a call light to see the response time, which has varied from 1-25 minutes, but has not checked the response routinely or on the night shift. The DON stated the facility began using registry nurses and CNAs in (MONTH) (YEAR) to supplement the staff shortages. Interviews were conducted with five residents on (MONTH) 22, (YEAR) at 2:31 p.m. Regarding staffing levels and the ability to receive timely care the residents stated the following: The wait time is long and right now they don't have enough help. It can take 1-2 hours to get medicine because the nurses have to do the whole floor. I had to wait a long time because all the CNAs were in the dining room. My medications were due at 8 p.m. and I didn't get them until midnight. I am having a hard time getting my medications. The response time is long and they just don't have enough help. Review of the shower schedules and daily sign-in sheets revealed multiple residents were not receiving showers as scheduled. Review of the facility policy titled Staffing revealed Our facility provides adequate staffing to meet needed care and services for our resident population. The policy included that adequate staffing is maintained on each shift to ensure that the resident's needs and services are met. The licensed nursing staff are available to provide and monitor the delivery of resident care services and that CNAs are available on each shift to provide the needed care and services of each resident, as outlined on the resident's care plan.",2020-09-01
689,MOUNTAIN VIEW MANOR,35114,1045 SANDRETTO DRIVE,PRESCOTT,AZ,86305,2018-05-29,732,E,0,1,JGXN11,"Based on facility documentation, staff interviews and policy review, the facility failed to ensure that the posted nurse staffing and census data were maintained for a period of at least 18 months. Findings include: A review of the facility's Daily Staff and Census Posting data from (MONTH) 1, (YEAR) through (MONTH) 21, (YEAR) was conducted on (MONTH) 22, (YEAR) and revealed the following: -January (YEAR): The records were only available for 9 out of 31 days. -February (YEAR): The records were only available for 10 out of 28 days. -March (YEAR): The records were only available for 14 out of 31 days. -April (YEAR): The records were only available for 12 out of 30 days. -May 1-21, (YEAR): The records were only available for 11 out of 21 days. In an interview conducted with the Director of Nursing (DON/staff#5) on (MONTH) 22, (YEAR) at 1:05 p.m., staff #5 stated these were the only records that she had on the postings and that maybe staff had taken them down and threw them away. The DON also stated that she was not aware of the time frame for maintaining the Daily Staff and Census posting records. Review of the facility's policy regarding Posting Direct Care Staffing Numbers revealed Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents . The policy also included that Records of staffing information for each shift will be kept for a minimum of eighteen (18) months .",2020-09-01
690,MOUNTAIN VIEW MANOR,35114,1045 SANDRETTO DRIVE,PRESCOTT,AZ,86305,2018-05-29,758,E,0,1,JGXN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to ensure one resident (#24) who was receiving [MEDICAL CONDITION] medications had consistent documentation of monitoring targeted behaviors. Findings include: Resident #24 was admitted on (MONTH) 8, (YEAR), with [DIAGNOSES REDACTED]. Review of the (MONTH) and (MONTH) (YEAR) physician orders [REDACTED]. Review of the resident's clinical record revealed Behavior/Intervention Monthly Flow records for (MONTH) and (MONTH) (YEAR). These records included that the resident was being monitored for depression, with targeted behaviors of self-isolation and not participating in social activities, related to the use of [MEDICATION NAME]. These records also included that the resident was being monitored for behaviors related to anxiety and hours of sleep regarding the use of Trazadone. Per the Behavior/Intervention Monthly Flow records, the behavior monitoring documentation was to be completed on the evening and night shifts. Further review of the Behavior/Intervention Monthly Flow record for (MONTH) (YEAR) revealed the following: there was no documentation of monitoring the resident's behaviors related to depression on 11 out of 30 days on the evening shift, and there was no documentation that the resident's behaviors were monitored for anxiety on 11 of 30 days on the evening shift. According to the Behavior/Intervention Monthly Flow record for (MONTH) (YEAR), there was no documentation that the resident's behaviors were monitored related to depression on 5 out of 24 days on the evening shift, and the behavior of not participating in social activities had no documentation for 4 of 24 days on the evening shift. An interview was conducted with a LPN (Licensed Practical Nurse/staff #18) on (MONTH) 25, (YEAR) at 11:25 a.m. Staff #18 stated that nurses should be documenting the resident's targeted behaviors on the Behavior/Intervention Monthly Flow record by the end of their shift. Staff #18 stated she did not know why there was missing documentation. During an interview on (MONTH) 25, (YEAR) at 11:30 a.m., the DON (Director of Nursing/staff #5) stated that the nurses should be documenting the residents' targeted behaviors on the Behavior/Intervention Monthly Flow record.",2020-09-01
691,MOUNTAIN VIEW MANOR,35114,1045 SANDRETTO DRIVE,PRESCOTT,AZ,86305,2018-05-29,761,E,0,1,JGXN11,"Based on facility documentation and staff interviews, the facility failed to ensure that the medication room refrigerator temperature logs were consistently completed. Findings include: Review of the medication room refrigerator logs revealed instructions which included that the temperature of the freezer/refrigerator were to be checked at least twice each day and to record the time. Review of the logs for (MONTH) (YEAR) revealed the temperatures were only checked 24 out of 62 times and the time was not recorded. Review of the logs for (MONTH) (YEAR) revealed the temperatures were only checked 23 out of 56 times and the time was not recorded. Review of the logs for (MONTH) (YEAR) revealed the temperatures were only checked 23 out of 62 times and the time was not recorded. Review of the logs for (MONTH) (YEAR) revealed the temperatures were only checked 10 out of 60 times. Review of the logs for (MONTH) (YEAR) revealed the temperatures were only checked 6 out of 62 times. An interview was conducted on (MONTH) 25, (YEAR) at 10:30 a.m. with a Licensed Practical Nurse/Assistant Director of Nursing (staff #3), who stated that staff are supposed to check the medication refrigerator temperatures twice each day and record the temperature and time on the log. An interview was conducted on (MONTH) 25, (YEAR) at 10:50 a.m., with the Director of Nursing (staff #5). She stated that it is their policy to have the medication room refrigerator temperatures checked and documented twice a day.",2020-09-01
692,MOUNTAIN VIEW MANOR,35114,1045 SANDRETTO DRIVE,PRESCOTT,AZ,86305,2018-05-29,812,D,0,1,JGXN11,"Based on observations, staff interviews and policy review, the facility failed to ensure the stove top and the area around the deep fryer were clean. Findings include: On (MONTH) 21, (YEAR) at 11:56 a.m., an observation was conducted of the facility's kitchen with the food service manager (staff #7) and the food service consultant (staff #83). At this time, the stove was observed to have grease build-up and burned debris on the grates and burners. Also, there was burned debris on the metal shelf on the front side of the deep fryer. During the observation, an interview was conducted with staff #7, who stated the evening cook was supposed to clean the stove/fryer area, before the end of his shift. Staff #7 stated she couldn't find the cleaning schedule for May. On (MONTH) 21, (YEAR) at 2:00 p.m., staff #7 presented a copy of the (MONTH) (YEAR) cleaning schedule. The list included that the range top and surrounding area were to be cleaned on Fridays, however, there was no documentation that the tasks had been completed. Staff #7 stated the schedule did not give any indications if the tasks had been done. An interview was conducted with the cook (staff #46) on (MONTH) 23, (YEAR) at 1:57 p.m. Staff #46 stated it was his responsibility to clean the stove and cook top areas. Staff #46 stated there used to be a cleaning schedule which had to be initialed, but there isn't one now. Staff #46 stated there was no way to document when the cleaning had been done. Review of the cleaning of the range policy revealed documentation that the cook on each shift is responsible for keeping the range as clean as possible and will be cleaned after each use. Spills and food particles will be wiped up as they occur. Scrape burned particles and grease off using proper cleaning items (a non-metal scouring pad may be needed for metal surfaces).",2020-09-01
693,MOUNTAIN VIEW MANOR,35114,1045 SANDRETTO DRIVE,PRESCOTT,AZ,86305,2019-08-07,600,D,0,1,PTZU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, facility documentation and policies and procedures, the facility failed to ensure that one resident (#38) was free from physical abuse by two residents (#7 and #24) and that one resident (#18) was free from abuse by resident (#38). The facility census was 50. The deficient practice could result in further incidents of resident-to-resident physicial abuse. Findings include: -Resident #7 was admitted to the facility on (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. Review of a care plan dated (MONTH) 20, (YEAR) revealed the resident has a history of anxiety, Alzheimer's and dementia with at times poor comprehension of directives secondary to advancing disease process, feeling of owning space within the facility related to length of stay and becoming upset with others use of said space. The resident fails to verbally communicate her feelings and will show them externally by shaking her walker. Risk for decline secondary to advancing disease process. A goal included that the resident will be able to express her ideas or wants. Approaches were to allow the resident plenty of time to respond as needed, provide a quiet environment when discussing important issues and the resident understands simple, direct communication best. A quarterly MDS assessment dated (MONTH) 22, 2019 revealed the resident had short and long term memory problems and was severely impaired with cognitive skills for daily decision making. -Resident #38 was admitted to the facility on (MONTH) 28, (YEAR), with [DIAGNOSES REDACTED]. A care plan dated (MONTH) 26, 2019 documented the resident has a history of wandering throughout the facility and placing herself in unsafe situations. [DIAGNOSES REDACTED]. A goal was I will not wander into unsafe situations. Approaches included Place me in area where frequent observation is possible. Alert staff to my wandering behavior. Provide diversional activities for me. Approach me positively and in calm, accepting manner. Record and report changes to MD (medical doctor) and family as needed. Review of the quarterly MDS (Minimum Data Set) assessment dated (MONTH) 17, 2019, revealed the resident had short and long term memory problems and was severely impaired with cognitive skills for daily decision making. Review of the nurse's notes for resident #38 dated (MONTH) 19, 2019 at 9:00 a.m. revealed the following: Heard patient (resident #38) state 'she hit me she hit me hard.' Ran to see another peer (resident #7) with her hands in the air . Resident #7 was immediately removed. No injuries were noted. The resident had two levels of long sleeves on. An Incident/Accident Report dated (MONTH) 19, 2019 included that resident #38 was heard saying She hit me she hit me hard. A CNA observed (resident #7) attempting to hit her again and they were immediately separated. A facility Reportable Event Record/Report revealed that on (MONTH) 19, 2019, resident (#7) hit resident (#38) while they were sitting in the 100/200 hall common area watching TV. Apparently resident #38 was too close to the recliner that resident #7 was sitting in and she hit resident #38. No injury was noted. Interventions implemented after the incident included the two residents were immediately separated and resident #7 was placed on 30 minute checks for 72 hours without further incident. As the resident's shared a room, resident #38 was moved to a room on a separate hall to maintain distance between them. A second recliner was placed approximately a foot and a half from the recliner that resident #7usually sits in, so that a permanent chair is a safe distance from her recliner, and no one in a wheelchair will be placed too close to her recliner to avoid any further potential incident. Further review of the nurses notes for resident #38 dated (MONTH) 9, 2019 at 9:30 a.m. revealed Patient (#38) observed to hit a female resident (#18) open handed on the forehead. No injury . Review of an Incident/Accident Report dated (MONTH) 9, 2019 revealed CNA's reported this client (#38) struck another female (#18) with her open hand in the forehead. Patients immediately separated. Core staff informed. Keep space between them. -Resident #18 was admitted to the facility on (MONTH) 13, 2007, with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment dated (MONTH) 20, 2019, revealed a Brief Interview for Mental Status score of 12, which indicated the resident had moderate cognitive impairment. Review of a care plan dated (MONTH) 31, 2019 documented the resident exhibits social isolation as evidenced by spending most of her day in her room. Another care plan dated (MONTH) 31, 2019 included the resident has potential for communication difficulty related to [MEDICAL CONDITION] and dysarthria. -Resident #24 was admitted to the facility on (MONTH) 29, 2019, with [DIAGNOSES REDACTED]. Review of a care plan dated (MONTH) 25, 2019 revealed the resident has a potential to wander into unsafe situations related to history of dementia with short and long term memory loss and fails to realize her safety need as evidenced by elopement. A goal was I will not wander into unsafe situations. Approaches were place in area where frequent observation is possible, provide diversional activities for me as needed, approach me positively and in a calm, accepting manner, nurses/CNA (certified nursing assistant) to account for my whereabouts throughout the day, 30 minute visual checks and to monitor and document my behavior and wandering and record and report changes to MD. A quarterly MDS assessment dated (MONTH) 3, 2019 revealed the resident had short and long term memory problems and was severely impaired with cognitive skills for daily decision making. Review of the nurse's notes for resident #24 dated (MONTH) 28, 2019 at 12:00 p.m. revealed Patient (#24) wandering halls per usual. Walked past 100/200 TV area. Hit a female (resident #38) of 200 hall in the head/shoulder. Did make some contact. No injury noted. Patient (#38) kept in observation area. Other female (resident #24) returned to her side of the building. Her nurse informed. An Incident/Accident Report dated (MONTH) 28, 2019 included a resident (#24) was walking by resident #38 and reached out and hit resident #38 in the head and shoulder. No injury occurred. An interview was conducted with a CNA (staff #24) on (MONTH) 7, 2019 at 8:12 a.m. Staff #24 stated that resident #24 was on 15 minute checks by staff to monitor where she is so that she does not bother the other residents. An interview was conducted with a licensed practical nurse (LPN/staff #52) on (MONTH) 7, 2019 at 8:58 a.m. Staff #52 stated that resident #38 talks a lot because of her dementia and says I love you, I love you frequently. Staff #52 stated that probably bothered resident #7 and that's why she hit resident #38. Staff #52 stated that resident #7 is very territorial and they try to keep other residents at least 18 inches away from her. Staff #52 further stated that the TV room was monitored very closely to prevent resident to resident altercations. An interview was conducted with a CNA (staff #44) on (MONTH) 7, 2019 at 9:13 a.m. Staff #44 stated that resident #7 was very territorial and did not like others in her space. Staff #44 stated they try not to have anyone in arm's reach of resident #7. Staff #44 further stated that resident #7 gets mad when someone is in her space and will shake her walker or swat out at them. An interview was conducted with the Director of Nursing (DON/staff #28) on (MONTH) 7, 2019 at 11:00 a.m. Staff #28 stated the residents with behaviors were monitored closely by staff. Staff #28 stated that staff get to know the residents and how close they can be to other residents. Staff #28 further stated that residents are involved in activities to prevent resident to resident altercations. Review of the Abuse Prevention Program policy dated (MONTH) 2019 revealed the facility had zero tolerance of physical, verbal and mental .abuse by .other residents. The facility will assure that all residents and staff understand that there is zero tolerance of abuse by any person known or unknown to the resident. An objective included to develop and implement a system for preventing, identifying, reporting and investigating any incident or suspected incident of abuse, neglect or misappropriation of resident property. The policy further included The facility will have a system in place to prevent abuse.",2020-09-01
694,MOUNTAIN VIEW MANOR,35114,1045 SANDRETTO DRIVE,PRESCOTT,AZ,86305,2019-08-07,607,D,0,1,PTZU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, facility documentation and policies and procedures, the facility failed to implement their abuse policy, by failing to thoroughly investigate two incidents of resident-to-resident physical abuse involving three resident's (#'s 18, 24 and 38), and by failing to report these incidents to the State Survey Agency. The deficient practice could result in further incidents of resident-to resident abuse. Findings include: -Resident #18 was admitted to the facility on (MONTH) 13, 2007, with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment dated (MONTH) 20, 2019, revealed a Brief Interview for Mental Status score of 12, which indicated the resident had moderate cognitive impairment. Review of a care plan dated (MONTH) 31, 2019 documented the resident exhibits social isolation as evidenced by spending most of her day in her room. Another care plan dated (MONTH) 31, 2019 included the resident has potential for communication difficulty related to [MEDICAL CONDITION] and dysarthria. -Resident #38 was admitted to the facility on (MONTH) 28, (YEAR), with [DIAGNOSES REDACTED]. A care plan dated (MONTH) 26, 2019 documented the resident has a history of wandering throughout the facility and placing herself in unsafe situations. [DIAGNOSES REDACTED]. A goal was I will not wander into unsafe situations. Approaches included Place me in area where frequent observation is possible. Alert staff to my wandering behavior. Provide diversional activities for me. Approach me positively and in calm, accepting manner. Record and report changes to MD (medical doctor) and family as needed. Review of the quarterly MDS (Minimum Data Set) assessment dated (MONTH) 17, 2019, revealed the resident had short and long term memory problems and was severely impaired with cognitive skills for daily decision making. Review of the nurses notes for resident #38 dated (MONTH) 9, 2019 at 9:30 a.m. revealed Patient (#38) observed to hit a female resident (#18) open handed on the forehead. No injury . Review of an Incident/Accident Report dated (MONTH) 9, 2019 revealed CNA's reported this client (#38) struck another female (#18) with her open hand in the forehead. Patients immediately separated. Core staff informed. Keep space between them. Further review of the facility's documentation revealed no evidence that this incident of resident-to-resident abuse was reported to the State Survey Agency, or that the incident was thoroughly investigated. -Resident #24 was admitted to the facility on (MONTH) 29, 2019, with [DIAGNOSES REDACTED]. Review of a care plan dated (MONTH) 25, 2019 revealed the resident has a potential to wander into unsafe situations related to history of dementia with short and long term memory loss and fails to realize her safety need as evidenced by elopement. A goal was I will not wander into unsafe situations. Approaches were place in area where frequent observation is possible, provide diversional activities for me as needed, approach me positively and in a calm, accepting manner, nurses/CNA (certified nursing assistant) to account for my whereabouts throughout the day, 30 minute visual checks and to monitor and document my behavior and wandering and record and report changes to MD. A quarterly MDS assessment dated (MONTH) 3, 2019 revealed the resident had short and long term memory problems and was severely impaired with cognitive skills for daily decision making. Review of the nurse's notes for resident #24 dated (MONTH) 28, 2019 at 12:00 p.m. revealed Patient (#24) wandering halls per usual. Walked past 100/200 TV area. Hit a female (resident #38) of 200 hall in the head/shoulder. Did make some contact. No injury noted. Patient (#38) kept in observation area. Other female (resident #24) returned to her side of the building. Her nurse informed. An Incident/Accident Report dated (MONTH) 28, 2019 included a resident (#24) was walking by resident #38 and reached out and hit resident #38 in the head and shoulder. No injury occurred. Further review of the facility's documentation revealed no evidence that this incident of resident-to-resident abuse was reported to the State Survey Agency, or that the incident was thoroughly investigated. An interview was conducted with the Director of Nursing (DON/staff #28) on (MONTH) 6, 2019 at 11:25 a.m. Staff #28 stated that the incidents that occurred on (MONTH) 9, 2019 and (MONTH) 28, 2019 were not reported to the State Survey Agency, because she had just been to a training and thought that if no injury or red marks occurred, the resident-to-resident incidents of physical abuse were not reportable to the State Survey Agency. An interview was conducted with the Administrator (staff #14) on (MONTH) 7, 2019 at 11:00 a.m. Staff #14 stated the two incidents were not reported and investigated, because they were considered a behavioral incident and not an abuse situation. Review of the Abuse Prevention Program policy dated (MONTH) 2019 revealed to develop and implement a system for preventing, identifying, reporting and investigating any incident or suspected incident of abuse, neglect or misappropriation of resident property. The policy included that events such as slapping, hitting, pinching, yelling at, cursing, threatening . should be reported to the State Survey Agency. The Administrator or Director of Nursing Services shall report allegations to the State Survey Agency immediately, but not later than 2 hours after the allegation is made. Regarding the investigation of possible abuse, neglect, mistreatment or misappropriation of property, the policy included the following: .If an incident occurs, or there is any allegation that an incident might have occurred, of abuse, neglect, mistreatment, exploitation or misappropriation of resident property, the Administrator, or designee, will investigate . The person doing the investigation will complete an initial report with the State Survey Agency. The Administrator will maintain all completed abuse/neglect investigation reports and investigation materials, and that the findings shall be reported to the State Survey Agency, within 5 days of the initial report.",2020-09-01
695,MOUNTAIN VIEW MANOR,35114,1045 SANDRETTO DRIVE,PRESCOTT,AZ,86305,2019-08-07,609,D,0,1,PTZU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, facility documentation and review of policies and procedures, the facility failed to report two incidents of resident-to-resident physical abuse involving three resident's (#'s 18, 24 and 38) to the State Survey Agency. The deficient practice could result in further incidents of resident-to-resident abuse not being reported to the State Survey Agency. Findings include: -Resident #18 was admitted to the facility on (MONTH) 13, 2007, with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment dated (MONTH) 20, 2019, revealed a Brief Interview for Mental Status score of 12, which indicated the resident had moderate cognitive impairment. Review of a care plan dated (MONTH) 31, 2019 documented the resident exhibits social isolation as evidenced by spending most of her day in her room. Another care plan dated (MONTH) 31, 2019 included the resident has potential for communication difficulty related to [MEDICAL CONDITION] and dysarthria. -Resident #38 was admitted to the facility on (MONTH) 28, (YEAR), with [DIAGNOSES REDACTED]. A care plan dated (MONTH) 26, 2019 documented the resident has a history of wandering throughout the facility and placing herself in unsafe situations. [DIAGNOSES REDACTED]. A goal was I will not wander into unsafe situations. Approaches included Place me in area where frequent observation is possible. Alert staff to my wandering behavior. Provide diversional activities for me. Approach me positively and in calm, accepting manner. Record and report changes to MD (medical doctor) and family as needed. Review of the quarterly MDS (Minimum Data Set) assessment dated (MONTH) 17, 2019, revealed the resident had short and long term memory problems and was severely impaired with cognitive skills for daily decision making. Review of the nurses notes for resident #38 dated (MONTH) 9, 2019 at 9:30 a.m. revealed Patient (#38) observed to hit a female resident (#18) open handed on the forehead. No injury . Review of an Incident/Accident Report dated (MONTH) 9, 2019 revealed CNA's reported this client (#38) struck another female (#18) with her open hand in the forehead. Patients immediately separated. Core staff informed. Keep space between them. Further review of the facility's documentation revealed no evidence that this incident of resident-to-resident abuse was reported to the State Survey Agency. -Resident #24 was admitted to the facility on (MONTH) 29, 2019, with [DIAGNOSES REDACTED]. Review of a care plan dated (MONTH) 25, 2019 revealed the resident has a potential to wander into unsafe situations related to history of dementia with short and long term memory loss and fails to realize her safety need as evidenced by elopement. A goal was I will not wander into unsafe situations. Approaches were place in area where frequent observation is possible, provide diversional activities for me as needed, approach me positively and in a calm, accepting manner, nurses/CNA (certified nursing assistant) to account for my whereabouts throughout the day, 30 minute visual checks and to monitor and document my behavior and wandering and record and report changes to MD. A quarterly MDS assessment dated (MONTH) 3, 2019 revealed the resident had short and long term memory problems and was severely impaired with cognitive skills for daily decision making. Review of the nurse's notes for resident #24 dated (MONTH) 28, 2019 at 12:00 p.m. revealed Patient (#24) wandering halls per usual. Walked past 100/200 TV area. Hit a female (resident #38) of 200 hall in the head/shoulder. Did make some contact. No injury noted. Patient (#38) kept in observation area. Other female (resident #24) returned to her side of the building. Her nurse informed. An Incident/Accident Report dated (MONTH) 28, 2019 included a resident (#24) was walking by resident #38 and reached out and hit resident #38 in the head and shoulder. No injury occurred. Further review of the facility's documentation revealed no evidence that this incident of resident-to-resident abuse was reported to the State Survey Agency. An interview was conducted with a licensed practical nurse (LPN/staff #52) on (MONTH) 6, 2019 at 8:47 a.m. Staff #52 stated that if resident-to-resident abuse should occur, she always notifies the Director of Nursing (DON) and Administrator (staff #14) immediately. An interview was conducted with a registered nurse (RN/staff #37) on (MONTH) 6, 2019 at 10:03 a.m. Staff #37 stated that she reports resident-to-resident abuse to the DON and Administrator immediately. Staff #37 further stated the DON and the Administrator then report the incidents to the State Survey Agency as required. An interview was conducted with the DON (staff #28) on (MONTH) 6, 2019 at 10:06 a.m. Staff #28 stated that staff are informed that they need to report resident-to-resident abuse incidents to her or the Administrator immediately, because of the 2 hour window for reporting the incident to the State Survey Agency. Another interview was conducted with the DON (staff #28) on (MONTH) 6, 2019 at 11:25 a.m. Staff #28 stated the incidents which occurred on (MONTH) 9, 2019 and (MONTH) 28, 2019 were not reported to the State Survey Agency, because she had just been to a training and she thought that if no injury or red marks occurred, then resident-to-resident incidents of physical abuse were not reportable to the State Survey Agency. An interview was conducted with the Administrator on (MONTH) 7, 2019 at 11:00 a.m. Staff #14 stated that incidents of resident-to-resident abuse are reported to him immediately, so he can report the incidents to the State Survey agency within the required time frame of two hours. Review of the Abuse Prevention Program policy dated (MONTH) 2019 revealed to develop and implement a system for preventing, identifying, reporting and investigating any incident or suspected incident of abuse, neglect or misappropriation of resident property. The policy included that events such as slapping, hitting, pinching, yelling at, cursing, threatening . should be reported to the State Survey Agency. The Administrator or Director of Nursing Services shall report allegations to the State Survey Agency immediately, but not later than 2 hours after the allegation is made.",2020-09-01
696,MOUNTAIN VIEW MANOR,35114,1045 SANDRETTO DRIVE,PRESCOTT,AZ,86305,2019-08-07,640,D,0,1,PTZU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and the RAI (Resident Assessment Instrument) manual, the facility failed to ensure a Death in the Facility Tracking Record was encoded and transmitted within the required timeframe for one sampled resident (#1). The deficient practice could result in resident specific information for payment and quality measure purposes not being provided. Findings include: Resident #1 was admitted on (MONTH) 16, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed a nursing progress note dated (MONTH) 5, 2019 that the resident had passed away. The note included hospice and the family were notified. Further review of the clinical record did not reveal a Death in the Facility Tracking Record had been encoded and transmitted. An interview was conducted with the MDS (Minimum Data Set) Coordinator (staff #29) on (MONTH) 7, 2019 at 2:29 p.m. The MDS Coordinator stated that the death tracking record is completed within 24 hours of a resident's death but that she has 7 days to complete the tracking record. She stated the transmission of MDS assessments including death tracking records are once a week but that she has 14 after completion of assessments and tracking records to transmit. After reviewing resident #1 clinical record, the MDS Coordinator stated that there was no death tracking record for resident #1. She stated that the death tracking record was missed. Review of the RAI manual revealed the Death in Facility Tracking Record must be completed within 7 calendar days after the resident's death and transmitted no later than 14 calendar days after the death date.",2020-09-01
697,MOUNTAIN VIEW MANOR,35114,1045 SANDRETTO DRIVE,PRESCOTT,AZ,86305,2019-08-07,678,E,0,1,PTZU11,"Based on personnel record reviews and staff interviews, the facility failed to ensure that four (#'s 13, 27, 32, and 37) of six sampled nursing staff had evidence of CPR (Cardiopulmonary Resuscitation) training, and failed to develop a policy regarding CPR to include CPR training for nursing staff. The deficient practice could result in untrained staff in CPR. Findings include: -Review of the personnel record for a Certified Nursing Assistant (CNA/staff #13), revealed a hire date of (MONTH) 14, 2019. Further review of staff #13's personnel record revealed no evidence of CPR training. -Review of the personnel record for a Registered Nurse (RN/staff #27), revealed a hire date of (MONTH) 9, (YEAR). Further review of staff #27's personnel file revealed no evidence of CPR training. -Review of the personnel record for a Licensed Practical Nurse (LPN/staff #32), revealed a hire date of (MONTH) 16, (YEAR). Further review of staff #32's personnel record revealed no evidence of CPR training. -Review of the personnel record for a RN (staff #37), revealed a hire date of (MONTH) 9, 2014. Further review of staff #37's personnel record revealed no evidence of CPR training. An interview was conducted with the Human Resources Director (staff #49) on (MONTH) 6, 2019 at 12:30 p.m. Staff #49 stated that she would have to check to see which staff are required by the facility to have CPR training. An interview was conducted with the Administrator (staff #14) on (MONTH) 6, 2019 at 12:50 p.m. Staff #14 stated that the facility did not have a requirement as to which staff were required to be trained in CPR. Staff #14 stated that next week the facility was providing certified CPR training for all RNs, LPNs, and CNAs. The Administrator further stated that the facility did not have a policy regarding CPR training for staff.",2020-09-01
698,MOUNTAIN VIEW MANOR,35114,1045 SANDRETTO DRIVE,PRESCOTT,AZ,86305,2019-08-07,686,G,0,1,PTZU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy and procedures, the facility failed to ensure that care and services were provided to prevent the worsening of pressure sores for one resident (#17). The deficient practices resulted in pressure ulcers not being thoroughly assessed and monitored, delays in treatment and worsening of pressure ulcers. Findings include: Resident #17 was admitted to the facility on (MONTH) 15, 2019, with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident was receiving hospice services. Regarding the pressure ulcer to the right heel: According to an untitled and undated transfer note, the resident had blisters on the right heel, which was protected with an ace bandage. The admission nursing evaluation dated (MONTH) 15, 2019 included the resident was admitted on hospice services. The evaluation included the resident had stage 2 pressure ulcers to both heels and that treatment orders were received. The evaluation did not include any further description of the right heel. A hospice nurse start of care visit note (MONTH) 15, 2019 included the resident was alert and oriented to place and was forgetful. It also included a Braden Risk Assessment, which identified that the resident was at moderate risk for pressure ulcer development. The note did not include any documentation regarding a right heel stage 2 pressure ulcer. Review of the admission physician orders revealed for weekly skin checks and for heel protectors while in bed. The orders did not include for any treatment for [REDACTED]. Hospice physician orders dated (MONTH) 15, 2019 included for heel protectors while in bed. The orders did not include any treatment for [REDACTED]. According to an initial Individual Resident Care Plan dated (MONTH) 19, 2019, the resident had actual alteration in skin integrity. The documentation included the resident had wounds to both heels. The goal was that the resident would show improvement in skin areas. Interventions included for skin assessments every week and as needed, assist to reposition resident when in bed and chair, treat per physician's order, measure open area weekly and document, and refer to wound consultant as needed. Review of the (MONTH) 2019 TAR (treatment administration record) revealed the orders for heel protectors to be on while in bed. However, there was no documentation this was done from (MONTH) 16 through 20, on the 6:00 a.m. to 2:00 p.m. shift. An admission MDS (Minimum Data Set) assessment dated (MONTH) 22, 2019 included the resident had short and long term memory problems, had moderate cognitive impairment with daily decision making skills and required extensive assistance with Activities of Daily Living. Per the MDS, the resident was also assessed to have three unhealed pressure ulcers, which included a pressure ulcer to the right heel, unspecified stage. A hospice nurse supervisory visit note dated (MONTH) 25, 2019 revealed under integumentary assessment that the resident had wounds. However, the documentation did not include the type of wounds, location, number and a description of the wounds. There was no mention that the resident had a pressure ulcer to the right heel. An initial dietary review dated (MONTH) 27, 2019 included the resident had stage 2 pressure injuries to bilateral heels. Further review of the hospice visit notes dated (MONTH) 16, 17, 21, 23, 24, 25, 27, 28 and 29, 2019, revealed documentation that the resident had wounds. However, the notes did not include any documentation regarding a right heel pressure ulcer. Review of the Daily Skilled Nurse's notes from (MONTH) 16 through 31, 2019 included the resident had pressure ulcer on the heels. However, the documentation did not include a description of the heel wounds, staging or any measurements. Despite documentation upon admission that the resident had blisters/stage 2 pressure ulcer to the right heel, there were no physician orders for any treatment, and there was no evidence that a thorough assessment of the right heel pressure ulcer was done upon admission through (MONTH) 31, 2019, which included a description of the wound bed and surrounding skin, measurements and if any drainage was present. Daily skilled nurse's notes from (MONTH) 1 through (MONTH) 5, 2019 included documentation that the resident had pressure ulcers on the heels. However, the documentation did not reflect a description of the right heel wound, staging or any measurements. A hospice nurse visit note dated (MONTH) 5, 2019 included the resident had wounds. However, the documentation did not include the resident had a pressure ulcer to the right heel. A pressure ulcer care plan dated (MONTH) 5, 2019 revealed the resident had multiple stage 2 pressure injuries, including a stage 2 pressure ulcer to the right heel. Interventions included floating the heels, use of heel protectors, reposition every 2 hours, pressure reducing mattress, wound care as directed and as needed and report changes to doctor as needed. Continue review of the clinical record revealed no physician orders for any treatment to the right heel pressure ulcer, nor was there documentation that a thorough assessment of the pressure ulcer was completed from (MONTH) 1 through 5, which included a description of the wound bed and surrounding skin, measurements and if any drainage was present. Hospice physician orders dated (MONTH) 7, 2019 now included to cleanse the right heel wound with wound cleanser, pat dry, leave open to air and to float heels. The orders also included for the hospice nurse to assess the wound every nurse visit, and for the facility nurse to do daily checks and notify hospice for wound changes, increase in size, pain, swelling, redness, bleeding, drainage or foul odor. The [DIAGNOSES REDACTED]. Despite wound care orders for a SDTI to the right heel, there was no documentation that a thorough assessment of the right heel had been done from (MONTH) 7 through 10, 2019, which included a description of the wound bed and surrounding skin and any measurements. A hospice visit note dated (MONTH) 11, 2019 now included the resident had an unstageable deep tissue injury (DTI) to the right mid-heel with an onset date of (MONTH) 7, 2019. The pressure ulcer measured 2.4 cm (centimeters) x 2.3 cm, with intact granulation tissue, 100% [MEDICATION NAME] and 0-25% necrotic tissue with slough/eschar, with indistinct edges and no odor or exudate was present. The note included that wound care was provided. A hospice visit note dated (MONTH) 13, 2019 included an unstageable DTI to the right mid-heel, with intact granulation tissue, indistinct edges, 100% [MEDICATION NAME], and 0-25% necrotic tissue slough/eschar, with no odor or exudate. The note also included that wound care was provided. A hospice visit note dated (MONTH) 14, 2019 included the fluid filled blister to the right heel had subsided, with a black discoloration on the edge. The right heel was described as an unstageable DTI with 0-25% necrotic tissue/slough/eschar and 100% [MEDICATION NAME]. No measurements were documented. The note further included that the order for the right heel was not on the treatment record. Review of a hospice visit note dated (MONTH) 18, 2019 revealed documentation that the right heel unstageable SDTI was assessed, however, there were no measurements or any description of the wound bed. Review of the (MONTH) 2019 TAR revealed the physician ordered wound treatment to the right heel from (MONTH) 7, was not initiated until (MONTH) 20. There was no documentation that wound care was provided to the right heal from (MONTH) 7 through 19. Additional hospice visits notes dated (MONTH) 20, 21, 24, 26 and 28, 2019 did not include any documentation regarding the right heel unstageable pressure ulcer. Review of the physician order recapitulation for (MONTH) 2019 revealed the following treatment orders: cleanse the wound on the right heel with wound cleanser, pat dry, leave open to air and to float heels. The orders also included for the hospice nurse to assess the wound every nurse visit, and for the facility nurse to do daily checks and notify hospice for wound changes, increase in size, pain, swelling, redness, bleeding, drainage or foul odor. The [DIAGNOSES REDACTED]. According to the (MONTH) 2019 TAR, the above orders were included. However, on (MONTH) 25, 29 and 30, there was no documentation that the treatment was provided. Review of the hospice notes for (MONTH) 1, 3, 5, 8, 11, 16, 19, 23 and 30, 2019 revealed no documentation regarding the right heel pressure ulcer. Further review of the clinical record revealed there was no documentation that a thorough assessment of the right heel pressure ulcer had been completed at least weekly, which included a description of the wound bed and surrounding skin, any measurements and if any drainage was present, since (MONTH) 11 and 13, 2019, when the pressure ulcer was described as having 0-25% necrotic tissue slough/eschar. During a wound observation conducted with a registered nurse (staff #37) on (MONTH) 6, 2019 at 12:55 p.m., the resident's right heel was observed and no open areas were noted. Staff #37 stated the resident has no open wounds. She said the hospice nurse does the treatments, but the facility nurse can do dressing changes on an as needed basis. She described the wound to the right heel as closed, with blanchable areas. Regarding the pressure ulcer to the right posterior ear: A physician's order dated (MONTH) 15, 2019 included for oxygen 2-5 liters per minute continuously via nasal cannula. A nursing note dated (MONTH) 11, 2019 included that a message was left with hospice related to a report made by a CNA (certified nursing assistant) that there was an odor present during resident care. The location of the odor was not documented. The hospice visit note dated (MONTH) 11, 2019 revealed that a new abrasion was noted above the resident's right ear and that the oxygen tubing cannot sit above the ear, as it causes pain. The note included that foam was ordered for the oxygen tubing. The note did not incude a description of the wound or any measurements. Despite documentation that foam was ordered for the oxygen tubing, there was no physician's order for this and there were no orders for any treatment to the right ear on (MONTH) 11, 2019. The hospice visit notes dated (MONTH) 13, 14 and 18, 2019 did not include the resident had a wound to the right ear. A nurse's note dated (MONTH) 19, 2019 included that a CNA reported finding 2 new wounds on the resident's ear. Per the documentation, treatment was provided and hospice was notified. The note did not include a description of the 2 wounds, nor were there any measurements. Further review of the physician orders revealed there were no treatment orders for the right ear pressure ulcers from (MONTH) 11-18, 2019. A physician's order dated (MONTH) 19, 2019 now included to cleanse the right posterior ear wound with normal saline or wound cleanser, apply antibiotic ointment twice daily and as needed for two weeks and then re-evaluate. A care plan dated (MONTH) 19, 2019 included the resident had impaired skin integrity, with two pressure ulcers to the right posterior ear. The goal was for the wounds to heal within 2 weeks. Interventions included treatment as ordered and to measure and record weekly. The hospice visit note dated (MONTH) 20, 2019 revealed no documentation regarding the right ear wound. Review of the (MONTH) 2019 TAR revealed the wound care order for the right posterior ear. However, there was no documentation that the wound treatment was provided on (MONTH) 22, 26, 27, 29 and 30, on the second shift. The (MONTH) 2019 TAR also included the orders for the right ear wound, however, it was not marked as administered on (MONTH) 1. Review of the hospice notes dated (MONTH) 1, 3, 5, 8, 11, 16, 19, 23 and 30, 2019, revealed no documentation regarding the right ear pressure ulcer. Continued review of the clinical record revealed no evidence that the pressure ulcers to the right posterior ear were thoroughly assessed from (MONTH) 11 through (MONTH) 31, 2019., which included a description of the wound beds and surrounding skin, staging of the wounds and if any drainage was present. During a wound observation conducted with a registered nurse (staff #37) on (MONTH) 6, 2019 at 12:55 p.m., the resident had a scabbed area, which reached behind the ear and under the right ear lobe, and was approximately 2 cm in length. Regarding the sacral/coccyx area: Review of the untitled and undated transfer note revealed the resident had a healing stage 2 pressure ulcer to the coccyx. The hospice physician orders dated (MONTH) 15, 2019 included for the application of zinc to the stage 2 pressure ulcer to the coccyx with each brief change. The admission nursing evaluation dated (MONTH) 15, 2019 included the resident was admitted on hospice and had a stage 2 pressure ulcer to the coccyx. The evaluation did not include a description of the wound bed and surrounding skin, any measurements, if any tunneling/undermining were present and if there was any drainage. It also included that treatment orders were received. A hospice nurse start of care visit note (MONTH) 15, 2019 included the resident was alert and oriented to place and was forgetful. The note included that a Braden Risk assessment indicated the resident was at moderate risk for developing pressure ulcers. Under the integumentary assessment, the resident was noted to be bedbound, but was able to adjust slightly in bed. It also included the resident had a stage 2 pressure injury to the coccyx and that zinc ointment was applied. However, the documentation did not include a description of the wound bed and surrounding skin, any measurements or if any drainage was present. Review of the physician order recapitulation for (MONTH) 2019 included to apply zinc with each brief change to the stage 2 pressure ulcer on the coccyx and for weekly skin checks. This order was transcribed onto the (MONTH) 2019 TAR and showed that the treatment was not marked as administered on (MONTH) 16 and 19, on the 6:00 a.m. to 2:00 p.m. shift. The Individual Resident Care Plan dated (MONTH) 19, 2019 included the resident had actual alteration in skin integrity, as the resident had a wound to the coccyx, which was present prior to admission. Interventions included treatment per physician's order, skin assessment every week and as needed and measuring/documenting open area weekly. The admission MDS assessment dated (MONTH) 22, 2019 included the resident had a pressure ulcer to the sacral region, unspecified stage. Review of the hospice visit notes dated (MONTH) 21 and 23, 2019 revealed documentation that the resident's skin was assessed, however, there was no assessment documentation regarding the coccyx pressure ulcer, which included measurements, a description of the wound bed and surrounding skin and if any drainage was present. The daily skilled nurse's notes from (MONTH) 16 through (MONTH) 24, 2019 also documented the resident had a pressure ulcer to the coccyx. However, the documentation did not include a thorough assessment of the wound. A hospice visit note dated (MONTH) 25, 2019 revealed the resident was lethargic, bedbound and had wounds. However, the assessment did not include any description of the coccyx pressure ulcer or any measurements. A hospice visit note dated (MONTH) 26, 2019 revealed the resident was alert and oriented to person, forgetful, had pale skin with poor turgor and had wounds. The note included the resident had a stage 2 pressure ulcer to the coccyx, with an onset date of (MONTH) 26, 2019. However, previous documentation showed that the coccyx pressure ulcer was identified on admission. Per the note, measurements were unable to be taken, but no explanation was given. The wound bed was described as having intact granulation tissue, distinct edges with 75- This hospice visit note also stated that wound care was ordered and included the following treatment: wound cleanser, pat dry with 4 x 4 and cover with foam dressing, which was to be removed every 3 days and as needed. The wound care was to be done by facility staff or the hospice nurse. Review of a hospice physician's order dated (MONTH) 26, 2019 revealed to cleanse the coccyx area with soap and water or wound cleanser, pat dry with 4 x 4, cover with foam dressing every 3 days or as needed by facility or hospice nurse. The orders also included to monitor for increase in redness or drainage. According to the (MONTH) 2019 TAR, this order was not transcribed onto the TAR. A hospice visit note dated (MONTH) 31, 2019 included a stage 2 pressure ulcer to the coccyx, which measured 8 cm x 6 cm. This is the first documentation of the measurements of the coccyx pressure ulcer. The note further included the coccyx wound bed had 25% of granulation tissue, 50- Review of a hospice physician order dated (MONTH) 31, 2019 included for wound care to be performed by hospice nurse weekly and as needed, and the facility nurse was to perform wound care as needed if dressing is soiled. The order further included to cleanse with soap and water or wound cleanser, pat dry, then apply 7 x 7 sacral foam dressing and to notify hospice if wound worsens or shows signs of infection. The order also included to turn resident every 2 hours for pressure relief. This order was transcribed onto the TAR for (MONTH) 2019 and provided as ordered. Further review of the clinical record revealed documentation that the coccyx pressure ulcer was assessed at least weekly in (MONTH) 2019 and healed by (MONTH) 19, 2019. A wound observation was conducted on (MONTH) 6, 2019 at 12:55 p.m., with a registered nurse (staff #37). At this time, staff #37 provided wound care to the sacral area. The sacral area appeared red, with no open areas. Staff #37 described the wound as a sacral, non-open, reddened, blanchable area, with no drainage and measured 12 cm x 9 cm. In an interview with a registered nurse (RN/staff #55) conducted on (MONTH) 7, 2019 at 1:57 p.m., she stated when a resident is admitted with or develops a pressure ulcer, a skin assessment is conducted and the Weekly Pressure Ulcer Healing Assessment form is completed for each pressure ulcer identified. She stated the pressure ulcer assessment included staging, measurements and a description of the wound such as; presence/absence of eschar or drainage. She stated the wound should be monitored every shift for signs and symptoms of infection, and that weekly wound assessments should be done and documented. An interview with a licensed practical nurse (LPN/staff #32) was conducted on (MONTH) 7, 2019 at 2:17 p.m. Staff #32 stated when a resident is admitted with or develops a pressure ulcer, she will conduct an assessment of the wound which includes measurements, staging and a description of the depth of the wound or presence/absence of drainage. She stated that treatment will then be initiated and administered based on the facility's standing orders for pressure ulcers. She said succeeding assessments of the pressure ulcer will be done weekly and as needed, and that findings will be documented in the pressure ulcer form, which is maintained in the resident's clinical record. Regarding resident's receiving hospice services and who have pressure ulcers/injuries, staff #32 stated that if hospice provides the treatment for [REDACTED]. She stated the facility nurse will conduct an assessment of the resident's wound as needed, if the wound dressing gets loose. She further stated that if there is no documentation found in the resident's chart from the facility nurse regarding the pressure ulcer/wound, it means the facility nurse did not do the dressing change or assessment. During an interview with the assistant Director of Nursing (ADON/staff #29) conducted on (MONTH) 7, 2019 at 2:29 p.m., she stated the floor nurses are expected to conduct an assessment and stage the pressure ulcer when they find it. She stated the floor nurses are expected to note the size, depth, description and measurement of the pressure ulcer, and that succeeding assessments of the wound should be done weekly or as needed when there are changes. She said if the resident is on hospice, the hospice nurse is expected to assess and document the wound on a weekly basis. An interview with the Director of Nursing (DON/staff #28) was conducted on (MONTH) 7, 2019 at 3:47 p.m. Staff #28 stated that pressure ulcer wounds are assessed by the nurses, and that assessments are done on a weekly basis, which includes staging, measurements and a description of the wound. She stated if the hospice nurse is providing the treatment for [REDACTED]. She said the facility nurse will conduct an assessment on an as needed basis, when the facility nurse changes the dressing. She further stated that all assessments including pressure ulcers are maintained in the resident's clinical record. Review of the Wound and Skin Care Protocols and Procedures revealed the purpose was to promote a systematic approach and monitoring process for the care of the residents with existing wounds and for those who are at risk for skin breakdown; and to prevent pressure ulcer formation by identifying those residents who are at risk for pressure ulcers and to develop appropriate interventions. The objective was to maintain skin integrity and promote wound healing. The policy further included that a complete wound assessment and documentation will be done weekly on all pressure ulcers until healed. The criteria included site/location, stage, size, appearance of wound bed, undermining/tunneling, surrounding skin and drainage/exudate. The policy also stated to provide ongoing documentation by the charge/treatment nurses in the medical record to describe the effectiveness of interventions and resident's response to therapy.",2020-09-01
699,MOUNTAIN VIEW MANOR,35114,1045 SANDRETTO DRIVE,PRESCOTT,AZ,86305,2019-08-07,689,E,0,1,PTZU12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews and policy review, the facility failed to ensure that additional interventions were implemented including adequate supervision for one resident (#24) with ongoing wandering behaviors, who was involved in an incident with resident #37. The deficient practice could result in a lack of interventions being implemented to address behaviors and possibly causing increased incidents and injuries to residents. Findings include: -Resident #37 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of a care plan revealed the resident displays periods of anxiety and verbal abruptness. A goal was the resident would not display any anxiety through the next review. Interventions included to monitor and document behavior, discuss options for appropriate channeling of anxiety, administer medications as ordered, talk to resident in a calm voice when behaviors are disruptive, and assist in selection of appropriate coping mechanisms. A quarterly Minimum Data Set (MDS) assessment dated [DATE] included the resident was cognitively intact and required supervision with bed mobility and transfers, and was independent with ambulating in room. The MDS also noted that the resident did not have any physical or verbal aggressive behaviors. According to the (MONTH) 2019 Medication Administration Record, [REDACTED]. A nurses note dated 10/16/19 at 6 a.m. included the nurse heard screams from down the hall and found another resident (#24) on the floor by the bed in the room of resident #37. Per the note, resident #24 had tried to climb in resident #37's bed, which startled him and he jumped up and pushed resident #24 away, which resulted in her landing on the floor. A nurses note written on 10/16/10 at 9:30 a.m. included that resident #37 was worked up and was reassured that they would keep closer observation on all roaming residents. Review of the (MONTH) 2019 Behavior/Intervention Monthly Flow Record revealed the resident was being monitored for high anxiety and panic behaviors and did exhibit a few behaviors of each throughout the month. -Resident #24 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. A care plan dated 4/25/19 included the resident has the potential to wander into unsafe situations and fails to realize her safety needs as evidenced by elopement. A goal included the resident would not wander into unsafe situations. Interventions were to place resident in area where frequent observation is possible, provide diversional activities, approach resident in a calm and positive manner, nurses/CNA to account for resident's whereabouts throughout the day with 30 minute visual checks, monitor and document wandering behaviors and record and report changes to physician. Review of an Unsafe Wandering/Elopement Risk assessment dated (MONTH) 3, 2019 revealed the resident was at risk for possible unsafe wandering/elopement risk. Nurses notes in (MONTH) 2019 included the resident continues to walk frequently in hallways. The notes also included that at times the resident was on 15 minute checks for wandering. The care plan for the potential to wander into unsafe situations was revised on 7/19/19 to reflect that the resident was getting into others occupied beds. An additional intervention included to monitor when out of bed. Nurses notes in (MONTH) 2019 included the resident was wandering halls as usual. A note dated (MONTH) 28, stated the resident was walking past the TV area on the 100/200 unit and hit a resident on the head/shoulder. Review of the nurses notes for (MONTH) 2019 revealed the resident frequently was pacing the halls. A nurses note dated (MONTH) 3, 2019 revealed that resident #24 smacked another resident in the back of the head. A nurses note dated (MONTH) 5 included the resident's power of attorney was given a 30 day notice and that the facility will help find placement. An Unsafe Wandering/Elopement Risk assessment dated [DATE] included the resident was at risk for possible unsafe wandering/elopement risk. According to a quarterly MDS assessment dated [DATE], the resident was assessed to have severe cognitive impairment, required limited assistance with transfers, was independent with ambulation and had no mood or behavior problems, including no physical or verbal aggressive behaviors. The MDS also included the resident had no wandering behaviors, despite clinical record documentation that the resident had ongoing wandering behaviors. Further review of the care plan for the potential to wander into unsafe situations revealed it was reviewed on 9/26/19. However, despite the residents ongoing wandering behaviors, there were no additional interventions which were implemented, including providing any increased supervision. A note dated (MONTH) 30, 2019 included the resident was found in an empty room sitting on the bed, and was taken to her own room and was changed. Further review of the (MONTH) 2019 nurses notes revealed the resident was up and down the halls and would often walk for an hour, then sit in a chair. The notes also included that resident #24 would swipe at other residents, as she passes by. Per the notes, the resident was toileted, given food/fluids and at times was on 15 minute checks. According to the Behavior/Intervention Monthly Flow Record dated (MONTH) 2019, the resident was being monitored for wandering/exit seeking behaviors. Per the record, the resident had multiple daily episodes of wandering throughout the shifts, with interventions that included redirection, 1:1, activity, gave food and fluids and changed positions. Review of the 15 and 30 minute logs for (MONTH) and (MONTH) 2019 revealed multiple times when either 15 minute or 30 minute checks were done on resident #24. Review of the (MONTH) 2019 physician orders [REDACTED]. A nursing note dated (MONTH) 1, 2019 included the resident was walking the halls as usual and oncoming staff were notified to be on the lookout for her tiring out. A note dated (MONTH) 6, stated the resident was walking the halls. Another note dated (MONTH) 9, included the resident walks for 1 hour then sits, and that snacks were offered. A nurses note dated 10/11/19 included the resident was approved for placement in a behavioral health unit. Nurses notes dated 10/13/19 and 10/14/19 included the resident wanders the halls for an hour. Although there were interventions implemented at times when the resident exhibited wandering behaviors, (such as redirection, 1:1, activities, 15-30 minutes checks, offering food/fluids and toileting), there was no evidence that the resident was reevaluated for the effectiveness of these interventions and that additional interventions were implemented to address the resident's ongoing behaviors. Review of a nurses note dated 10/16/19 at 4:45 a.m. revealed the nurse heard yelling and screaming and went to the room of resident #37. Another resident (#24) was lying on the floor. The resident (#24) had tried to get into resident #37's bed, which startled him and he jumped up and pushed the resident (#24) off of him onto the floor. No injuries were noted. Review of the facility's investigative report revealed that on (MONTH) 16, 2019 at 4 a.m., resident #24 wandered into resident #37's room and tried to get in bed with resident #37, which startled him and he jumped up pushing resident #24 off the bed resulting in her landing on the floor. No injuries were noted. The report included that resident #24 has the potential to wander into unsafe situations, due to a history of dementia. Review of the Behavior/Intervention Monthly Flow Record for (MONTH) 2019 revealed that resident #24 was being monitored for wandering/exit seeking behaviors through (MONTH) 18. Per the record, the resident had multiple daily episodes of wandering each day, with interventions that included redirection, 1:1, activity, gave food and fluids and changed positions. A nurses noted dated 10/18/19 included the resident was discharged from the facility to a closed behavioral wandering unit. A phone interview was conducted on (MONTH) 19, 2019 at 9:03 p.m., with a Certified Nursing Assistant (CNA/staff #3), who stated that she usually works nights and had taken care of resident #24 when she was in the facility. She said the resident would wander around the facility and go into other resident's rooms. Regarding interventions in place to address this behavior she said that she would redirect her, try and help her get back into bed and keep a close eye on her. A phone interview was conducted on (MONTH) 19, 2019 at 9:18 p.m. with a registry CNA (staff #10). She said that she works nights and has taken care of resident #24. She said that the resident did go into other rooms with residents in them and would also go into empty rooms. Regarding the incident on 10/16/19, she said that she was working that night. She said when she and the nurse went into resident #37's room, resident #24 was on the floor. She said resident #37 told them that he had been asleep and resident #24 tried to get in his bed and it scared him and he pushed her. A phone interview was conducted on (MONTH) 19, 2019 at 10:35 p.m. with a Registered Nurse (staff #4). Staff #4 stated that resident #24 wandered around the building and would go into other residents rooms, but some were empty. She said they would keep a close eye on her, do frequent checks during the night and that she was easily redirected. Regarding the incident on 10/16/19, she said that she was working that night. She said that she was charting around 4 a.m. when she heard screaming and went into resident #37's room. She said the room was dark and resident #24 was on the floor. She said resident #37 told her that resident #24 was trying to get in his bed and it startled him and he tried to get her off the bed. She said resident #37 is very anxious, so this really startled him. An interview was conducted on (MONTH) 20, 2019 at 8:50 a.m. with a CNA (staff #5). She said that resident #24 wandered around the facility and would often go into rooms that were not occupied. She said the resident had to be monitored closely and they would redirect her, get her involved in activities including 1:1 activities, would offer her snacks and would try and keep her busy. In an interview with a CNA (staff #6) conducted on (MONTH) 20, 2019 at 9:55 a.m., staff #6 stated that she knew resident #24. She said the resident wandered in the facility and went into other resident rooms, but some of the times the rooms were empty. Regarding interventions to address the wandering behavior, staff #6 stated that they tried activities, gave her snacks and redirected her. During an interview with the Director of Nursing (DON/staff #8) on (MONTH) 20, 2019 at 2:30 p.m., the DON stated the resident (#24) wandered the halls and would go into resident rooms, but was not sure if she did it a lot. Regarding interventions in place to address the ongoing wandering behavior, she said that staff redirected her, involved her in activities and gave her snacks. In an interview with resident #37 on (MONTH) 20, 2019 at 4 p.m., the resident stated that he remembered the incident. He said it happened in the middle of the night. He said his door was open and he was sound asleep. He said he felt someone touch him and get into his bed. He said it scared him and he reacted and kicked out his leg and the resident fell down. Another interview was conducted on (MONTH) 20, 2019 at 4:25 p.m. with the DON. Regarding providing increased supervision for residents with behaviors, including wandering behaviors, she said behaviors are discussed in the morning meetings and if a resident needs increased supervision, they will do 15 or 30 minute checks. Review of a policy regarding Behavioral Assessment, Intervention and Monitoring revealed that residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and care plan. Behaviors will be identified using the behavioral tools and the comprehensive assessment. Residents will have minimal complications associated with the management of altered or impaired behaviors. The interdisciplinary team (IDT) will evaluate behavioral symptoms to determine the degree of severity, distress and potential safety risk to the resident and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. Interventions will be individualized and part of an overall environment that supports physical, functional and psychosocial needs, and strives to understand, prevent or relieve the resident's distress or loss of abilities. Interventions will be based on a detailed assessment of physical, psychological and behavioral symptoms and their underlying causes, as well as the potential situational and environment reasons for the behavior. The care plan will include the following: a description of the behavioral symptoms including frequency, intensity, duration, outcomes, location environment and precipitating factors or situations; targeted and individualized interventions for the behavioral symptoms; the rationale for the interventions; and how staff will monitor for effectiveness of the interventions. The policy further included that the DON or designee will evaluate whether the staffing needs have changed based on the acuity of the residents and their plans of care. Additional staff and/or staff training will be provided if determined that the needs of the residents cannot be met with the current level of staff or staff training. Under monitoring it included that IDT will monitor the progress of individuals with impaired cognition and behavior until stable. Interventions will be adjusted based on the impact on behavior and other symptoms.",2020-09-01
700,MOUNTAIN VIEW MANOR,35114,1045 SANDRETTO DRIVE,PRESCOTT,AZ,86305,2019-08-07,758,E,0,1,PTZU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, staff interviews and policy review, the facility failed to ensure two of five sampled residents (#41 and #48) receiving [MEDICAL CONDITION] medications had GDR's (gradual dose reductions) attempted or that there was documentation that GDR's were clinically contraindicated, and failed to ensure that resident #41 was monitored for specific target behaviors related to the use of an antidepressant medication. The deficient practice could result in residents receiving [MEDICAL CONDITION] medications which are not necessary and could result in residents experiencing possible adverse consequences. Findings include: -Resident #41 was admitted to the facility on (MONTH) 17, (YEAR) with a [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The order did not include what target behaviors were to be monitored. Review of the Psychoactive Drug Use Authorization form dated (MONTH) 17, (YEAR) revealed the resident was informed regarding the use of [MEDICATION NAME]. The form also included that all medications will be reviewed by a pharmacist and that a gradual dose reduction will be done to identify the lowest optimal dose. The form did not include what the specific target behaviors were related to the use of this medication. Review of the Medication Administration Records (MAR) from (MONTH) (YEAR) through (MONTH) 2019 revealed the resident was administered [MEDICATION NAME] daily. However, there was no evidence in the clinical record that the resident was being monitored for any specific target behaviors related to depression from (MONTH) (YEAR) through (MONTH) 2019. Review of the Pharmacy Consultation Reports for (MONTH) (YEAR) through (MONTH) 2019 revealed the resident's medication regimen was reviewed and contained no new irregularities. A Care plan with a revision date of (MONTH) 12, 2019 revealed the resident was at risk for side effects related to the use of an antidepressant. The goal was that the resident would not have any injury related to medication usage and side effects. Interventions included to administer the medication as ordered, monitor and record the resident's target behaviors, observe for adverse side effects and document and report them to the physician, and monthly review of the medication by the pharmacy consultant. The care plan did not include what target behaviors were to be monitored. The Significant Change Minimum Data Set (MDS) assessment dated (MONTH) 13, 2019 revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. The MDS included the resident had no depression and received an antidepressant during the 7 day look-back period. Review of the Pharmacy Consultation Report for (MONTH) 2019, revealed a pharmacy recommendation to the provider dated (MONTH) 22, 2019 that certain antidepressants are associated with an increase in blood pressure in some individuals and to consider a dose reduction or discontinuation of [MEDICATION NAME] in these individuals. The report was signed by the Director of Nursing (DON/staff #28) on (MONTH) 1, 2019. There was also a handwritten note checked on MAR from the provider. The documentation did not include whether [MEDICATION NAME] would be reduced or discontinued or that a gradual dose reduction (GDR) was contraindicated. According to the MARs for (MONTH) 2019 through (MONTH) 2019, the resident continued to receive [MEDICATION NAME] 100 mg 2 tablets by mouth daily. Review of the Pharmacy Consultation Reports for (MONTH) 2019 through (MONTH) 2019 revealed the resident's medication regimen was reviewed and contained no new irregularities. The reports did not include any recommendations regarding the [MEDICATION NAME]. Review of the Behavior/Intervention Monthly Flow Record sheets from (MONTH) 2019 through (MONTH) 2019, did not reveal any target behaviors related to depression which were being monitored. Further review of the clinical record revealed there was no documentation by the physician/provider for a GDR related to the use of [MEDICATION NAME], or the rationale as to why a GDR was contraindicated. In an interview conducted with a Registered Nurse (RN/staff #55) on (MONTH) 7, 2019 at 1:57 p.m., the RN stated that she reviews the order for a [MEDICAL CONDITION] medication to ensure the order includes the target behaviors that are to be monitored and it should be documented in the clinical record. An interview was conducted on (MONTH) 7, 2019 at 2:17 p.m with a Licensed Practical Nurse (LPN/staff #32). The LPN stated that when the pharmacist makes a recommendation, the nurses are informed of the recommendation by the DON. She said the nurses will then notify the physician/provider who will either agree or disagree with the recommendation. The LPN stated that if the physician/provider agrees with the recommendation, an order to reflect the recommendation will be written. In an interview conducted with the DON (staff #28) on (MONTH) 7, 2019 at 3:35 p.m., she stated that resident #41's medications were reviewed monthly by the pharmacist and that the review did not include GDR recommendations. The DON stated that when a pharmacist makes a recommendation for a GDR, she reviews it and it is sent to the physician/provider for review and signature. The DON stated the physician/provider has to agree or disagree with the pharmacist's recommendation. She also stated that they will ensure that GDR's are attempted for [MEDICAL CONDITION] medications. -Resident #48 was readmitted to the facility on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. A care plan revised on (MONTH) 23, 2019 identified that the resident was at risk for side effects related to an antidepressant medication. The goal was that the resident would not have an injury related to medication usage or side effects. Interventions included to discuss potential side effects of [MEDICATION NAME] with resident/responsible party, administer medication as ordered, monitor and record target behaviors and keep [MEDICATION NAME] at the lowest therapeutic dose possible. A quarterly MDS assessment dated (MONTH) 8, 2019 revealed the resident had severe cognitive impairment. The MDS also included the resident received an antidepressant medication during the 7 day look-back period. Review of a behavioral care plan revised on (MONTH) 9, 2019 revealed the resident had the following behaviors: crying or talking very quickly in a non-sensical manner; increased signs/symptoms of anxiety behaviors focusing on hair, dental care, pain or family. The goals were that the resident would not have any behavior outbursts that put her or others at risk and the resident will take medications as ordered. An intervention included administering [MEDICATION NAME] as ordered. Further review of the physician's orders [REDACTED]. Review of the Medication Administration Records (MARs) for (MONTH) and (MONTH) 2019 revealed the resident was administered [MEDICATION NAME] at bedtime. Further review of the clinical record revealed there was no documentation that a GDR was attempted related to the use of [MEDICATION NAME] or documentation by the physician/provider of the rationale as to why a GDR was contraindicated. During an interview conducted with the pharmacist (staff #62) on (MONTH) 7, 2019 at 3:21 p.m., staff #62 stated that he follows the Centers for Medicare/Medicaid Services (CMS) guidelines when recommending GDR's. The pharmacist stated that GDR's are recommended yearly for antidepressant medications, every 6 month for antianxiety medications, and every 3 month for antipsychotic and hypnotic medications. He also stated that if the physician/provider contraindicated his GDR recommendation, he would continue to recommend a GDR on his next review. In an interview conducted with the DON (staff #28) on (MONTH) 7, 2019 at 3:30 p.m., the DON stated that the team meets monthly with the pharmacist and they review all residents receiving [MEDICAL CONDITION] medications and discuss the recommendations for GDR's. Review of the facility's policy on Behavioral Assessment, Intervention and Monitoring revealed the facility will comply with regulatory requirements related to the use of medications to manage behavioral changes. Behavioral symptoms will be identified using facility approved behavioral screening tools and the comprehensive assessment. The interdisciplinary team will thoroughly evaluate new or changing behavioral symptoms in order to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition. When medications are prescribed for behavioral symptoms, documentation will include the rationale for its use, specific target behaviors and expected outcomes, monitoring for adverse consequences and plans (if applicable) for gradual dose reductions. Review of the facility's pharmacy consultant agreement revealed the pharmacy shall provide Consultant Services to the facility in accordance with applicable law and the State Operations Manual, Appendix PP.",2020-09-01
701,THE REHABILITATION CENTER AT THE PALAZZO,35116,6246 NORTH 19TH AVENUE,PHOENIX,AZ,85015,2019-01-18,552,D,0,1,I21U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#7) was informed of the risks and benefits of [MEDICAL CONDITION] medications, prior to administration. Findings include: Resident #7 was readmitted on (MONTH) 3, (YEAR) with [DIAGNOSES REDACTED]. Review of the physician's recapitulation of orders dated (MONTH) 3, (YEAR)-January 31, 2019 revealed orders for the following medications: [REDACTED]. The admission MDS (Minimum Data Set) assessment dated (MONTH) 10, (YEAR) revealed a score of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact. Review of the Medication Administration Records for October, November, (MONTH) (YEAR) and (MONTH) 2019, revealed the resident was administered [MEDICATION NAME], aripiprazole and [MEDICATION NAME] per the physician's orders [REDACTED]. However, continued review of the clinical record revealed no evidence that the resident had been informed of the risks and benefits of these medications. An interview was conducted with the Director of Nursing (DON/staff #1) on (MONTH) 15, 2019 at 3:20 PM. The DON stated that informed consents should be obtained from the resident before they receive [MEDICAL CONDITION] medications. She stated that if the resident is unable to sign, the informed consent can be obtained from the resident's representative. The DON stated that the nurses may have been waiting for a family member to sign the informed consents for resident #7 and then forgot about it. The facility's policy regarding informed consents stated the facility shall promote the resident's right to self-determination and the right to participate in his/her plan of care, including the right to accept or refuse treatment. The policy included that informed consent is an educational process that must take place between the facility and the resident that includes the following elements: the nature of the decision or treatment; any reasonable alternatives; relative risks and benefits; and acceptance of the treatment by the resident.",2020-09-01
702,THE REHABILITATION CENTER AT THE PALAZZO,35116,6246 NORTH 19TH AVENUE,PHOENIX,AZ,85015,2019-01-18,607,D,1,1,I21U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews, facility documentation and policy review, the facility failed to implement their policy regarding allegations of abuse for two residents (#19 and #4). Findings include: -Resident #19 was readmitted on (MONTH) 22, 2103 with [DIAGNOSES REDACTED]. Review of the facility's investigation dated (MONTH) 4, 2019 revealed that on (MONTH) 28, (YEAR) at 4:40 p.m., resident #19 reported to a Certified Nursing Assistant (CNA/staff #13) an allegation of verbal abuse by a CNA (staff #66). The investigation included interviews with the resident (#19) and an interview with the CNA (staff #66). However, there was no documentation of any interviews with other staff members or residents regarding the allegation. An interview was conducted with the Administrator (staff #64) on (MONTH) 15, 2019 at 2:05 p.m. He stated that the allegation was investigated as a potential abuse so the facility policy should have been followed in the investigation. An interview was conducted with the Director of Nursing (DON/staff #1) on (MONTH) 15, 2019 at 2:30 p.m. She stated that she did not interview any residents other than resident #19 and that she interviewed other CNA's but did not document the interviews. Another interview was conducted with the DON (staff #1) on (MONTH) 17, 2019 at 2:56 p.m. She stated that for a staff to resident allegation of abuse she would interview other CNAs and nurses as well as other residents that the alleged perpetrator had provided care for. The DON also stated that for this allegation they should have conducted interviews with other staff and other residents and documented the interviews. She stated that their policy regarding investigating was not followed. During an interview conducted with the Administrator (staff #64) on (MONTH) 17, 2019 at 3:30 p.m., he acknowledged that the investigation should have included further interviews with staff and residents. He stated that their policy was not followed for this investigation. -Resident #4 was admitted to the facility on (MONTH) 29, (YEAR) with [DIAGNOSES REDACTED]. Review of a significant change in status MDS (Minimum Data Set) assessment dated (MONTH) 3, 2019 revealed a BIMS (Brief Interview Mental Status) score of 7, which indicated the resident had severe impaired cognition. Review of the facility's investigation report dated (MONTH) 16, 2019 revealed the resident made an allegation of rape on (MONTH) 10, 2019 at approximately 12:00 p.m. The resident stated that she had been raped twice on the night shift and identified a certified nursing assistant (staff #74) as the person who had raped her. Further review of the report did not reveal any documentation that the alleged perpetrator had been interviewed or had been removed from providing care to residents, pending the investigation. The investigation further revealed that the allegation was unable to be substantiated. In addition, review of the State Agency data base revealed the allegation was not reported to the State Agency until (MONTH) 11, 2019 at 11:25 a.m., which was over the two hour timeframe for reporting. An interview was conducted with the Administrator (staff #64) on (MONTH) 17, 2019 at 12:23 p.m. The Administrator stated that staff #74 was not suspended because resident #4 was not able to give a description of the staff person. He stated that the resident stated she was raped at night and staff #74 does not work the night shift. The Administrator stated the information did not match and he would need for the information to match if he was going to suspend a staff member accused of rape. He also said that his expectation is that all allegations of abuse be reported to him immediately. The facility's policy titled Abuse Investigation and Reporting revealed the role of the investigator included conducting interviews with the person(s) reporting the incident, any witnesses to the incident, the resident (if medically appropriate), staff members on all shifts who have had contact with the resident during the period of the alleged incident, the resident's roommate, family members, and visitors, and other residents to whom the accused staff provided care or services. The policy included all alleged violations involving abuse will be reported by the Administrator, or his/her designee, to the State Agency within two hours. The policy also included that the administrator or designee will suspend immediately any staff who has been accused of resident abuse, pending the outcome of the investigation.",2020-09-01
703,THE REHABILITATION CENTER AT THE PALAZZO,35116,6246 NORTH 19TH AVENUE,PHOENIX,AZ,85015,2019-01-18,609,D,1,1,I21U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, facility documentation, staff interviews and policy review, the facility failed to report an allegation of sexual abuse for one resident (#4) to the State Agency within the required time frame. Findings include: Resident #4 was admitted to the facility on (MONTH) 29, (YEAR), with [DIAGNOSES REDACTED]. Review of a significant change in status MDS (Minimum Data Set) assessment dated (MONTH) 3, 2019 revealed a BIMS (Brief Interview Mental Status) score of 7, which indicated the resident had severe impaired cognition. Review of the facility's investigation report dated (MONTH) 16, 2019 revealed the resident made an allegation of sexual abuse on (MONTH) 10, 2019 at approximately 12:00 p.m. The resident stated that she had been raped twice on the night shift and identified a certified nursing assistant (staff #74) as the person who had raped her. The investigation further included that the allegation was unable to be substantiated. Review of the State Agency data base revealed the allegation was not reported to the State Agency until (MONTH) 11, 2019 at 11:25 a.m., which was over the two hour timeframe for reporting. An interview was conducted on (MONTH) 17, 2019 at 11:01 p.m. with the Director of Nursing (DON/staff #1). The DON stated that the resident made the allegation when she was being taken to the dining room for lunch and that staff #74 reported the allegation to her immediately. During an interview conducted with the Administrator (staff #64) on (MONTH) 17, 2019 at 12:23 p.m., the Administrator stated that his expectation is that all allegations of abuse be reported to him immediately. The facility's policy titled Abuse Investigation and Reporting revealed that all alleged violations involving abuse will be reported by the Administrator, or his/her designee, to the State Agency within two hours.",2020-09-01
704,THE REHABILITATION CENTER AT THE PALAZZO,35116,6246 NORTH 19TH AVENUE,PHOENIX,AZ,85015,2019-01-18,610,D,1,1,I21U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility documentation, clinical record reviews, staff interviews, and policy review, the facility failed to thoroughly investigate two allegations of abuse for two residents (#19 and #4) and failed to protect residents from the potential for further abuse during an investigation for one resident (#4). Findings include: -Resident #19 was readmitted on (MONTH) 22, 2103 with [DIAGNOSES REDACTED]. Review of the facility investigation dated (MONTH) 4, 2019 revealed that on (MONTH) 28, (YEAR) at 4:40 p.m. resident #19 reported to a Certified Nursing Assistant (CNA/staff #13) an allegation of verbal abuse by a CNA (staff #66). The investigation included interviews with the resident (#19) and an interview with a CNA (staff #66), however, there was no documentation of interviews with any other staff members, residents, or family members regarding the allegation. An interview was conducted with the Administrator (staff #64) on (MONTH) 15, 2019 at 2:05 p.m. He stated that the allegation was investigated as a potential abuse so the facility policy should have been followed in the investigation. An interview was conducted with the Director of Nursing (DON/staff #1) on (MONTH) 15, 2019 at 2:30 p.m. She stated that she did not interview any residents other than resident #19 and that she interviewed other CNAs but did not document the interviews. Another interview was conducted with the DON (staff #1) on (MONTH) 17, 2019 at 2:56 p.m. She stated that for a staff to resident allegation of abuse she would interview other CNAs and nurses as well as other residents that the alleged perpetrator had provided care for. The DON also stated that for this allegation they should have conducted interviews with other staff and other residents and documented the interviews. She stated that their policy regarding investigating was not followed. During an interview conducted with the Administrator (staff #64) on (MONTH) 17, 2019 at 3:30 p.m., he acknowledged that the investigation should have included further interviews with staff and residents. He stated that their policy was not followed for this investigation. -Resident #4 was admitted to the facility on (MONTH) 29, (YEAR), with [DIAGNOSES REDACTED]. Review of a significant change in status MDS (Minimum Data Set) assessment dated (MONTH) 3, 2019 revealed a BIMS (Brief Interview Mental Status) score of 7, which indicated the resident had severe impaired cognition. Review of the facility's investigation report dated (MONTH) 16, 2019 revealed the resident made an allegation of rape on (MONTH) 10, 2019 at approximately 12:00 p.m. The report included the resident stated that she had been raped twice on the night shift and identified a certified nursing assistant (staff #74) as the person who had raped her. Further review of the report revealed the alleged perpetrator had not been interviewed or removed from providing care to residents, pending the investigation. Per the report, the allegation was unable to be substantiated. An interview was conducted on (MONTH) 17, 2019 at 11:01 p.m. with the DON. The DON stated that staff #74 was not suspended because the resident's statement changed when she interviewed the resident and staff #74 did not work the night shift. During an interview conducted with the Administrator (staff #64) on (MONTH) 17, 2019 at 12:26 p.m., the Administrator stated that if an employee has been accused of sexual abuse, he would suspend the employee if the resident is able to give some type of description and the staff was working at the time the alleged incident occurred. He stated that staff #74 does not work the night shift and that since the resident stated that she had been raped at night, he did not think that staff #74 should have been suspended. The facility's policy titled Abuse Investigation and Reporting revealed the role of the investigator included conducting interviews with the person(s) reporting the incident, any witnesses to the incident, the resident (if medically appropriate), staff members on all shifts who have had contact with the resident during the period of the alleged incident, the resident's roommate, family members, and visitors, and other residents to whom the accused staff provided care or services. The policy included that the administrator or designee will suspend immediately any staff who has been accused of resident abuse, pending the outcome of the investigation.",2020-09-01
705,THE REHABILITATION CENTER AT THE PALAZZO,35116,6246 NORTH 19TH AVENUE,PHOENIX,AZ,85015,2019-01-18,655,D,0,1,I21U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews and staff and resident interviews, the facility failed to provide two residents (#7 and #9), with a written summary of their baseline care plans. Findings include: -Resident #7 was admitted to the facility on (MONTH) 3, (YEAR), with [DIAGNOSES REDACTED]. According to the admission Minimum Data Set (MDS) assessment dated (MONTH) 10, (YEAR), revealed the resident had a Brief Interview for Mental Status score of 15, which indicated the resident had intact cognition. Review of the clinical record revealed the resident was receiving narcotic pain medication, an anticoagulant, antianxiety medication, antipsychotic medication, antidepressant medication and medication for ADHD (attention deficit [MEDICAL CONDITION] disorder). Review of the resident's baseline care plans revealed that care plans had been developed which addressed anticoagulant therapy, [MEDICAL CONDITION] medications, pain and psychosocial needs. However, there was no documentation in the clinical record or on the baseline care plans that the resident was provided a summary of the baseline care plans. An interview was conducted on (MONTH) 14, 2019 at 1:53 p.m., with resident #7. She stated that she had no knowledge of her plan of care. She reported that she was not given a copy of her care plans and that no one had spoken with her about the topic. An interview was conducted on (MONTH) 15, 2019 at 3:20 p.m., with the DON (Director of Nursing) (staff #1). She stated that the process is to complete the baseline care plan on paper and after 24 hours, the resident signs the care plan and is given a copy. She said if a resident refused to sign or was unable to sign, there should be some kind of notation. She stated that it is a new process, we're still getting used to it. When asked about the lack of signature on resident #7's baseline care plan she stated that if there was no signature, it could have been misplaced or forgotten. -Resident #9 was admitted to the facility on (MONTH) 8, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed that baseline care plans dated (MONTH) 8, (YEAR) had been developed to address various care areas. An admission MDS assessment dated (MONTH) 15, (YEAR) included the resident had a BIMS score of 14, indicating she was cognitively intact. Further review of the clinical record including the baseline care plans revealed no documentation that the resident was provided a summary of the baseline care plans. An interview was conducted with the resident on (MONTH) 14, 2019 at 10:45 a.m. She stated that she didn't know anything about a care plan, but thought it would be nice to know about it. She said that she would like to feel involved in her plan of care. An interview was conducted on (MONTH) 16, 2019 at 12:41 p.m., with a licensed practical nurse (staff #11). She stated that after the resident signs the baseline care plan, the nurses make a copy of it and puts the copy in the resident's chart, That way we both have a copy.",2020-09-01
706,THE REHABILITATION CENTER AT THE PALAZZO,35116,6246 NORTH 19TH AVENUE,PHOENIX,AZ,85015,2019-01-18,658,E,0,1,I21U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews and staff interviews, the facility failed to ensure that physician's orders were followed for two residents (#19 and #47). Findings include: -Resident #47 was admitted to the facility on (MONTH) 17, 2013, with readmissions on (MONTH) 14, (YEAR) and (MONTH) 16, 2019. [DIAGNOSES REDACTED]. An admission MDS assessment dated (MONTH) 26, (YEAR) included the resident scored a 15 on the BIMS (Brief Interview for Mental Status), indicating intact cognition. Physician orders dated (MONTH) 30, (YEAR) included for Nephrostomy site care every shift; monitor for redness and swelling; keep the catheter bags below the bladder; and monitor for signs and symptoms of a UTI. The orders also included to monitor nephrostomy tube drainage every shift. A care plan dated (MONTH) 30, (YEAR) included the resident had nephrostomy tubes in place related to [MEDICAL CONDITION]. The goal was for the resident to remain free from catheter related trauma through the review date. Interventions included the following: catheter care every shift; monitor/record/report to M.D. signs or symptoms of UTI (blood tinged urine, burning, cloudiness, no output, deepening of urine color, urinary frequency, foul smelling urine, fever). Review of a nursing progress note dated (MONTH) 4, (YEAR) revealed the total output from both nephrostomy bags was 1950 ml for the previous 12 hours. A nursing progress note dated (MONTH) 18, (YEAR) revealed the nephrostomy tube output on the resident's right side was 900 ml, but the left side was unknown as the resident was lying on it and being unwilling to have it looked at. There was no additional documentation in the nursing progress notes regarding the nephrostomy tube output amounts for (MONTH) (YEAR). Review of the Medication Administration Record [REDACTED]. As a result, there was no documentation on the MAR indicated [REDACTED]. A physician's order dated (MONTH) 4, (YEAR) (YEAR) included to monitor nephrostomy tube drainage every shift. Review of the MAR for (MONTH) (YEAR) revealed the above order. For (MONTH) 4 and 14 on the 7p-7a shift, there was no documentation of any output from the right and left nephrostomy tube, and on (MONTH) 28 on the 7a-7p shift, there was no output amount documented for the right tube. On (MONTH) 16, 2019 at 2:52 p.m., an interview was conducted with a licensed practical nurse (LPN/staff #11). She stated that she has cared for resident #47. She stated that her process was to empty the nephrostomy bag, measure the urine output, then input the information into the computer. -Resident #19 was readmitted on (MONTH) 22, 2013, with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 3, (YEAR), revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. Review of the physician's orders revealed an order dated (MONTH) 19, (YEAR) to be started on (MONTH) 20, (YEAR) for [MEDICATION NAME] cream 5%, apply per direction topically one time only for scabies until (MONTH) 21, (YEAR). The order included to apply cream to body, neck, behind ears, and down to soles of feet getting in between fingers/toes. Leave on 10 hours and shower off in a.m. Change all bed linens after shower. Review of the Medication Administration Record [REDACTED]. However, there was no documentation that the cream for scabies was applied as ordered. The MAR further included a response of 9 (other/see nurse notes) regarding the [MEDICATION NAME] cream. However, review of the nurse's progress notes for (MONTH) 19, (YEAR) revealed no documentation regarding the administration of the [MEDICATION NAME] cream. Further review of the MAR for (MONTH) 21, (YEAR) revealed the [MEDICATION NAME] cream was to start on (MONTH) 20, (YEAR). However, a response of 9 was again documented. Review of the corresponding nurse's progress notes for (MONTH) 21, (YEAR) revealed the following documentation: no cream available. An interview was conducted with a Licensed Practical Nurse (LPN/staff #11) on (MONTH) 18, 2019 at 9:09 a.m. She stated that when there is a physician's order and the medication or treatment is not available, staff should call the pharmacy and call the physician to see if a stock item could be used. She stated that if the nurse documented the code (9) it refers you to the nurses notes, and there should have been an entry done at that time. She also stated if the nurse documented that there was no cream available, then the resident did not receive the treatment at that time. An interview was conducted with the Director of Nursing (DON/staff #1) on (MONTH) 18, 2019 at 10:09 a.m. She stated that her expectation is that the physician's order be followed as written. She stated that if the order is on the TAR and the medication is not available, the nurse should notify the physician, follow any orders given and document in the nurses notes. An interview was conducted with a Registered Nurse (staff #36 ) on (MONTH) 18, 2019 at 12:19 p.m. She reviewed the entry on the MAR from (MONTH) 21 for the [MEDICATION NAME] cream. She stated that she was the nurse that shift and she did not administer the treatment, because the cream was not available. She stated she would have reported to the oncoming nurse that she was unable to administer the treatment and the oncoming nurse would need to call the pharmacy and the physician. She stated the documentation does not indicate that the treatment was completed or that the physician's order was followed.",2020-09-01
707,THE REHABILITATION CENTER AT THE PALAZZO,35116,6246 NORTH 19TH AVENUE,PHOENIX,AZ,85015,2019-01-18,691,E,0,1,I21U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy review, the facility failed to ensure that care and services were provided as ordered for one resident (#19), with a suprapubic catheter. Findings include: Resident #19 was readmitted on (MONTH) 22, 2013, with [DIAGNOSES REDACTED]. Review of a physician's history and physical dated (MONTH) 10, (YEAR) revealed the resident's suprapubic catheter occasionally becomes clogged and that staff are able to flush and resolve. Review of the physician's orders [REDACTED]. -clean the suprapubic catheter site with normal saline/wound cleanser, pat dry, apply [MEDICATION NAME] cream and cover with drain sponge and secure with a dry dressing every day for skin integrity. -monitor the peri suprapubic catheter site for signs and symptoms of infection and to call doctor if positive every shift for skin integrity. -flush catheter with 30 cc of normal saline every shift to prevent clogging. Review of a care plan revealed the resident had a suprapubic catheter. The goal included that the resident would be free of complications related to catheter use. Approaches included to observe for signs and symptoms of infection and to do suprapubic catheter care daily. Review of the Treatment Administration Record (TAR) for (MONTH) (YEAR) revealed the above orders for the suprapubic catheter. However, there was no documentation that the suprapubic catheter site was cleansed on (MONTH) 14 or 23; or documentation that the peri suprapubic catheter site was monitored for signs and symptoms of infection on (MONTH) 14 and 23 on the 7 a.m. to 7 p.m. shift or on (MONTH) 5, 7, 14, 18, 19 or 26 on the 7 p.m. to 7 a.m. shift. Review of the TAR for (MONTH) (YEAR) revealed the following: -no documentation that the suprapubic catheter was cleansed on (MONTH) 6, 14 or 18. -no documentation that the peri suprapubic catheter site was monitored for signs and symptoms of infection on (MONTH) 6 and 14 for the 7 a.m. to 7 p.m. shift or on (MONTH) 5 and 6 for the 7 p.m. to 7 a.m. shift. Review of the TAR for (MONTH) (YEAR) revealed the following: -no documentation that the suprapubic catheter was cleansed on (MONTH) 7, 8 or 16. -no documentation that the peri suprapubic catheter site was monitored on (MONTH) 7 and 8 on the 7 a.m. to 7 p.m. shift or on (MONTH) 11, 14 and 26 on the 7 p.m. to 7 a.m. shift. A physician's orders [REDACTED]. Review of the TAR for (MONTH) (YEAR) revealed the following: -no documentation the suprapubic catheter was cleansed on (MONTH) 18 and 25. -no documentation that the peri suprapubic catheter site was monitored for signs and symptoms of infection on (MONTH) 18 and 25 on the 7 a.m. to 7 p.m. shift or on (MONTH) 18 and 21 on the 7 p.m. to 7 a.m. shift. Review of the TAR for (MONTH) (YEAR) revealed the following: -no documentation that the suprapubic catheter was cleansed on (MONTH) 3, 5, 7 and 31. -no documentation that the peri suprapubic catheter site was monitored for signs and symptoms of infection on (MONTH) 3, 5 and 7 on the 7 a.m. to 7 p.m. shift or from (MONTH) 14-16, 19, 21-23 and from 28-30 on the 7 p.m. to 7 a.m. shift. Review of the Medication Administration Record [REDACTED]. Review of the TAR for (MONTH) (YEAR) revealed the following: -no documentation that the suprapubic catheter was cleansed on (MONTH) 4, 9-14, 18 and 28. -no documentation that the peri suprapubic catheter site was monitored for signs and symptoms of infection on (MONTH) 4, 9-14, 18 and 28 on the 7 a.m. to 7 p.m. shift. Review of an annual Minimum Data Set (MDS) assessment dated (MONTH) 2, (YEAR), revealed the resident had a Brief Interview for Mental Status score of 15, which indicated intact cognition. The MDS documented the resident had an indwelling catheter, a [MEDICAL CONDITION] bladder and artificial openings of the urinary tract. The urinary Care Area Assessment (CAA) included that the indwelling catheter would be care planned, with an overall objective to avoid complications. Review of the TAR for (MONTH) (YEAR) revealed the following: -no documentation that the suprapubic catheter was cleansed on (MONTH) 3, 17, 28 and 31. -no documentation that the peri suprapubic catheter site was monitored for signs and symptoms on (MONTH) 3, 17, 28 and 31 on the 7 a.m. to 7 p.m. shift. Review of the TAR for (MONTH) 2019 revealed the following: -no documentation that the suprapubic catheter was cleansed on (MONTH) 1, 5, 6, and 12. -no documentation that the peri suprapubic catheter site was monitored for signs and symptoms of infection on (MONTH) 1, 5, 6 and 12 on the 7 a.m. to 7 p.m. shift. An interview was conducted with the resident (#19) on (MONTH) 14, 2019 at 9:57 a.m. He stated that the dressing for the suprapubic catheter does not get changed as ordered, and that the catheter gets clogged which causes spasms, leakage and pain. An interview was conducted with a Licensed Practical Nurse (LPN/staff #11) on (MONTH) 18, 2019 at 9:09 a.m. She stated that there should not be blanks in the MAR indicated [REDACTED]. She stated that a blank could mean the treatment or medication was provided but the nurse forgot to sign it off, or it could mean that the nurse did not provide the medication or treatment. She stated if the nurse was unable to provide the medication or treatment, the system will give the nurse options to indicate why the service was not provided, including refusal, held or to see the nurse notes. She stated that if the nurse chooses the option to see the nurses note, there should be some kind of documentation that explains what happened. She said if there is no progress note and the area was left blank on the MAR indicated [REDACTED]. An interview was conducted with the Director of Nursing (DON/staff #1) on (MONTH) 18, 2019. She stated if there is no entry on the MAR/TAR and it was not addressed in any other documentation, then it does not follow facility expectations, as the staff have not documented that a treatment has been done or that the medication was given. On review of the MARS/TARS from (MONTH) (YEAR) to (MONTH) 2019 for resident #19, the DON stated that staff did not follow her expectation for documentation. Regarding the blanks in the MAR/TAR for suprapubic catheter care, flushing the catheter and catheter site monitoring there was no documentation that the care was given. Review of the policy on Nursing Documentation revealed that documentation must be accurate and complete, including medications and treatments. The policy further indicated that documentation should be completed at soon as possible after care is given. According to the Catheter Care protocol, direct care staff are responsible for ensuring that a resident with an indwelling urinary catheter receives appropriate infection control prevention and practices at all times. The protocol noted to check the area for signs of infections, such as irritated, swollen, red or tender skin at the insertion site or drainage around the catheter and to report any signs of infection or changes in urine condition to the physician. The protocol included that all resident with indwelling catheters will have twice daily routine catheter care documented on the TAR. The protocol did not address suprapubic catheter care specifically.",2020-09-01
708,THE REHABILITATION CENTER AT THE PALAZZO,35116,6246 NORTH 19TH AVENUE,PHOENIX,AZ,85015,2019-01-18,757,D,0,1,I21U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy review, the facility failed to ensure each resident's drug regimen is free from unnecessary drugs, by failing to administer pain medication per the physician ordered parameters for one resident (#7). Findings include: Resident #7 was admitted to the facility on (MONTH) 3, (YEAR), with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The admission MDS (Minimum Data Set) assessment dated (MONTH) 10, (YEAR) revealed the resident scored a 15 on the Brief Interview for Mental Status, which indicated that the resident was cognitively intact. Review of the resident's eMAR (electronic medication administration record) for the month of (MONTH) (YEAR) revealed the resident was administered [MEDICATION NAME]-[MEDICATION NAME] 10/325 for pain outside of the physician ordered parameters six times. (The resident's pain level documented was less than 6 out of 10). Review of the resident's eMAR for (MONTH) (YEAR) revealed the resident was administered [MEDICATION NAME]-[MEDICATION NAME] 10/325 four times for pain levels less than 6 out of 10. The pharmacy review report dated (MONTH) 19-November 20, (YEAR) revealed resident #7's medications had been reviewed. An interview was conducted with a LPN (licensed practical nurse/staff #11) on (MONTH) 18, 2019 at 8:44 a.m. She stated that she follows the physician's orders [REDACTED]. An interview was conducted on (MONTH) 18, 2019 with the DON (Director of Nursing/staff #1). She stated that the physician's orders [REDACTED].",2020-09-01
709,THE REHABILITATION CENTER AT THE PALAZZO,35116,6246 NORTH 19TH AVENUE,PHOENIX,AZ,85015,2016-10-13,253,D,0,1,WV1R11,"Based on observations, staff interviews, and review of facility documents, the facility failed to provide housekeeping services to maintain a sanitary and comfortable interior. Findings include: An observation of a resident room was conducted on (MONTH) 11, (YEAR) at 12:58 p.m. The vanity sink counter was observed to have a large black area, which measured approximately 8 inches by 3 inches. In addition, the vanity where the top connects with the facing had separated at the joint, exposing blackened wood. There was also an area which was approximately 1 1/2 inches above and below the exposed joint, which had multiple spots of a brownish black dried substance. In a follow up observation conducted on (MONTH) 13, (YEAR) at 10:15 a.m., the sink counter still had the same large black area and the area above and below the exposed joint still had the multiple spots of a brownish black dried substance. In an interview with a housekeeping aide (staff #132) conducted on (MONTH) 13, (YEAR) at 10:30 a.m., staff #132 stated the room had been cleaned. At this time, staff #132 sprayed a cleaner on the sink counter and on the vanity where the brownish black spots were observed. The large black area on the sink counter lightened in color, but remained as a stain on the surface, and the spots on the vanity were able to be removed. Staff #132 stated she does clean each room daily. In an interview with the Director of Environmental Services (staff #135), he stated each housekeeping aide has a list of things that should be cleaned daily in each room. He stated that he will randomly choose 2-3 rooms to check, but does not have a process to track what is cleaned in each room, because the checklists are not kept. The Director stated he had not done a follow-up check on that room. Review of the Room Cleaning Checklist revealed various items to be cleaned in each resident room each day, which included the sink and bathroom.",2020-09-01
710,THE REHABILITATION CENTER AT THE PALAZZO,35116,6246 NORTH 19TH AVENUE,PHOENIX,AZ,85015,2016-10-13,314,G,0,1,WV1R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, observations, resident and staff interviews, and review of policies and procedures, the facility failed to ensure care and services were provided to three residents (#'s 61, 96 and 156) with pressure ulcers. Findings include: -Resident #156 was admitted to the facility on (MONTH) 5, (YEAR) from a hospital, with [DIAGNOSES REDACTED]. A hospital wound care note dated (MONTH) 5, (YEAR), included the resident had a suspected deep tissue injury on the left heel, which evolved into an unstageable pressure ulcer. The suspected deep tissue injury on the left heel is covered by eschar, which measures 1.2 centimeters (cm) in width by 1.2 cm in length, and surrounding skin has no [DIAGNOSES REDACTED] or induration. The note further included for [MEDICATION NAME] to be applied daily and leave open to air. Review of a nursing note dated (MONTH) 5, (YEAR) revealed the resident was admitted on the evening shift and was alert and oriented x 4. Review of the facility's physician admission orders [REDACTED]. Further review revealed that there were no treatment orders for the pressure ulcer on the left heel. Review of the facility's standing physician orders [REDACTED]. According to the clinical record, there was no documentation that the physician had been notified regarding the left heel unstageable pressure ulcer. A Braden Scale for Predicting Pressure ulcers dated (MONTH) 5, (YEAR), documented that the resident was at low risk. A nursing note dated (MONTH) 6, (YEAR), documented the resident's left heel had an open area that was dark, black in color and that the resident had a protective boot in place. However, a weekly head to toe skin assessment signed by a licensed practical nurse (LPN/wound nurse/staff #85) dated (MONTH) 7, (YEAR), revealed no documentation of an open area on the resident's left heel. A nutritional services progress note dated (MONTH) 7, (YEAR), documented that the resident had a possible pressure ulcer to the left heel . The note included that staff would continue to monitor for further interventions. Review of the clinical record revealed there was no documentation that the resident's left heel was thoroughly assessed upon admission. Review of a skin monitoring comprehensive shower review form dated (MONTH) 8, (YEAR) revealed instructions to perform a visual assessment of the resident's skin and report any abnormal looking skin to the nurse and to use the form to show the exact location and describe the skin abnormality. The documentation included that the resident did not have any skin problems. The form was signed by a licensed nurse. Further review of the clinical record revealed that a care plan for skin breakdown/pressure ulcers had not been developed upon admission. physician progress notes [REDACTED]. Review of the Treatment Administration Record (TAR) for (MONTH) (YEAR) revealed there were no treatment orders for the left heel, nor was there documentation of any treatment which had been provided. Continued review of the clinical record revealed there was no documentation that a thorough assessment of the resident's left heel was done, which included measurements from the time of admission through (MONTH) 11. An interview with a LPN (staff #136) who was working on the resident's unit was conducted on (MONTH) 11, (YEAR) at 2:11 p.m. She stated the resident had an unstageable pressure ulcer on the left heel, which was present on admission. She also stated that the wound nurse (staff #85) had not yet seen the wound. According to the admission Minimum Data Set (MDS) assessment dated (MONTH) 12, (YEAR), the resident was cognitively intact and required extensive assistance of two persons with bed mobility and transfers. The MDS also identified that the resident had one unstageable pressure ulcer, due to being covered with slough or eschar and that it was present upon admission. An interview was conducted on (MONTH) 12, (YEAR) at 1:00 p.m., with a LPN (staff #97) who was caring for the resident. Staff #97 stated that she did not know that the resident had a pressure ulcer and she could not locate any physician orders [REDACTED]. Following this interview, staff #97 inspected the resident's left heel and stated that an unstageable pressure ulcer was present. At this time, the resident stated that the left heel had not been treated since admission. An interview was conducted with the Director of Nursing (DON/staff #43) on (MONTH) 12, (YEAR) at 1:45 p.m. Staff #43 stated the physician should have been been notified on (MONTH) 6, when staff documented the left heel problem. Staff #43 stated that the head to toe skin assessment (conducted on (MONTH) 8) was not accurate, as it did not include the left heel pressure ulcer. She further stated that physician's standing orders could have been implemented. At this time, staff #85 joined the interview. Staff #85 stated that she signed and dated the head to toe skin assessment from (MONTH) 7, but she did not physically assess the resident's heels. An observation of the resident's left heel was then conducted with staff #85 on (MONTH) 12, (YEAR) at 2:17 p.m. The resident was observed to have two areas on the left heel as follows: area #1 was located on the distal heel and was non-blanchable, dark purple in color, and measured 3/4 inch in length by 1/2 inch in width, with no depth; area #2 was located on the left lateral heel and was not open, the area was blanchable and measured 1 inch in length by 3/4 inch in width, with no depth. Staff #85 stated both were unstageable pressure ulcers and that area #2 was a possible blister with fluid or pus. Staff #85 stated she would immediately notify the physician of the pressure ulcers and obtain treatment orders. A physician's orders [REDACTED]. -Resident #96 was admitted to the facility on (MONTH) 26, (YEAR) and a readmitted on (MONTH) 13, (YEAR). [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated (MONTH) 3, (YEAR) revealed the resident had a BIMS score of 12, which indicated the resident had moderate cognitive impairment. Review of the skin condition section revealed the resident was at risk for the development of pressure ulcers but did not have any pressure ulcers at the time of the assessment. A Weekly Skin assessment dated (MONTH) 17, (YEAR) did not indicate that the resident had any pressure ulcers. A Wound Progress Note dated (MONTH) 22, (YEAR) did not indicate that the resident had any pressure ulcers. A Nurses Progress Note dated (MONTH) 24, (YEAR) indicated that while a Certified Nursing Assistant (CNA) was changing the resident, an open area was noted on the resident's coccyx. The note indicated the wound nurse would follow up with the resident. A Wound Progress Note dated (MONTH) 24, (YEAR) indicated a wound to the right buttock area, which measured 0.5 x 0.5 cm. 0.1 cm in size with a red wound bed and barrier cream was applied. A physician's orders [REDACTED]. The Weekly Skin assessment dated (MONTH) 1, (YEAR) indicated the resident had an open area on the coccyx. A Wound Progress Note dated (MONTH) 3, (YEAR) indicated the left buttock ulcer was unchanged and measured 1 x 0.5 x 0.1, with no drainage and that barrier cream was applied. The Weekly Skin assessment dated (MONTH) 15, (YEAR) indicated the coccyx had an open area and barrier cream was applied with each brief change. Review of the TAR for (MONTH) (YEAR) revealed the barrier cream was not completed on the night shift on (MONTH) 22 and (MONTH) 29. The TAR also included that the open area on the left buttocks was not monitored for signs and symptoms of infection on the day and night shift on (MONTH) 10, or on the night shift on (MONTH) 22 or (MONTH) 29. A physician's orders [REDACTED]. The Weekly Skin assessment dated (MONTH) 5, (YEAR) indicated the left buttock open area was being followed by the wound nurse and cream is being applied with each brief change. A Wound Progress Note dated (MONTH) 9, (YEAR) indicated the resident had a pressure injury to the right sacrum, with no exudate. The note included the stage 2 wound measured 2.2 x 2.3 x 0.1 cm with 100% granulation tissue, wound edges were defined but macerated, and the periwound was intact with tenderness. The Weekly Skin assessment dated (MONTH) 19, (YEAR) indicated the left buttock had an open area. Review of the (MONTH) (YEAR) TAR revealed to cleanse the left buttocks ulcer with wound cleanser, pat dry, and apply Solosite gel to wound bed. However, the treatment was not competed on (MONTH) 6 and (MONTH) 22. In addition, the TAR indicated the open area on the left buttocks was not monitored for signs and symptoms of infection on the night shift on (MONTH) 5, the day shift on (MONTH) 8, the night shift on (MONTH) 13, and the day shift on (MONTH) 22. A Wound Progress Note dated (MONTH) 25, (YEAR) indicated the wound to the coccyx is resolved. The documentation contained in the resident's clinical record as noted above described a pressure ulcer to four different locations (sacrum, coccyx, left buttocks and right buttocks). The clinical record documentation did not clarify if the resident had one pressure ulcer or if multiple pressure ulcers were present. In an interview with a Licensed Practical Nurse (wound nurse/LPN/staff #136) on (MONTH) 12, (YEAR) at 9:03 a.m., staff #136 stated the difference in describing the location of the wound was because she has been told she was getting too specific with her descriptions and that she should be more general. She further stated that although the documentation appears as though the resident had four pressure ulcers because of the different locations described (sacrum, coccyx, left buttocks and right buttocks), the resident only had one pressure ulcer. -Resident #61 was admitted to the facility on (MONTH) 13, (YEAR), with [DIAGNOSES REDACTED]. Review of the nurse's notes from (MONTH) 13, through (MONTH) 15, (YEAR) revealed no documentation that the resident had any pressure ulcers. However, a skin integrity care plan initiated on (MONTH) 15, (YEAR) documented the resident had a right heel unstageable pressure ulcer. Interventions included to evaluate skin condition on a weekly basis, provide treatments per physician orders [REDACTED]. A physician's orders [REDACTED]. Review of the clinical record revealed there was no documentation regarding a thorough assessment of the resident's heels, which was completed upon admission. A nurse's note dated (MONTH) 18, (YEAR) included the resident did not have any pressure ulcers. Review of the admission MDS assessment dated (MONTH) 20, (YEAR) revealed the resident had a BIMS score of 15, which indicated the resident was cognitively intact. The MDS also assessed the resident to be at risk for the development of pressure ulcers, however, did not have any pressure ulcers at the time of admission. Review of the functional section of the MDS revealed the resident required extensive assistance/total dependence for all ADLs (activities of daily living). According to two nursing notes dated (MONTH) 29, (YEAR), the resident had a suspected deep tissue injury (SDTI) to the right heel which measured 7 x 6.5 cm and the depth was unable to be determined. The pressure ulcer was described as purple and maroon in color and the skin was intact. The second note indicated the resident had a SDTI to the left heel which measured 5.2 x 3.5 and the depth was unable to be determined and the skin was intact. Review of the Treatment Administration Record for (MONTH) (YEAR) revealed the treatment for [REDACTED]. A nursing note dated (MONTH) 4, (YEAR) included the SDTI to the right heel had drainage. The physician was called and a new order for treatment to the right heel was received. A physician's orders [REDACTED]. A Wound Progress Note dated (MONTH) 17, (YEAR) indicated skin prep was applied and the dressing changed to the right heel, which measured 4.9 x 6.8 cm. The note indicated the left heel SDTI measured 2.3 x 4.7 cm and skin prep was applied. Both wounds were described as being dark in color. Review of a physician's note dated (MONTH) 26, (YEAR) revealed the resident had bilateral heel decubitus ulcers with eschar caps and the left was larger than the right, and both were hard. Will continue [MEDICATION NAME] daily and off loading heels. A physician's orders [REDACTED]. A physician's note dated (MONTH) 30, (YEAR) revealed the deep tissue injury to the right heel was opening and that the orders will be changed to [MEDICATION NAME], and Kerlix and the left heel decubitus treatment included [MEDICATION NAME]. A physician's orders [REDACTED]. Review of the TAR for (MONTH) (YEAR) revealed skin prep to the left heel was not completed on two shifts, and the right and left heels were not monitored for signs of infection on six shifts. Further review of the clinical record revealed there was no additional assessment documentation of the resident's left heel from (MONTH) 18-31, (YEAR). The right heel pressure ulcer continued to be assessed weekly. Review of a physician's note dated (MONTH) 6, (YEAR) included the resident had a left heel decubitus with eschar. A physician's orders [REDACTED]. A Wound Progress Note dated (MONTH) 15, (YEAR) indicated the presence of a SDTI to the right heel, which measured 2.5 x 2 cm and depth was UTD, with a scant amount of drainage. A physician's note dated (MONTH) 16, (YEAR) documented the resident had a decubitus ulcer with eschar to the left heel. Continued review of the clinical record revealed there were no thorough assessments of the resident's left heel decubitus ulcer in (MONTH) (YEAR). The right heel pressure ulcer continued to be assessed weekly. A physician's note dated (MONTH) 1, (YEAR) included the resident had a decubitus ulcer with eschar to the left heel. A Wound Progress Note dated (MONTH) 3, (YEAR) indicated the right heel wound continues to be scabbed over and measured 2.5 x 2 cm. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's note dated (MONTH) 27, (YEAR) included the resident had a decubitus ulcer with eschar to the left heel. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Review of the TAR for (MONTH) (YEAR) revealed skin prep to bilateral heels was not completed on six shifts, floating heels was not documented as performed on two shifts, left heel ulcer care was not documented on nine shifts, and the right and left heels were not monitored for signs of infection on two shifts. Further review of the clinical record revealed there was no thorough assessment documentation of the resident's left heel decubitus ulcer in (MONTH) (YEAR). The right heel pressure ulcer continued to be assessed weekly. A physician's note dated (MONTH) 1, and 26, (YEAR) did not include any documentation regarding a left heel decubitus ulcer. There was also no clinical record documentation regarding the left heel decubitus ulcer in (MONTH) (YEAR). The right heel pressure ulcer continued to be assessed weekly. In an interview with the Director of Nursing (registered nurse/DON/staff #43) on (MONTH) 12, (YEAR) at 1:45 p.m., the DON stated there were problems identified with pressure ulcers over the past 4-6 weeks, such as incomplete documentation and follow-up. The DON stated that the wound nurses are supposed to evaluate the wounds as soon as possible after the wound is identified, and contact the physician for orders. She further stated that the physician should be called any time there is a change for the worse in the condition of the wound or when the wound is healed. A pressure ulcer treatment observation was conducted on (MONTH) 13, (YEAR) at 9:01 a.m., with licensed staff present. The right heel was observed to be dried and without redness or drainage and was covered with eschar and measured 1 x 2 cm. The resident did not have a wound to the left heel. Review of the facility's policies regarding pressure ulcers revealed that a head to toe skin assessment should be done on all residents upon admission, then every shift for the first 24 hours. The policy included that the CNA's are to communicate skin integrity issues noted during daily care and to complete the form and ensure delivery to the licensed nurse. The licensed nurse then assesses the resident's skin issue and intervenes as necessary by documenting, communicating the findings to the physician and implementing appropriate interventions. The policies further included that the licensed nurse will monitor pressure ulcers daily to include status of the dressing, condition of the peri-wound, and presence of possible complications. Weekly, the treatment nurse will document wound location, measurements, characteristics, absence of odor, etc. Licensed nurse to provide treatment as ordered. Residents admitted with pressure ulcers will have appropriate preventive interventions, care plans with interventions, and physician orders [REDACTED]. When a new skin issue is identified the licensed nurse validates the observation by examining the resident and complete documentation on the wound tracking worksheet. Document only one area or site per form. Determine the stage of the pressure ulcer, measure the pressure ulcer and describe the pressure ulcer. Notify the physician and collaborate on a treatment order.",2020-09-01
711,THE REHABILITATION CENTER AT THE PALAZZO,35116,6246 NORTH 19TH AVENUE,PHOENIX,AZ,85015,2016-10-13,441,D,0,1,WV1R11,"Based on observations, staff interviews, and review of policies and procedures, the facility failed to ensure a dietary staff member (staff #45) used proper hand washing techniques. The facility also failed to ensure staff washed their hands after each glove change during wound care. Findings include: During an observation conducted on (MONTH) 14, (YEAR), staff #45 was observed washing her hands after preparing pureed food. After staff #45 washed her hands, she was observed to turn off the water faucet without utilizing a barrier. An interview was conducted with corporate dietary staff (staff #140). Staff #140 stated that a barrier should be used when turning off the faucet. Review of a policy regarding Proper Handwashing, revealed that staff are to wash their hands After working with different food products . The policy also included after staff wash their hands they are to dry their hands with a paper towel and then Turn off tap with paper towel. -During an observation of wound care conducted on (MONTH) 13, (YEAR) at 2:51 p.m., the Licensed Practical Nurse (LPN/staff #100) prepared the supplies using clean technique. Staff #100 then washed her hands and applied gloves and removed the existing dressing from the wound. Staff #100 then removed her gloves and applied a new pair of gloves, without washing her hands. Staff #100 then cleaned the wound, removed the gloves, wrote a date on the dressing to be applied, and then donned another set of gloves and secured the dressing. Following the observation, staff #100 stated that hands should be washed with each glove change. Staff #100 also stated that she should have washed her hands, when she changed gloves. During an interview conducted on (MONTH) 13, (YEAR) at 11:36 a.m., the Director of Nursing (staff #43) stated that when performing wound care the nurse should wash their hands when they enter the room, before starting the procedure, each time gloves are changed, and then at the end of the procedure.",2020-09-01
712,THE REHABILITATION CENTER AT THE PALAZZO,35116,6246 NORTH 19TH AVENUE,PHOENIX,AZ,85015,2017-10-13,279,D,0,1,UYHV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure that a nutritional care plan was developed for one resident (#128). Findings include: Resident #128 was admitted to the facility on (MONTH) 18, (YEAR), with [DIAGNOSES REDACTED]. The resident was discharged from the facility on (MONTH) 6, (YEAR). A review of the nursing admission evaluation dated (MONTH) 18, (YEAR) revealed the resident was alert and oriented, and was on a regular diet. A physician's orders [REDACTED]. A physician's orders [REDACTED]. According to the Weight and Vital Signs Summary, the resident's weight on (MONTH) 21, (YEAR) was 100.2 lbs. Review of the Nutrition Risk Review dated (MONTH) 21, (YEAR) revealed the resident had chewing and swallowing problems. The resident's IWR (ideal weight range) was between 108-132 lbs, and had a BMI (body mass index) of 16.8, but required a BMI of The admission MDS (Minimum Data Set) assessment dated (MONTH) 25, (YEAR) included a Brief Interview for Mental Status score of 7, which indicated the resident had severe cognitive impairment. The MDS also assessed the resident to have difficulty with swallowing and required limited assistance of one person with eating. A nutritional approach included for a mechanically altered diet. In the CAA (Care Area Assessment) Summary, nutritional status triggered for care planning. However, a review of the resident's comprehensive care plans revealed that a nutritional care plan was not developed to address the resident's nutritional status, nor were there interventions to address any nutritional needs. An interview with the MDS Coordinator (staff #52) was conducted on (MONTH) 12, (YEAR) at 3:37 p.m. She stated that she is responsible for the development of the comprehensive care plan, which is based on the triggered areas in the MDS. She stated that she includes information on the care plan from the clinical record and from interviews. However, she stated that nutrition is a specialized area and the dietary staff are responsible for creating the nutritional care plan for residents. During an interview with the Director of Nursing (DON/staff #130) conducted on (MONTH) 13, (YEAR) at 9:33 a.m., she stated the dietary staff are expected to create the nutrition care plan. She stated that she was not aware that resident #128 did not have a nutritional care plan developed. An interview with a dietary tech (staff #36) was conducted on (MONTH) 13, (YEAR) at 10:12 a.m. She stated that she checks the new admissions and the census reports daily to ensure that she does not miss any new admissions. She said that a nutrition screen should be conducted and nutrition risks identified, within 72 hours of admission. She also stated that she has six days from the date of the resident's admission to write her assessment and complete the nutrition care plan. Staff #36 was not aware that the care plan was missing for this resident. Review of the facility's policy on Comprehensive Care Plans revealed an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The policy further included that the comprehensive care plan is developed within seven days of completion of the resident's assessment.",2020-09-01
713,THE REHABILITATION CENTER AT THE PALAZZO,35116,6246 NORTH 19TH AVENUE,PHOENIX,AZ,85015,2017-10-13,309,D,0,1,UYHV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy and procedures, the facility failed to provide the necessary care and services to maintain the highest practicable well-being, by failing to ensure that consistent and thorough wound assessments were completed, and that wound treatments were consistently provided for one resident (#122), with multiple wounds. Findings include: Resident #122 was admitted to the facility from the hospital on (MONTH) 22, (YEAR), with [DIAGNOSES REDACTED]. The resident was discharged to home on hospice care on (MONTH) 18, (YEAR). Review of the admission nursing assessment dated (MONTH) 22, (YEAR) revealed the resident was admitted with wounds to the scrotum and penis. However, the specific locations of the wounds on the scrotum and penis were not included. A physician's orders [REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 29, (YEAR), revealed the resident scored a 4 on the Brief Interview for Mental Status (BIMS), which indicated severe cognitive impairment. A skin care plan identified the resident had actual skin impairment. The goals included that the resident would be free from skin breakdown and have no complications. The interventions included to evaluate skin condition on a daily and weekly basis, monitor effectiveness of treatment and to monitor and document location, size and treatment of [REDACTED]. Regarding the scrotal wound (wound #4): A wound progress note dated (MONTH) 23, (YEAR) identified the resident had a wound on his scrotum (identified as wound #4), which measured 1.9 cm by 1.4 cm by 0.2 cm, with slough and no redness or drainage. The note did not include what type of wound it was or the specific location on the scrotum. Review of the physician's orders [REDACTED]. Review of the Treatment Administration Record (TAR) for (MONTH) 23 through 30, (YEAR) revealed there were multiple times with no documentation that the above physician's orders [REDACTED]. Review of the clinical record revealed that the scrotal wound was measured next on (MONTH) 5, (YEAR), which was 12 days after the previous assessment. Per the wound notes, the scrotal wound measured 1.9 cm by 1.4 cm by 0.2 cm with slough, but no redness or drainage were present. Review of the TAR for (MONTH) 1 through 18, (YEAR) revealed that there were multiple times with no documentation that the treatment to the scrotal wound was done or that the wound was monitored for infection, as ordered. The scrotal wound was not assessed again until (MONTH) 22, (YEAR), which was 17 days after the last assessment, and three days after the resident was discharged . Per the wound progress note which was not identified as a late entry, the wound measured 1.7 cm by 1.3 cm by 0.1 cm with slough, and no redness or drainage were present. Regarding the penile wound (wound #5): A wound progress note dated (MONTH) 23, (YEAR) identified that the resident had a penile wound (identified as wound #5) with slough, but no redness or drainage were present. Per the note, there were no measurements of the wound, nor was the specific location of the wound on the penis documented. Also, the wound was not classified as to what type of wound it was. Review of the physician's orders [REDACTED]. A physician's orders [REDACTED]. Review of the TAR for (MONTH) 23 through 30, (YEAR) revealed the above orders, however, there were multiple times with no documentation the wound treatment was provided and that the penis was monitored for signs and symptoms of infection. Further review of the clinical record revealed that the penile wound was assessed next on (MONTH) 5, (YEAR), which was 12 days after the previous assessment. Per the wound note, the penile wound had slough, and no redness or drainage. The documentation did not include any measurements, nor was the wound classified. Review of the TAR for (MONTH) 1 through 18, (YEAR) revealed there were multiple times with no documentation the wound treatment was provided and that the penis was monitored for signs and symptoms of infection. The penile wound was not assessed again until (MONTH) 22, (YEAR), which was 17 days after the prior assessment, and three days after the resident was discharged . Per the wound progress note which was not identified as a late entry, the penile wound had slough and no redness or drainage. The documentation did not include the specific location of the wound on the penis, any measurements, nor the wound classification. Regarding the perianal wound (wound #6): A wound progress note dated (MONTH) 23, (YEAR) identified the resident had a perianal wound (identified as wound #6), and had a rectal tube previously. Per the note, the wound was superficial and did not have any redness or drainage. The wound was not classified and there were no measurements. Review of the physician's orders [REDACTED]. The orders also included to monitor for signs and symptoms of infection, and call physician if positive. Review of the TAR for (MONTH) 23 through 30, (YEAR) revealed the above orders, however, there were multiple times with no documentation the wound treatments were done, and that the wound was monitored for signs and symptoms of infection. Further review of the clinical record revealed the perianal wound was not assessed again until (MONTH) 5, (YEAR), which was 12 days after the last assessment. Per the wound note, the wound did not have redness or drainage. The assessment did not include any measurements or classification of the wound. Review of the TAR for (MONTH) 1 through 18, (YEAR) revealed there were multiple times with no documentation the wound treatments were done, and that the wound was monitored for signs and symptoms of infection. The next wound assessment was completed on (MONTH) 22, (YEAR), which was 17 days after the prior assessment, and three days after the resident was discharged . Per the wound progress note which was not identified as a late entry, the wound did not have any redness or drainage and there were no measurements or classification of the wound. An interview was conducted with a Licensed Practical Nurse (LPN/staff #14) at 11:05 a.m. on (MONTH) 12, (YEAR). She stated the wound treatments are done by the nurse working on the floor or by the wound nurse. Staff #14 stated that the wound nurse only works during the week, so the nurses on the floor have to do the treatments on the weekends. She stated when a treatment is done, it should be documented in the TAR. Staff #14 stated if there are blanks on the TAR, it means the treatments were not done. During an interview with the wound nurse (staff #20) at 2:45 p.m. on (MONTH) 12, (YEAR), she stated that she started working as the wound nurse the end of (MONTH) (YEAR). Staff #20 stated that the process is to complete a head to toe assessment upon admission, and document any wounds identified. She stated that the admission assessment should include measurements of the wound, a description of the wound bed and surrounding skin, any drainage, and any signs of infection. Staff #20 stated the wounds should be assessed weekly and should include measurements, a description of the wound bed and surrounding skin, classification of the wound, and the progress of the wound. After reviewing the resident's clinical record, staff #20 stated that the resident's wounds were not classified as to the type of wounds. She further stated that she did not know why there were missing treatments in the TAR, but could have been because the wound nurse only worked certain days so the floor nurses should have completed the treatments on the other days and that may have created confusion. In an interview with the Director of Nursing (DON/staff #130) at 9:30 a.m. on (MONTH) 13, (YEAR), she stated that she is new and did not work when this resident was in the facility, but she had reviewed the resident's chart. She stated when it comes to wounds, the expectation is that staff should be aware of any open areas on the resident's skin upon admission, and the wound nurse should assess the wounds by the next morning. The DON stated that the wound assessments should be done weekly and should be thorough, which includes wound measurements, a description of the wound bed and surrounding skin, any drainage, treatments and any recommendations. She stated that wounds should be identified as to what kind of wound they are, so it can be determined if they are pressure related or not. Staff #130 further stated that the wound treatments should be documented in the TAR, and should be completed as ordered. Review of a policy and procedure regarding skin and wound management revealed to promote skin integrity through appropriate measures. The policy included that upon admission, a licensed nurse will complete a head to toe assessment of the resident and that measurements and wound characteristics will be documented. Following admission, the licensed nurse will conduct a weekly head-to-toe skin assessment to identify any existing wounds. The policy further included that weekly, the treatment nurse will document wound location, measurements, wound characteristics, presence or absence of odor, etc. on the weekly wound tracking worksheet, which are maintained in the resident's treatment record. Licensed nurses will provide wound treatments as ordered. The policy also noted that the interdisciplinary team will review the interventions in place to determine if they are effective and will review the progress of healing.",2020-09-01
714,THE REHABILITATION CENTER AT THE PALAZZO,35116,6246 NORTH 19TH AVENUE,PHOENIX,AZ,85015,2017-10-13,314,E,0,1,UYHV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy and procedures, the facility failed to ensure the necessary treatment and services were provided to one resident (#122), with multiple pressure ulcers. Findings include: Resident #122 was admitted to the facility from the hospital on (MONTH) 22, (YEAR), with [DIAGNOSES REDACTED]. The resident was discharged to home on hospice care on (MONTH) 18, (YEAR). A Braden Scale for predicting pressure sore risk dated (MONTH) 22, (YEAR) identified that the resident was at moderate risk for pressure ulcer development. Review of the admission nursing assessment dated (MONTH) 22, (YEAR) revealed the resident had multiple wounds as follows: -Coccyx -Right ischium -left heel -SDTI under the left great toe -Wounds on the back of the left and right shoulder (scapula) Review of the skin care plan revealed the resident had actual skin integrity impairment. The goals were for the resident to be free from skin breakdown and have no complications. The interventions included to evaluate skin condition on a daily and weekly basis, monitor effectiveness of treatment, weekly skin assessments, and to monitor and document location, size and treatment of [REDACTED]. Regarding the coccyx pressure ulcer (wound #1): A wound progress note dated (MONTH) 23, (YEAR) identified that the resident had a stage 2 pressure ulcer on the coccyx (identified as wound #1), which measured 1.4 cm by 1.2 cm by 0.2 cm. The wound bed was pink, with no redness or drainage. Review of the physician's orders [REDACTED]. A physician's orders [REDACTED]. Review of the Treatment Administration Record (TAR) for (MONTH) 23 through (MONTH) 30, (YEAR) revealed the above orders, however, there were two days, with no documentation that the above physician's orders [REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 29, (YEAR), revealed the resident scored a 4 on the Brief Interview for Mental Status (BIMS) section, which indicated severe cognitive impairment. The resident was also assessed to have two stage 2 pressure ulcers and two deep tissue injuries. These pressure ulcers were noted to be present upon admission. Review of the clinical record revealed the coccyx pressure ulcer was measured next on (MONTH) 5, (YEAR), which was 12 days after the previous assessment. Per the wound note, the coccyx wound measured 1.4 cm by 1.2 cm by 0.2 cm, and the wound bed was pink with no redness or drainage. The coccyx wound was not assessed again until (MONTH) 22, (YEAR), which was 17 days after the previous assessment, and three days after the resident was discharged . Per the wound note which was not identified as a late entry, the coccyx wound measured 1.5 cm by 1.1 cm by 0.2 cm and was pink, with no drainage. Further review of the TAR for (MONTH) 1 through 18, (YEAR), revealed there were multiple days with no documentation that either the treatment to the coccyx was provided or that the wound was monitored for signs and symptoms of infection as ordered. Regarding the right ischium pressure ulcer (wound #2/right buttocks): A wound progress note dated (MONTH) 23, (YEAR) included the resident had a pressure ulcer on the right ischium (identified as wound #2). The wound measured 0.4 cm by 0.5 cm, with a pink, superficial wound bed which was almost healed. A physician's orders [REDACTED]. Review of the TAR for (MONTH) 24 through (MONTH) 30, (YEAR) revealed the above order, however, there were multiple shifts with no documentation that the treatment was completed. Continued review of the wound progress notes revealed that the right ischium pressure ulcer was not assessed again until (MONTH) 5, (YEAR), which was 12 days after the last assessment. Per the wound note, the right ischium wound was superficial and measured 0.4 cm by 0.5 cm, with a pink wound bed. Review of the TAR for (MONTH) 1 through 18, (YEAR) revealed there were multiple shifts with no documentation that the treatment was provided. The right ischium wound was assessed next on (MONTH) 22, (YEAR), which was 17 days after the last assessment, and three days after the resident was discharged . Per the wound progress note which was not identified as a late entry, the right ischium wound measured 0.3 cm by 0.5 cm and was superficial, with a pink wound bed. Regarding the left heel (wound #3): A wound progress note dated (MONTH) 23, (YEAR) identified that the resident had a SDTI (suspected deep tissue injury) on the left heel (identified as wound #3), which measured 0.6 cm by 0.7 cm. The wound was described as a darkened area. A physician's orders [REDACTED]. Review of the TAR for (MONTH) 23 through 30, (YEAR) revealed the above order, however, there were multiple shifts with no documentation that the treatment to the left heel was done. Per the wound documentation, the left heel SDTI was not assessed again until (MONTH) 5, (YEAR), which was 12 days after the previous assessment. Per the wound note, the left heel pressure ulcer measured 0.6 cm by 0.7 cm and was dark, with no redness. Review of the TAR for (MONTH) 1 through 18, (YEAR) revealed there were multiple shifts with no documentation that the treatment to the left heel was done. There was also no explanation as to why the treatments were not completed. According to the wound documentation, the left heel SDTI was not assessed again until (MONTH) 22, (YEAR), which was 17 days after the previous assessment and three days after the resident was discharged from the facility. A wound note dated (MONTH) 22, (YEAR) which was not identified as a late entry, documented that the left heel SDTI measured 0.6 cm by 0.7 cm, with no redness. Regarding the SDTI under the left great toe (wound #8): A wound progress note dated (MONTH) 23, (YEAR) identified that the resident had a SDTI under the left great toe (identified as wound #8), which measured 1.4 cm by 1.2 cm. The wound was noted to be dark, with no redness. Review of the physician's orders [REDACTED]. The orders also included to monitor for signs and symptoms of infection, and call physician if positive. Review of the TAR for (MONTH) 23 through 30 and from (MONTH) 1 through 18, (YEAR) revealed the above orders, however, there were multiple times with no documentation that the orders were done. Continued review of the clinical record revealed there was no further documentation regarding the SDTI to the left great toe from (MONTH) 24-July 18. Regarding the left and right scapula wounds: The physician's orders [REDACTED]. -Wash with mild soap and water, pat dry and cover with a foam dressing every day shift. The physician's orders [REDACTED]. -Cleanse with wound cleanser, pat dry, apply [MEDICATION NAME], and cover with a foam dressing every day shift. Review of the TAR for (MONTH) 22 through (MONTH) 18, (YEAR), revealed the above orders, however, there were multiple times with no documentation that the treatments to the left and right scapula were done. An interview was conducted with a Licensed Practical Nurse (LPN/staff #14) at 11:05 a.m. on (MONTH) 12, (YEAR). She stated that the wound treatments are done by either the nurse working on the floor or by the wound nurse. She stated the wound nurse usually provides the treatments for more complicated wounds, like stage 2 pressure ulcers or above, but the simpler wounds can be completed by the floor nurse. Staff #14 stated that the wound nurse only works certain days, so the nurses on the floor have to do the treatments on the weekends. She said that when a treatment is done is should be documented in the TAR. She stated that if there are any blanks on the TAR, it means the treatments were not done. During an interview with the wound nurse (staff #20) at 2:45 p.m. on (MONTH) 12, (YEAR), she stated that she started working as the wound nurse the end of (MONTH) (YEAR). Staff #20 stated that the process is to do a head to toe assessment upon admission and that any wounds identified should be documented. She said the admission assessment includes measuring the wound, describing the wound bed, including the type of tissue surrounding the wound bed, any drainage, and assessing for infection. She stated the wound assessments are to be done weekly and should always include measurements, description of the wound bed, classification of the wound, any issues with the wound, and the progress of the wound. After reviewing the wound documentation, she stated that the right ischium wound should have been staged and that if there was any confusion, it should have been clarified. Staff #20 stated that some of the wounds were not classified as to the type and they should have been. She said that it is possible that the perianal wound was a pressure ulcer which resulted from the rectal tube, but based on the documentation it could not be determined what kind of wounds they were. She said that she did not know why there were missing treatments in the TAR, but could have been because the wound nurse would work certain days and then expect the floor nurses to do the treatments on the other days and that may have created confusion. In an interview with the Director of Nursing (DON/staff #130) at 9:30 a.m. on (MONTH) 13, (YEAR), she stated that she is new and did not work when this resident was in the facility, but she had reviewed the resident's chart. She stated when it comes to pressure ulcers, the expectation is that staff should be aware of any open areas on the resident's skin upon admission, and the wound nurse should assess the wounds by the next morning. The DON stated that the wound assessments should be done weekly and should be thorough, which includes wound measurements, a description of the wound bed and surrounding skin, stage of the pressure ulcer, any drainage, treatments and any recommendations. She stated that wounds should be identified as to what kind of wound they are, so it can be determined if they are pressure related or not. Staff #130 further stated that the wound treatments should be documented in the TAR, and should be completed as ordered. Review of a policy and procedure regarding skin and wound management revealed to promote skin integrity through appropriate measures. The policy included that upon admission, a licensed nurse will complete a head to toe assessment of the resident and document any wounds. The documentation should include measurements and wound characteristics. Residents admitted with pressure ulcers will have a physician's orders [REDACTED]. Following admission, the licensed nurse will conduct a weekly head-to-toe skin assessment to identify any existing wounds. The policy further included that weekly, the treatment nurse will document wound location, measurements, wound characteristics, presence or absence of odor, etc. on the weekly wound tracking worksheet, which are maintained in the resident's treatment record. Licensed nurses will provide wound treatments as ordered. The policy also noted that the interdisciplinary team will review the interventions in place to determine if they are effective and will review the progress of healing.",2020-09-01
715,THE REHABILITATION CENTER AT THE PALAZZO,35116,6246 NORTH 19TH AVENUE,PHOENIX,AZ,85015,2017-10-13,315,E,0,1,UYHV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy and procedures, the facility failed to ensure that catheter care was consistently provided for one resident (#122). Findings include: Resident #122 was admitted to the facility on (MONTH) 22, (YEAR), with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. -Catheter size 16 French with 10 cubic centimeter (cc) balloon. -Catheter care every shift. -Change Foley bag and tubing as needed A physician's orders [REDACTED]. An admission Minimum Data Set (MDS) assessment dated (MONTH) 29, (YEAR) included the resident scored a 4 on the Brief Interview for Mental Status (BIMS), which indicated severe cognitive impairment. The MDS also noted that the resident had an indwelling urinary catheter. A care plan included the resident had an indwelling urinary catheter related to [DIAGNOSES REDACTED]. The goal was that the resident would show no signs or symptoms of a UTI. The interventions included to change the catheter per physician's orders [REDACTED]. The care plan did not address the need for catheter care every shift as ordered. A physician's orders [REDACTED]. Review of a physician's progress note dated (MONTH) 17, (YEAR) revealed the resident was having cloudy urine. A nursing note dated (MONTH) 17, (YEAR) revealed that the urinalysis was still pending. Review of the clinical record including the nursing notes, the Treatment Administration Record (TAR) and the Activities of Daily Living (ADL) documentation by the Certified Nursing Assistants (CNA), revealed that from (MONTH) 23, (YEAR) through (MONTH) 18, (YEAR), there was no evidence that catheter care was provided each shift, per the physician's orders [REDACTED].>Clinical record documentation showed that the resident was discharged from the facility to home on (MONTH) 18, (YEAR). In an interview with a Licensed Practical Nurse (LPN/staff #14) at 11:05 a.m. on (MONTH) 12, (YEAR), she said that residents with catheters should have a physician's orders [REDACTED]. Staff #14 stated that the CNAs provide the catheter care every shift and they are to document this under the resident's ADL care. An interview was conducted with a CNA (staff #15) at 11:15 a.m. on (MONTH) 12, (YEAR). He stated that the CNAs do the catheter care for the residents. He said there is no specific area to chart Foley care, but it should go under the ADL documentation for toileting. He stated that he completes catheter care at least once per shift. During an interview with the Director of Nursing (staff #130) at 9:30 a.m. on (MONTH) 13, (YEAR), she stated that the CNAs provide catheter care to residents. She stated that since this resident had catheter care ordered each shift, it should be documented on the TAR, and it should be signed off each shift by the nurse. Staff #130 further stated that this resident was very impaired and had a history of [REDACTED]. Review of a policy for urinary catheter care revealed that the purpose was to prevent catheter associated urinary tract infections. The policy included that catheter care should be recorded in the resident's medical record and include the following: the date and time when catheter care was performed; the name and title of the individual giving the catheter care; all assessment data obtained when giving catheter care such as the character of urine (such as odor, color, cloudy, or blood); any problems noted during perineal care; any complaints made by the resident related to the procedure; how the resident tolerated the procedure and a reason why if the resident refused the procedure.",2020-09-01
716,THE REHABILITATION CENTER AT THE PALAZZO,35116,6246 NORTH 19TH AVENUE,PHOENIX,AZ,85015,2017-10-13,325,D,0,1,UYHV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure one resident (#128) was provided nutritional care and services to maintain body weight. Findings include: Resident #128 was admitted to the facility on (MONTH) 18, (YEAR), with [DIAGNOSES REDACTED]. The resident was discharged from the facility on (MONTH) 6, (YEAR). A review of the nursing admission evaluation dated (MONTH) 18, (YEAR) revealed the resident was alert and oriented, had her own teeth and was on regular diet. A physician's orders [REDACTED]. Another physician's orders [REDACTED]. Review of the Weight and Vital Signs Summary revealed that the resident's weight on (MONTH) 21, (YEAR) was 100.2 lbs. According to the Nutrition Risk Review dated (MONTH) 21, (YEAR), the resident's diet was regular mechanical soft, as the resident had chewing and swallowing problems. The assessment also included the resident leaves 25% plus at most meals and intake percentage was 44% x 4 meals. Per the review, the resident's caloric needs were 1320-1540 calories per day, and required a caloric percentage of greater than 60%, which was not always met. The assessment also included the resident's protein needs were 52 g daily and required greater than 62%. The resident's IWR (ideal weight range was between 108-132 lbs) and the resident had a BMI (body mass index) of 16.8 (normal range 18.5-24.9). The recommendations included for SNP (Special Nutrition Program) three times a day to better meet estimated needs. A physician's orders [REDACTED]. However, this order was not transcribed onto the Medication Administration Record [REDACTED]. Review of the dietary meal tickets dated (MONTH) 23, 24, 26 and 27, (YEAR) revealed the resident was to receive SNP and included the following: -April 23: The resident refused breakfast and dinner. -April 24: meal intake was zero for lunch. -April 26 and 27: meal intake was 25% for breakfast. -May 1: meal intake was 25% for breakfast, 50% for lunch and 75% for dinner. The facility was unable to provide any additional documentation regarding the resident's meal percentages and there was no clinical record documentation that meal alternates or snacks were offered or provided to the resident on these dates with poor intake. The admission MDS (Minimum Data Set) assessment dated (MONTH) 25, (YEAR) included a BIMS (Brief Interview for Mental Status) score of 7, indicating the resident had severe cognitive impairment. The MDS also assessed the resident to have difficulty or pain with swallowing, and required limited assistance of one person with eating. A nutritional approach included mechanically altered diet. In the CAA (Care Area Assessment) Summary, nutritional status triggered for care planning. However, a review of the resident's comprehensive care plans revealed that no care plan had been developed to address the resident's nutritional status, nor were there interventions to address any nutritional needs. Review of the Weights and Vitals Summary revealed that on (MONTH) 28, (YEAR), the resident's recorded weight was 92.2 lbs. (an 8 lb weight loss in 7 days). A physician's progress note dated (MONTH) 28, (YEAR) included there were no new staff concerns. Per the documentation, the reason for the visit was post-op and hypertension monitoring. There was no mention of the resident's weight loss. Review of the Weights and Vitals Summary revealed that on (MONTH) 30, (YEAR), the resident continued to experience weight loss. The resident's recorded weight was 91.2 lbs (for a total weight loss of 9 lbs in 9 days). Per the documentation, there was a 7.5% change from the last weight. Despite documentation of weight loss in the past 9 days, there was no clinical record documentation that the physician was notified or that any additional nutritional interventions were implemented. In addition, there was no clinical record documentation that the resident received the SNP cereal or SNP pudding as ordered from (MONTH) 21, through (MONTH) 1, (YEAR). A nutrition progress note was completed on (MONTH) 2, (YEAR). Per the note, the resident was on a mechanical soft diet, with SNP three times a day. The documentation included the resident's meal intake was 33%, which provided 1088 kcal and 43 g of protein, and the resident's BMI had decreased to 15.6. The note further included that the resident's adjusted calorie needs were estimated to be 1230-1505 kcal (which was a decrease), and protein requirements also decreased to 43 g. A recommendation included for the addition of boost (nutritional drink and supplement) twice daily. A physician's orders [REDACTED]. This order was transcribed onto the TAR for (MONTH) (YEAR) and was administered from (MONTH) 2-6, (YEAR). In an interview with a certified nursing assistant (CNA/staff #35) conducted on (MONTH) 12, (YEAR) at 11:05 a.m., she stated that weights are done mainly by RNA (restorative nursing assistant), but CNAs can also do the weights when RNA is not available. She stated when there is a difference with the previous and the current weight, she will report this immediately to the nurse. An interview with a licensed practical nurse (LPN/staff #14) was conducted on (MONTH) 12, (YEAR) at 2:22 p.m. She stated that SNP cereal or pudding are recommended for residents with weight loss by the dietary staff. She said that once the order is received, then a dietary ticket will be sent to the kitchen. Staff #14 stated that there is no way the nurses can document the meal percentages and SNP intake percentages, because it is no longer part of the MAR/TAR. She further stated that dietary and RNA staff are responsible for documenting meal intake percentages and SNP intake percentages. An interview with RNA staff (staff #10) was conducted on (MONTH) 12, (YEAR) at 2:26 p.m. She stated that residents are weighed on admission, then once a week for 3-4 weeks thereafter. She also stated that any deviations in weights should be immediately reported to the nurse. An interview with the facility's nutrition consultant (staff #132) was conducted on (MONTH) 12, (YEAR) at 2:30 p.m. She stated that she was not aware of this resident's weight loss, as it was a previous dietician who had evaluated the resident. She stated that dietary staff chart by exception, so when a resident has weight loss, the meal intakes and SNP intakes should be documented in the clinical record. Review of the clinical record with staff #132 was conducted immediately following the interview. Staff #132 stated that she could not locate any further documentation of the resident's meal intakes and SNP intakes. During an interview with the Director of Nursing (DON/staff #130) conducted on (MONTH) 13, (YEAR) at 9:33 a.m., she stated weights are taken upon admission, then weekly for 3 weeks and monthly thereafter if stable. She stated that RNA weighs the residents. Staff #130 stated that RNA staff also record the meal percentages which includes SNP intake. She stated that this should be documented on the CNA ADL sheets. She said that when there is weight loss, RNA is expected to the report it to the nurse, who will then inform the dietary staff. She also stated that RNA staff are expected to re-weigh a resident the same day if weight loss was identified. Staff #130 stated that she expects the dietary tech or dietician to see the resident as soon as possible or on the same day that the weight discrepancy was found. Further she stated that it was not acceptable that the dietician re-evaluated resident #128 on (MONTH) 2, (YEAR), which was four days after the weight loss. Review of the policy on Weight Assessment and Intervention revealed that the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for the residents. It also included that any weight change of 5% or more since the last weight assessment will be retaken and the dietician will be notified, and will respond within 24 hours of receipt of the notification. A policy regarding the Special Nutrition Program included to correctly record percentages of intake of the Special Nutrition Program. The policy also included that the dietary manager should monitor those who are refusing the Special Nutrition Program and implement an individualized program for the resident.",2020-09-01
717,THE REHABILITATION CENTER AT THE PALAZZO,35116,6246 NORTH 19TH AVENUE,PHOENIX,AZ,85015,2017-10-13,431,D,0,1,UYHV11,"Based on observations, staff interviews and policy review, the facility failed to discard expired medications from a medication cart. Findings include: An observation of medication cart #3 was conducted on (MONTH) 12, (YEAR) at 12:25 p.m., with a licensed practical nurse (staff #14) present. During the observation, a medication card of Hydroxyzine HCL (antihistamine) 25 mg had an expiration date of (MONTH) 31, (YEAR). In addition, two medication cards of Lorazepam (benzodiazepine/anti-anxiety) 0.5 mg tablets had expiration dates of (MONTH) 31, (YEAR). At this time, an interview was conducted with staff #14. She stated that the nursing staff were responsible for checking the medication cart for expired medications. During an interview on (MONTH) 12, (YEAR) at 12:55 p.m., with the Director of Nursing (staff #130), she stated the nurses were responsible for checking their carts for outdated medications. She further stated that the expectation was there should be no expired medications in the carts. Review of a policy regarding the Storage of Medication revealed the facility shall not use discontinued, outdated or deteriorated drugs or biologicals, and that all such drugs shall be returned to the dispensing pharmacy or destroyed. The policy also noted that the nursing staff shall be responsible for maintaining medication storage.",2020-09-01
718,PAYSON CARE CENTER,35117,107 EAST LONE PINE DRIVE,PAYSON,AZ,85541,2017-05-11,156,D,0,1,5HVF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of the Instructions for Notice of Medicare Non-Coverage (NOMNC), the facility failed to ensure adequate notification was given to one resident (#18) for non-coverage of Medicare services. The sample size was three. Findings include: Resident #18 was admitted on (MONTH) 15, (YEAR) with the [DIAGNOSES REDACTED].#18 was discharged from the facility on (MONTH) 17, (YEAR). A NOMN[NAME] dated (MONTH) 16, (YEAR) issued by the social services assistant (staff #104) to the resident included an end of coverage date (MONTH) 16, (YEAR). Per the documentation, the resident's family was notified by phone on (MONTH) 16, (YEAR). In an interview with the social services director (staff #5) conducted on (MONTH) 10, (YEAR) at 2:45 p.m., she stated that she did not know why the NOMN[NAME] for resident #18 was issued on the same date as the end of coverage date. She further stated that the issue date on the notice did not reflect the facility's policy of a 48 hour window for issuing the NOMN[NAME] to resident or responsible party. On (MONTH) 11, (YEAR) at 3:16 p.m., an interview with social services assistant (staff #104) was conducted. Staff #104 stated she might have issued the NOMN[NAME] to resident #18 on the same date as the end date of Medicare coverage because at that time she was new to the responsibility and did not know the importance and significance of these dates. She stated the NOMN[NAME] letter should be given to the resident/responsible party and they should be notified of their rights to appeal at least 48-72 hours before the end of Medicare coverage date. Review of the Form Instructions for Notice of Medicare Non-Coverage (NOMNC) included that a completed copy of the NOMNC letter must be given to the beneficiaries/enrollees receiving covered services at least two calendar days before Medicare covered services end.",2020-09-01
719,PAYSON CARE CENTER,35117,107 EAST LONE PINE DRIVE,PAYSON,AZ,85541,2017-05-11,223,D,1,1,5HVF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, facility documents, resident and staff interviews, and review of facility policy, the facility failed to ensure one resident (#6) was free from abuse. Findings include: Resident #6 was admitted (MONTH) 9, 2013 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set assessment dated (MONTH) 8, (YEAR) revealed the resident had a Basic Interview for mental Status score of 14, which indicated the resident was cognitively intact. Review of the functional status revealed the resident required extensive assistance of one person for most activities that were completed, with the exception of eating where the resident required limited assistance. On (MONTH) 18, (YEAR) at approximately 10:00 p.m., the resident reported to Certified Nursing Assistant (CNA/staff #131) that a male CNA (staff #160) had entered her room and pulled down his pants to check his hernia, then exposed himself and masturbated in front of her, the resident also stated he had taken $25.00 from her pants when he changed her. The CNA #131 stated the resident told her the event occurred at approximately 7:30 p.m. on (MONTH) 18, (YEAR) and CNA #131 reported the incident to the Registered Nurse (RN/staff #34) on Sunday, (MONTH) 19, (YEAR). Review of the facility schedule revealed CNA #160 worked a double shift on (MONTH) 18, (YEAR) from 2:00 p.m. to 6:00 a.m. on (MONTH) 19, (YEAR): The summary of the facility investigation revealed that on (MONTH) 19, (YEAR) at approximately 8:55 a.m., the Director of Nursing (DON/staff #15) received a call from RN #34 to advise her that CNA #160 had exposed himself to resident #6. The summary included resident #6 was interviewed by the DON on (MONTH) 19, (YEAR) at 10:00 a.m., the resident stated CNA #160 came to her room and asked if it was OK if he fixed his girdle, (an ace wrap he had over a hernia or hernia repair site), and then CNA #160 pulled down his pants to re-wrap the bandage and exposed himself. The summary included the resident stated this happened on 4 occasions. The resident also reported she lost $27 dollars during the time staff #160 changed her pants. The summary included CNA #160 was called in for an interview with the DON and Administrator (staff #157) on (MONTH) 19, (YEAR) at 11:00 a.m. and denied the event of exposing himself. Staff #160 was immediately suspended and was escorted out of the building. The investigation summary included a female family member of another resident reported during the evening of (MONTH) 19, (YEAR), CNA #160 went outside with the family member to smoke and on returning to the building CNA #160 pulled down his pants and asked if his ass looked big. The female family member told him not to do that and later when she went to the restroom CNA #160 opened the door with his pants already pulled down and asked her if she wanted it. The family member told him that was not appropriate and that he needed to leave. In an interview conducted with the Administrator on (MONTH) 10, (YEAR) at 9:00 a.m., the Administrator stated that this event was reported to the DON by phone from the nurse that was working. The Administrator stated that after some initial information was obtained, he and the DON called CNA #160 and asked him to tell them about last night, CNA #160 discussed the missing money. When CNA #160 was asked about the sexual behavior he denied it. CNA #160 was told he was suspended. CNA #160 never returned to the building. In a telephonic interview with CNA #131 on (MONTH) 10, (YEAR) at 10:50 a.m., CNA #131 stated she reported resident #6 told her that CNA #160 did something inappropriate. CNA #131 stated she didn't say anything until the end of her shift because the resident had been making false accusations but then she thought about it and reported it to the nurse. CNA #131 stated resident #6 told her that CNA #160 had exposed himself and masturbated in her room after he exposed himself to her. The previous false accusations was because resident #6 could not find her money and thought staff #160 had taken the money, but the money was found later on. In an interview conducted with Licensed Practical Nurse (LPN/staff #81) on (MONTH) 10, (YEAR) at 11:09 a.m., LPN #81 stated that on the evening of (MONTH) 18, (YEAR), CNA #160 told her that resident #6 stated she was missing $20. LPN #81 further stated she did nothing and did not even go in and speak with resident #6. LPN #81 further stated as she looked back on the situation she should have spoken with resident #6 right away on that issue. LPN #81 stated that later she did talk with the DON about it, but the money was found. In an interview conducted with resident #6 on (MONTH) 11, (YEAR) at 1:41 p.m., resident #6 stated that CNA #160 would come to her room and ask if his pants made his ass look big and when she would tell him he didn't have an ass, he would pull down his pants and show her his butt. She stated he had done that about four times, but she never told anyone. Resident #6 stated on the night of (MONTH) 18, (YEAR), CNA #160 came in to assist her roommate and then came to her side of the curtain and asked if he could fix his girdle, an ace wrap around his hernia. She stated he dropped his pants to re-wrap the ace bandage over the hernia on his abdomen, and when he started to do this his penis came out and he started stroking it and asked her if she wanted him to get her off and she said no. Resident #6 stated he was watching in the mirror to see if anyone entered the room. Review of the facility policy titled Protection of Residents: Reducing the Threat of Abuse and Neglect included All residents have the right to be free from willful physical and/or emotional injury, punishment, intimidation, or unreasonable confinement. Residents must not be subjected to abuse by anyone. This includes but is not limited to: staff, other residents, consultants, volunteers, staff from other agencies serving our residents, family members, the responsible party, friends, or any other individuals.",2020-09-01
720,PAYSON CARE CENTER,35117,107 EAST LONE PINE DRIVE,PAYSON,AZ,85541,2017-05-11,225,D,0,1,5HVF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical record, facility documents review, staff interview, and review of facility policy, the facility failed to ensure an allegation of abuse was reported immediately. Findings include: Resident #6 was admitted to the facility on (MONTH) 9, 2013 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set assessment dated (MONTH) 8, (YEAR) revealed the resident had a Basic Interview for mental Status score of 14, which indicated the resident was cognitively intact. On (MONTH) 18, (YEAR) at approximately 10:00 p.m., the resident reported to Certified Nursing Assistant (CNA/staff #131) that a male CNA (staff #160) had entered her room and pulled down his pants to check his hernia, then exposed himself and masturbated in front of her. The resident also stated he had taken $25.00 from her pants when he changed her pants. CNA #131 stated the resident told her the event occurred at approximately 7:30 p.m. on (MONTH) 18, (YEAR) and staff #131 reported the incident to the Registered Nurse (RN/staff #34) on Sunday, (MONTH) 19, (YEAR) at the end of her shift (6:00 a.m.). Review of the facility schedule revealed CNA/staff #160 worked a double shift on (MONTH) 18, (YEAR) from 2:00 p.m. to 6:00 a.m. on (MONTH) 19, (YEAR). In a telephonic interview with CNA #131 on (MONTH) 10, (YEAR) at 10:50 a.m., CNA #131 stated she reported resident #6 told her that CNA #160 did something inappropriate. CNA #131 stated she did not say anything until the end of her shift because the resident had been making false accusations but then she thought about it and reported it to the nurse. CNA #131 stated resident #6 told her that CNA #160 had exposed himself and masturbated in her room. The previous false accusations was because resident #6 could not find her money and thought staff #160 had taken the money, but the money was found later on. Review of the facility policy Protection of Residents: Reducing the Threat of Abuse and Neglect included all alleged violations of abuse are reported to the administrator immediately and that the facility must prevent further potential abuse while the investigation is in progress.",2020-09-01
721,PAYSON CARE CENTER,35117,107 EAST LONE PINE DRIVE,PAYSON,AZ,85541,2017-05-11,226,D,0,1,5HVF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical record, resident and staff interviews, and review of facility documents, the facility failed to ensure their policy related to the reporting of abuse was followed. Findings include: Resident #6 was admitted to the facility on (MONTH) 9, 2013 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set assessment dated (MONTH) 8, (YEAR) revealed the resident had a Basic Interview for mental Status score of 14, which indicated the resident was cognitively intact. On (MONTH) 18, (YEAR) at approximately 10:00 p.m., the resident reported to Certified Nursing Assistant (CNA/staff #131) that a male CNA (staff #160) had entered her room and pulled down his pants to check his hernia, then exposed himself and masturbated in front of her. The resident also stated he had taken $25.00 from her pants when he changed her. CNA #131 stated the resident told her the event occurred at approximately 7:30 p.m. on (MONTH) 18, (YEAR) and staff #131 reported the incident to the Registered Nurse (RN/staff #34) on Sunday, (MONTH) 19, (YEAR) at the end of her shift (6:00 a.m.). Review of the facility schedule revealed CNA/staff #160 worked a double shift on (MONTH) 18, (YEAR) from 2:00 p.m. to 6:00 a.m. on (MONTH) 19, (YEAR). In a telephonic interview with CNA #131 on (MONTH) 10, (YEAR) at 10:50 a.m., CNA #131 stated she reported resident #6 told her that CNA #160 did something inappropriate. CNA #131 stated she did not say anything until the end of her shift because the resident had been making false accusations but then she thought about it and reported it to the nurse. CNA #131 stated resident #6 told her that CNA #160 had exposed himself and masturbated in her room. The previous false accusations was because resident #6 could not find her money and thought staff #160 had taken the money, but the money was found later on. Review of the facility policy titled Protection of Residents: Reducing the Threat of Abuse and Neglect included the facility must ensure all alleged violations of abuse are reported to the administrator immediately and that the facility must prevent further potential abuse while the investigation is in progress.",2020-09-01
722,PAYSON CARE CENTER,35117,107 EAST LONE PINE DRIVE,PAYSON,AZ,85541,2017-05-11,281,D,0,1,5HVF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, clinical record review, facility policy review, and the Rules of the Arizona State Board of Nursing, the facility failed to ensure treatment was administered to one resident (#24) according to physician order. Findings include: Resident #24 was admitted on (MONTH) 11, 2014 with [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set) assessment dated (MONTH) 12, (YEAR) revealed the resident had moderate difficulty in his ability to hear. The Communication Care Plan included the resident has impaired communication relating to a hearing problem. Approaches included anticipating and meeting resident's needs and follow-up as indicated. The Audiology Record dated (MONTH) 14, (YEAR) included the resident is blind, deaf, and has dementia. Ear Examination notes revealed impaction in both ears. Orders included [MEDICATION NAME] (otic solution used for ear wax removal) apply nightly prior to bath, cork with cotton, and rinse in showers every week for 3 months. On (MONTH) 15, (YEAR) a physician order [REDACTED]. However, per the documentation in the TAR (Treatment Administration Record), the treatment was not documented as provided on (MONTH) 28 and the month of (MONTH) (YEAR). Further review of the clinical record revealed no documentation the treatment was provided to the resident as ordered by the physician. During an interview with a licensed practical nurse (LPN/staff #64) conducted on (MONTH) 11, (YEAR) at 10:26 a.m., she stated the documentation for the administration of [MEDICATION NAME] is found only in the TAR. She stated if the resident refused or the treatment was not administered, the box will be circled and the reason why would be documented in the narrative section on the back of the TAR. She further stated that if the box is blank then it was probably omitted. She later stated she does not know the reason why the treatment was not administered to the resident as ordered by the physician. An interview with a registered nurse (RN/staff #100) was conducted on (MONTH) 11, (YEAR) at 3:23 p.m. She stated that all medications and treatments must be administered as ordered by the physician and are documented in the Medication Administration Record [REDACTED]. She further stated if the resident refused and/or treatment was not administered, the box in the MAR/TAR will be circled and the reason would be documented on the back of the MAR/TAR sheet. Further, she stated when there are boxes in the MAR/TAR that are not initialed; the medication/treatment was not administered. During an interview with the director of nursing (DON/staff #16) and the regional nurse (staff #159) conducted on (MONTH) 11, (YEAR) at 4:21 p.m., Staff #16 stated she expects the nurse to administer medications and/or treatments as ordered by the physician. She further stated when medications and treatments are not administered, she expects the nurse to circle the corresponding box in the MAR/TAR and document the reason on the narrative section on the back of the MAR/TAR. Also, she stated when there are holes in the MAR/TAR not initialed by the nurse, medications and/or treatments were not administered. Staff #159 who was present during the interview stated she reviewed the resident's record and did not find any documentation the [MEDICATION NAME] treatment was provided for the month of (MONTH) (YEAR). The policy on Administration of Medications included that all medications are administered safely and appropriately to help residents overcome illness, relieve/prevent symptoms and help in diagnosis. The Rules of the Arizona State Board of Nursing included that a registered nurse and/or LPN administers prescribed aspects of care including treatment, therapies and medications; and, clarifies orders with health care providers when needed.",2020-09-01
723,PAYSON CARE CENTER,35117,107 EAST LONE PINE DRIVE,PAYSON,AZ,85541,2017-05-11,325,D,0,1,5HVF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, staff interviews, and policy review, the facility failed to ensure a therapeutic diet recommended by the dietician was provided for one resident (#24). Findings include: Resident #24 was admitted on (MONTH) 11, 2014 with [DIAGNOSES REDACTED]. The resident's record of weight changes were as follows: -November 7, (YEAR) - 164 lbs. (pounds) -December 6, (YEAR) - 160 lbs. -January 4, (YEAR) - 158 lbs. -February 7, (YEAR) - 154 lbs. -March 3, (YEAR) - 151 lbs. -April 5, (YEAR) - 147 lbs. -May 5, (YEAR) - 146 lbs. Review of the Quarterly MDS (Minimum Data Set) assessment dated (MONTH) 12, (YEAR) revealed the resident was on a mechanically altered diet. The nutrition care plan included that the resident received a mechanically altered diet due to chewing difficulty related to missing teeth and history of dysphagia. This care plan was revised multiple times to address identified problems on weight loss. Interventions included diet as ordered and fortified foods with meals. Review of the quarterly nutrition documentation dated (MONTH) 21, (YEAR) included a diet order for regular mechanical soft diet with fortified foods with breakfast, lunch and dinner. Per the documentation, the trend for weight change was decreased 6.5% x 180 days and there was no significant weight change. Intervention included fortified foods. The routine monthly nutrition note dated (MONTH) 9, (YEAR) included a monthly weight of 146 lbs. indicating a weight loss of 10.9% x 180 days. It also included the resident had a gradual weight loss for 180 days and was receiving fortified cereal with breakfast and fortified pudding with lunch. Plan included providing larger portions with meals. During an observation of resident #24 having lunch in the dining room on the secured unit conducted (MONTH) 11, (YEAR) at 12:23 p.m., food was served to the resident on a blue lip plate containing noodles with vegetables, a slice of cake with white icing, a small bowl of blue corn mush and a small glass of juice. There was no fortified pudding served with the resident's meal. In an interview with a licensed practical nurse (LPN/staff #64) conducted on (MONTH) 11, (YEAR) at 10:52 a.m., staff #64 stated the resident is receiving fortified foods but it is not documented anywhere in the clinical record. She stated the dietary recommendation was not carried out in the orders but should have been; and, the physician should have been notified and a diet order should have been completed. An interview with the diet technician (staff #63) and the dietary consultant (staff #156) was conducted on (MONTH) 11, (YEAR) at 2:26 p.m. Staff #63 stated resident #24 has had a gradual weight loss so she added fortified pudding for lunch and dinner; and, that the resident is still on fortified pudding every lunch and dinner and this has not changed. She stated she recently added large portion to the meal as a recommendation which together with the fortified pudding must be served to the resident each meal. In an interview with the director of nursing (DON/staff #16) conducted on (MONTH) 11, (YEAR) at 4:21 p.m., she stated the dietary recommendation should be followed. The facility policy on Nutrition Intervention Program Overview revealed residents at risk or already experiencing impaired nutrition is identified and assessed and interventions are defined and implemented or clinical justification is provided if not done. The facility policy on Fortified Foods stated Residents will be assessed and the fortified foods will be used on an individualized basis. The items used will be placed on the resident's care plan and there will be careful monitoring of the intake of these food items.",2020-09-01
724,PAYSON CARE CENTER,35117,107 EAST LONE PINE DRIVE,PAYSON,AZ,85541,2018-07-13,550,D,0,1,RX0S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure that one resident (#187) was treated in a dignified and respectful manner. Findings include: Resident #187 was admitted to the facility on (MONTH) 13, (YEAR), with [DIAGNOSES REDACTED]. Per the MDS assessment dated (MONTH) 6, (YEAR), the resident scored a 12 on the Brief Interview for Mental Status, which indicated moderate cognitive impairment. Review of facility documentation revealed that on (MONTH) 10, (YEAR), two staff (staff #107 and staff #37) heard a Licensed Practical Nurse (staff #137) tell resident #187 in a loud voice that he was acting like a five year old child and that a five year old listened better than he did. Per the documentation, resident #187 was interviewed and stated that staff #137 called him a five year old and talked loudly to him. An interview was conducted with the Director of Rehabilitation (staff #107) on (MONTH) 10, (YEAR) at 10:27 a.m. She stated that she heard staff #137 tell resident #187 in a loud voice if you don't want to take your medications, whatever! Staff #107 also stated that staff #137 said to resident #187 that she had a five year old child that listened better than he did. An interview was conducted with the Assistant Director of Rehabilitation (staff #37) on (MONTH) 10, (YEAR) at 10:47 a.m. She stated that she heard staff #137 speak loudly to the resident about him acting like a five year old, because he was refusing meds. Review of the Resident Rights policy revealed that residents have the right to be treated with respect and dignity.",2020-09-01
725,PAYSON CARE CENTER,35117,107 EAST LONE PINE DRIVE,PAYSON,AZ,85541,2018-07-13,558,D,0,1,RX0S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, facility documentation and policy and procedures, the facility failed to ensure one resident's (#37) call light was accessible. Findings include: Resident #37 was admitted on [DATE], with [DIAGNOSES REDACTED]. An admission MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15, which indicated the resident was cognitively intact. The MDS also assessed the resident to have unclear speech and mumbled words, and had upper and lower extremity limitation with range of motion on one side. Review of the facility's investigative documentation revealed that resident #37 reported to the Social Worker (staff #4) that she had thrown a water pitcher on the floor to get staff's attention on 6/6/18, because her call light was not accessible. During an interview with resident #37 on 7/09/18 at 9:41 a.m., the resident stated that she had thrown a water pitcher on the floor, because her call light was not accessible. The resident stated that the call light had been hanging down the side of her bed. The resident identified a CNA (staff #31) as being the staff who responded at the time of the incident. A telephone interview was conducted on 7/12/18 at 10:06 a.m. with staff #31, who stated that she heard a noise in the resident's room around 4:00 a.m. Staff #31 stated that when she went into the resident's room, she saw water on the floor as well as the water pitcher. Staff #31 stated the resident was in bed, and the call light was hanging down the side of the bed and the resident could not reach the call light. Review of the facility's call light policy revealed documentation that when providing care to residents, be sure to position the call light conveniently for the resident to use and make sure all call lights are placed on the bed at all times, and never on the floor or bedside stand.",2020-09-01
726,PAYSON CARE CENTER,35117,107 EAST LONE PINE DRIVE,PAYSON,AZ,85541,2018-07-13,600,G,1,1,RX0S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff and resident interviews, facility documentation and policy and procedures, the facility failed to ensure that one resident (#17) was free from physical abuse by resident (#337), that one resident (#16) was free from sexual abuse by resident (#437) and that one resident (#35) was free from physical abuse by resident (#286). Findings include: -Resident #337 was admitted on (MONTH) 25, (YEAR), with [DIAGNOSES REDACTED]. Review of the admission MDS assessment dated (MONTH) 1, (YEAR) revealed the resident had a BIMS score of 5, which indicated severe cognitive impairment. The MDS also included that the resident had disorganized thinking and exhibited wandering behaviors. A nurse progress note dated (MONTH) 24, (YEAR) revealed that resident #337 was outside of a female resident's room and he struck her in the abdomen, and the female resident fell to the floor. Review of a behavior care plan dated (MONTH) 24, (YEAR) revealed that resident #337 was physically abusive, as evidence by striking another resident. The goal was that the resident would not harm themselves or others. The approaches included to report changes in behavioral status to the physician, provide non confrontational environment for care, administer and monitor the effectiveness and side effects of medications as ordered, if the resident is reasonable then discuss behavior with resident and explain/reinforce why the behavior is unacceptable and re-approach resident later if he becomes agitated. A nurse progress note dated (MONTH) 25, (YEAR) stated the resident (#337) remained very anxious and was pacing, and had torn the name plate from the door to his room. A nurse progress note dated (MONTH) 29, (YEAR) revealed the resident got into a verbal confrontation with a visitor of his roommate. A nurse progress note dated (MONTH) 3, (YEAR) included that resident #337 was agitated and was cursing and threatening staff, was threatening to break a window, and stated that he wished the place would burn down. The note further included that re-direction was attempted by activities and by social services without success, as a few minutes later he was agitated again with staff and was yelling and cursing. A nurse progress note dated (MONTH) 8, (YEAR) revealed that a visitor who was visiting the resident's roommate stated that on the previous night, resident #337 was putting beads in the hallway and saying he hoped that someone fell and hurt themselves, and said that he saved the string from the necklace and was going to choke someone. The note included that a call was placed to the crisis mobile team, as directed by the Director of Nursing. Two team members came to see resident #33 and spoke with him and staff. The note included that a crisis team member called after the visit and informed the nurse that there was nothing they could do, and that this was the best place for him. Review of the crisis mobile team intervention report dated (MONTH) 8, (YEAR) revealed the resident had been threatening others. The report included that the resident would be stabilized at the community level. The report did not include any recommendations to address the resident's aggressive physical behaviors. A nurse progress note dated (MONTH) 9, (YEAR) revealed that resident #337 was yelling at a female resident to stay out of his room, which was actually her room. The note included that resident #337 told her that he would knock her on her ass. A nurse progress note dated (MONTH) 20, (YEAR) revealed that after breakfast, resident #337 was sitting on a female resident's bed and was confrontational and was arguing saying that it was his room. A nurse progress note dated (MONTH) 11, (YEAR) revealed that resident #337 continued to be agitated and was cursing and gesturing to residents, as if he was going to hit them. Review of the updated behavior care plan dated (MONTH) 11, (YEAR) revealed the resident (#337) had increased agitation, as evidenced by cursing at staff, giving the middle finger and threatening to hit others. Review of the nurse practitioner note dated (MONTH) 2, (YEAR) revealed the resident had periods of agitation and aggression, which decreased with the addition of Nudexta twice a day. According to a quarterly MDS assessment dated (MONTH) 2, (YEAR), resident #337 had a BIMS score of 3, which indicated that he had severe cognitive impairment. The MDS also assessed the resident to have disorganized thinking, had physical and verbal behavioral symptoms directed toward others, and continued to exhibit wandering behaviors. A nurse progress note dated (MONTH) 8, (YEAR) revealed that resident #337 was in a female resident's room and demanded that she get out, because it was his room. A second note dated (MONTH) 8, (YEAR) included that resident #337 became agitated with several residents and was going in and out of their rooms and was difficult to re-direct. The note further stated that the resident was raising his voice and cursing at staff and other residents, and threatening to hit staff. A nurse progress note dated (MONTH) 16, (YEAR) revealed that resident #337 took a Bingo card from a lady at his table and threw the card on the floor, and when he was told that she was using the card he mocked and cursed at her. Review of the Medication Administration Record [REDACTED]. Review of a nurse progress note dated (MONTH) 26, (YEAR) revealed that resident #337 was in the room of resident #17, and resident #337 took resident #17 out of her wheelchair and pushed her to the floor. The note further indicated that resident #337 was placed on every 15 minute checks. Review of the facility's investigative documentation revealed that a resident to resident altercation took place between resident #17 and resident #337 on (MONTH) 26, (YEAR). The report included that resident #17 stated that resident #337 went into her room and was messing with her drawers, when she came in and told him this was not his room. Per the report, resident #17 said that she stood up from her wheelchair and continued to tell him not to touch her drawers and then he grabbed her by the back of her sweat shirt and pushed her and she fell on the ground. The report also included that resident #337 was interviewed and stated that resident #17 had approached him and slapped him three times, so he pushed her. However, the investigative report further included that another resident had witnessed the incident and reported it to the nurse on duty. This resident reported that resident #337 was in the room of resident #17 and when resident #17 told him to leave, he pushed her out of her wheelchair and onto the floor. According to the report, a Licensed Practical Nurse (LPN/staff #33) said that she was standing in the hall when someone yelled out for a nurse to come. When she arrived at resident #17's room, resident #17 was on the floor on her right side. The nurse reported that resident #337 said that he was in his room and resident #17 came in yelling and he yelled back and pushed her. Per the report, resident #17 sustained a T9 vertebral compression fracture. Review of a crisis mobile team intervention report dated (MONTH) 27, (YEAR) revealed the resident (#337) slapped another resident and pushed her down. The report included that resident #337 stated that resident #17 had slapped him twice, so he slapped her back and that resident #17 tried to push into him, so he pushed her down. The documentation also included that resident #337 said that he would do it again in a similar situation, because she shouldn't have hit him. The report further included that a witness stated that resident #17 did not slap resident #337 and that resident #337 was physical with resident #17. Per the report, resident #337 would be stabilized at the community level. Review of a nurse practitioner note dated (MONTH) 2, (YEAR) revealed that resident (#337) recently was confused about which room was his and he became angry and caused a resident to fall. The note stated that social services were involved and they were looking for other placement, where his outbursts could be managed better. Further review of the clinical record revealed the facility could not meet resident #337's behavioral needs and was transferred to a behavioral health facility. -Resident #17 was admitted on (MONTH) 5, 2014, with [DIAGNOSES REDACTED]. Review of the psychosocial well-being care plan revealed the resident had a history of [REDACTED]. The goal included that the resident would not harm self or others. An approach was to monitor for increased agitation between residents. Review of another care plan revealed the resident had a problem area of being physically abusive. The goal was that the resident would not harm themselves or others. The approaches included to intervene as needed to protect the rights and safety of others, approach in a calm manner, divert attention, remove from situation and take to another location as needed, observe behavior episodes and attempt to determine underlying cause and provide a non confrontational environment for care. Review of a nurse progress note dated (MONTH) 31, (YEAR) revealed that resident #17 became agitated, when other residents entered her room. An annual Minimum Data Set (MDS) assessment dated (MONTH) 9, (YEAR) revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. The MDS included the resident had disorganized thinking and verbal behavioral symptoms directed toward others. A nurse progress note dated (MONTH) 9, (YEAR) included that resident #17 yelled out at other residents who entered her room. A nurse progress note dated (MONTH) 26, (YEAR) revealed that resident #17 had an altercation with another resident (#337), when she found him in her room. The noted included that resident #337 became upset and took resident #17 out of her wheelchair and pushed her to the floor. The noted stated when resident #17 was assisted to her wheelchair she complained of right lower back pain and was sent to the emergency room for x-rays. Review of the hospital emergency notes dated (MONTH) 26, (YEAR) revealed that resident #17 was having low back pain after a fall. The hospital documentation included that a resident from her facility pulled her out of her chair and pushed her to the ground. The note further revealed that the resident was found to have a T9 vertebral body compression fracture, status [REDACTED]. Review of the clinical record revealed the resident returned to the facility on (MONTH) 26, (YEAR). An interview was attempted with resident #17 on (MONTH) 9, (YEAR) at 12:22 p.m. The resident was unable to perform the interview, due to her cognitive status and had no memory of the incident between her and resident #337. An interview was conducted with a Certified Nursing Assistant (staff #35) on (MONTH) 11, (YEAR) at 9:06 a.m. He stated that he never knew what kind of mood resident #337 would be in, nice or angry. He stated that the resident was sometimes confrontational with residents. He stated that resident #337 often went into resident #17's room as it was set up like his, and when this happened, resident #17 would yell at him that he was in the wrong room and he would yell and curse back. He said that after the incident, resident #337 was placed on 1:1 monitoring. An interview was conducted with a LPN (staff #136) on (MONTH) 11, (YEAR) at 9:27 a.m. She stated that resident #337 was confused, forgetful, and was easily agitated and that he didn't like people coming into his room. Staff #136 stated that resident #337 wandered into other resident's rooms and had been physical with other residents. She said that previously (October 24 incident) she was in the hall outside of another resident's room and heard a thump, and a female resident was on the floor. She stated when she went down to see what happened, resident #337 said that he didn't hit her and the female resident was unable to say what happened. She further stated that she has found resident #337 sitting on resident #17's bed a couple of times. She stated that sometimes #17 would call out that there was a man in her room and it was usually him. She said that she was not working at the time of the incident between #17 and #337, but after the incident resident #337 was put on 1:1, and they looked for a more appropriate place for him. An interview was conducted with the Director of Nursing (staff #10) on (MONTH) 11, (YEAR) at 9:48 a.m. She stated that resident #337 had dementia and would get very irritable. She stated that they were trying to figure out how to approach him, without triggering him. She stated that he was always being monitored as he was in a secured unit. Staff #10 said that they reached out to the crisis mobile team between incidents and the crisis mobile team came in, but did not feel that the resident was a danger to himself or others at the time of their visits, so they felt he could be stabilized in the facility and was not sent out. She stated that they discussed with the resident's fiduciary the need for other placement, as they could not keep him because he was not appropriate and he hurt another resident. -Resident #16 was admitted on (MONTH) 8, (YEAR), with [DIAGNOSES REDACTED]. Review of a quarterly MDS assessment dated (MONTH) 4, (YEAR), revealed the resident had severe cognitive impairment. The MDS also included the resident had verbal behaviors directed toward others (such as threatening others, screaming and cursing at others). -Resident #437 was admitted on (MONTH) 12, (YEAR), with [DIAGNOSES REDACTED]. Review of a quarterly MDS assessment dated (MONTH) 23, (YEAR) revealed the resident had a BIMS score of 1, which indicated the resident had severe cognitive impairment. The MDS also included the resident had verbal behaviors directed toward others (such as threatening others, screaming and cursing at others). Review of the facility's investigative report revealed that on (MONTH) 10, (YEAR), the Director of Nursing (staff #10) was informed by a registered nurse (staff #51) that resident #437 was observed touching and rubbing the breasts of resident #16, while in the day room. Per the report, a certified nursing assistant (staff #75) observed the incident and removed resident #437 from the day room and was placed on 15 minute monitoring. A nursing note dated (MONTH) 15, (YEAR) revealed resident #437 was discharged home with family. An interview was conducted with staff #10 on (MONTH) 11, (YEAR) at 8:00 a.m. She stated that she was informed by staff #51 that resident #437 inappropriately touched and rubbed resident #16's breasts. Staff #10 reported that staff #75 removed resident #437 from the day room and was placed on 15 minute checks. Staff #10 stated that resident #16 did not recall the incident. She stated that they substantiated the allegation of resident to resident sexual abuse. An interview was conducted with staff #75 on (MONTH) 11, (YEAR) at 9:30 a.m. She said that she witnessed resident #437 rubbing resident 16's breasts under her shirt on (MONTH) 10, (YEAR). She stated that as soon as she witnessed this, she removed him from the day room. -Resident #286 was admitted to the facility on (MONTH) 6, (YEAR), with [DIAGNOSES REDACTED]. A quarterly MDS assessment dated (MONTH) 20, (YEAR) included that resident #286 had severe cognitive impairment. The MDS also included that the resident was short tempered, was easily annoyed and required supervision by staff with activities of daily living. Review of a care plan dated (MONTH) 24, (YEAR) revealed a behavior problem of being physically abusive as evidenced by physical contact with another resident and with staff. The goal included that the resident will not harm themselves or others. Interventions included the following: if reasonable discuss behavior with resident and why behavior is unacceptable, intervene as needed to protect the rights and safety of others, divert attention, remove resident from situation and take to another location as needed, and observe behavior episodes and attempt to determine underlying cause. -Resident #35 was admitted to the facility on (MONTH) 12, (YEAR), with [DIAGNOSES REDACTED]. A quarterly MDS assessment dated (MONTH) 27, (YEAR) included that resident #35 had a BIMS score of 5, which indicated severe cognitive impairment. The MDS also included the resident required limited to extensive assistance from staff with activities of daily living. Review of a self care deficit care plan revealed the resident was at risk for being vulnerable related to dementia and wandering. Nursing notes dated (MONTH) 24, (YEAR) revealed that resident #35 was in an altercation with another resident (#286), after wandering into resident #286's room. Per the notes, resident #286 became angry and hit resident #35. The notes further included that resident #35 did not remember the incident. Review of the facility's investigative documentation revealed that on (MONTH) 23, (YEAR) around 8:30 p.m., resident #286 saw resident #35 backing out of his room in her wheelchair as she had the wrong room. As resident #35 was exiting the room, resident #286 struck her with an open palm on her arm. The incident was witnessed by a certified nursing assistant (staff #11), who immediately separated the residents. Resident #35 was assessed and there were no apparent injuries. The documentation further included that resident #286 was placed on 1:1 supervision. During an interview on (MONTH) 10, (YEAR) at 1:18 p.m. with a LPN (staff #27), she stated that resident #286 had a history of [REDACTED]. She stated that resident #286 became angry when the female resident inadvertently entered his room and he struck her. During an interview on (MONTH) 10, (YEAR) at 1:52 p.m., resident #35 stated that she could not recall anyone hitting her. Review of the facility's Abuse policy revealed that all residents will be protected from abuse. The policy included that residents have the right to be free from abuse and must not be subjected to abuse by anyone. This includes but is not limited to staff, other residents, consultants, volunteers, staff from other agencies, family members, the resident's representative, friends or any other individuals. The policy also included to identify, assess and care plan for appropriate interventions and monitor residents with needs and behaviors, which might lead to conflict or neglect.",2020-09-01
727,PAYSON CARE CENTER,35117,107 EAST LONE PINE DRIVE,PAYSON,AZ,85541,2018-07-13,609,E,0,1,RX0S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, hospital documentation and policies and procedures, the facility failed to follow their Abuse policy regarding the reporting and investigating of an injury of an unknown source for one resident (#141). Findings include: Resident #141 was admitted on [DATE] and discharged on [DATE], then readmitted on [DATE], with [DIAGNOSES REDACTED]. An annual MDS assessment dated [DATE] included the resident had a BIMS (Brief Interview for Mental Status) score of 2, which indicated severe cognitive impairment. The MDS also included the resident needed extensive assistance of one staff with bed mobility and transfers. Review of a fall care plan revealed the resident was at risk for falls due to decreased mobility, incontinence, dementia and decreased safety awareness. Nurses notes dated 6/12/17 included that a CNA (Certified Nursing Assistant) found the resident on the floor in the resident's room and notified the nurse. Upon entering the room, the nurse found the resident sitting on her buttocks on the floor, with her legs out in front between the bed and the radiator. The resident's head and left eye were bleeding profusely and the right knee was swollen. Per the note, 911 was called immediately and the resident was transferred to the hospital. Review of the hospital records revealed the resident sustained [REDACTED]. The facility was unable to provide any documentation that this incident of an unknown injury was investigated or reported to the State Agency. An interview was conducted on 7/11/18 at 2:22 p.m., with the DON (Director of Nursing/staff #10). Staff #10 stated that an injury of unknown origin, such as an unwitnessed fall which was not able to be explained by the resident, should be reported and investigated the same as an abuse allegation to rule out abuse or neglect. Staff #10 stated that the investigation should include statements from staff, residents or anyone with knowledge of how the injury occurred including preventative measures. Staff #10 stated the only documentation she had was the nursing notes regarding the fall and an incident report which only stated that the resident fell and was sent to the hospital. Staff #10 stated it was assumed that the resident fell . Staff #10 provided a statement written by the previous DON dated 7/12/18, which summarized what was presumed had occurred, however, there was no documentation of an actual investigation or that the injury of an unknown source was reported to the State Agency. Review of the policy regarding Protection of Residents - Reducing the Threat of Abuse and Neglect revealed that an injury of unknown source was an injury not observed by any person or the source of the injury could not be explained by the resident, and the injury was suspicious because of the extent of the injury or location of the injury, or the number of injuries observed at a particular point in time or the incidence of injuries over time. The Abuse policy also included that reports of abuse, neglect, mistreatment, including injuries of unknown source, exploitation and misappropriation of property are promptly and thoroughly investigated. All alleged or suspected violations involving mistreatment, abuse, neglect, injuries of unknown origin will be immediately reported to the Administrator and/or Director of Nursing and must ensure that all alleged violations are reported immediately to the State Agency, and other agencies as required by law and regulation.",2020-09-01
728,PAYSON CARE CENTER,35117,107 EAST LONE PINE DRIVE,PAYSON,AZ,85541,2018-07-13,637,D,0,1,RX0S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that a significant change Minimum Data Set (MDS) assessment was completed for one resident (#42). Findings include: Resident #42 was readmitted to the facility on (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident was receiving Hospice services in January, February, (MONTH) and (MONTH) (YEAR). Review of a quarterly MDS assessment dated (MONTH) 8, (YEAR) revealed the resident was receiving Hospice services during the look back period. A physician's orders [REDACTED]. However, there was no significant change MDS assessment which was completed, as there had been a significant change in the resident's status, since Hospice services were discontinued. An interview was conducted with a Licensed Practical Nurse (MDS coordinator/staff #54) on (MONTH) 12, (YEAR) at 2:15 p.m. She stated that the facility does not have a policy regarding MDS assessments, but they use the RAI manual for completing the MDS. She stated that any time a resident goes on or off hospice services, a significant change assessment must be completed within 14 days. She stated the assessment is important because it establishes a new baseline for the resident's MDS, Care Area Assessments (CAA) and the care plans, so they can provide appropriate care. Staff #54 stated that resident #42 had an order to come off Hospice services on (MONTH) 13, (YEAR) at midnight, so a significant change MDS assessment should have been completed by (MONTH) 26, (YEAR), but it was not done. She stated they did not follow the RAI requirements for significant change assessments for this resident. An interview was conducted with the Director of Nursing (staff #10) on (MONTH) 12, (YEAR) at 2:29 p.m. She stated that she would expect accuracy of the MDS assessments and would expect staff to follow the directions from the RAI Manual. She stated that they do not have a policy regarding the MDS, as they use the RAI manual. She stated it is important for the RAI manual to be accurately followed, so the resident gets appropriate care. She stated that she expects the MDS nurses to be aware of order changes and the information contained on the 24 hour report. Review of the RAI manual revealed that a significant change in status assessment is required to be performed when a resident is receiving Hospice services and when it is decided to discontinue those services. The assessment reference date (ARD) must be within 14 days from the effective date of the Hospice election revocation.",2020-09-01
729,PAYSON CARE CENTER,35117,107 EAST LONE PINE DRIVE,PAYSON,AZ,85541,2018-07-13,641,D,0,1,RX0S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff and resident interviews, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that a Minimum Data Set (MDS) assessment was accurate regarding oral/dental status for one resident (#17). Findings include: Resident #17 was admitted (MONTH) 5, 2014, with [DIAGNOSES REDACTED]. Review of the nutrition data collection assessment dated (MONTH) 15, (YEAR) revealed the resident had missing/decayed teeth. Review of the annual MDS assessment dated (MONTH) 9, (YEAR) revealed the resident had a Brief Interview for Mental Status score of 3, which indicated the resident had severe cognitive impairment. Review of the oral/dental status section revealed that the resident had no oral/dental issues, including no broken teeth. Review of the current care plans revealed they did not address any problems, goals or approaches related to the resident having any missing/decayed teeth. An observation was conducted on (MONTH) 9, (YEAR) at 12:25 p.m. of resident #17. The resident was observed to have several missing and broken teeth, with noted decay. At this time, the resident stated that her teeth are worn out and that she needed new teeth. An interview was conducted with a MDS nurse (Licensed Practical Nurse/staff #54) on (MONTH) 11, (YEAR) at 1:35 a.m. She stated that she uses the information from the nurse's monthly assessments under oral status and teeth to complete the MDS. She stated that the person filling out the dental section on the MDS is supposed to look into the resident's mouth and do an oral exam on the resident. Another interview was conducted with staff #54 on (MONTH) 12, (YEAR) at 9:22 a.m. She stated that the RAI manual directions requires that the person filling out the dental section of the MDS look in the resident's mouth. She stated that based on the nutritional assessment dated (MONTH) 15, (YEAR), the resident had missing/decayed teeth at that time. Staff #54 stated that the dental assessment section on the annual MDS assessment dated (MONTH) 9, (YEAR) was marked incorrectly, and that if the assessment had been coded correctly, a CAA area would have triggered and a deeper assessment of the area of concern would have been completed. She stated that the CAA would have led to developing a care plan with goals and interventions regarding the broken and missing teeth. She stated that the risk of an inaccurate MDS assessment of dental status could include not having appropriate dental care and follow up. She stated that the assessment would have included asking the resident about pain or chewing difficulties and if an issue was noted it would have been communicated to social services for outside dental follow up. She stated that the expectation is that the MDS is filled out accurately, so there is a complete picture of the resident and to provide the most appropriate care. An interview was conducted with the Director of Nursing (DON/staff #10) on (MONTH) 12, (YEAR) at 10:16 a.m. She stated that she expects that the MDS assessments are accurate. She stated that the assessment needs to be accurate as it affects the resident's care. She stated that the dental section in the (MONTH) (YEAR) assessment for resident #17 should have been marked with broken/carious teeth and that a care plan should have been formulated that addressed the dental issues. She stated that inaccurate assessments put the resident at health and infection risk. Staff #10 stated when a resident has a dental issue they have an outside company that will come in as needed. She stated the facility uses the RAI manual for completing the MDS. Review of the oral assessment policy revealed that a licensed nurse will establish the condition of the oral cavity and will complete oral assessments on all admissions. Review of the RAI manual for the assessment of dental status revealed to conduct an exam of the resident's lips and oral cavity. Use a light source that is adequate to visualize the back of the mouth. Visually observe and feel all oral surfaces including lips, gums, tongue, palate, mouth floor, and cheek lining. Check for abnormal mouth tissue, abnormal teeth, or inflamed or bleeding gums. The assessor should use his or her gloved fingers to adequately feel for masses or loose teeth. The directions included to code the MDS dental section if any cavity or broken teeth are seen.",2020-09-01
730,PAYSON CARE CENTER,35117,107 EAST LONE PINE DRIVE,PAYSON,AZ,85541,2019-09-19,578,E,0,1,KLKQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, and policy review, the facility failed to ensure advance directives were accurately documented for 2 of 20 sampled residents (#35 and #74). Failing to have accurate documentation for advanced directives could result in performing emergency treatment against residents' wishes. Findings include: -Resident #35 was admitted to the facility on (MONTH) 6, (YEAR) with [DIAGNOSES REDACTED]. Review of the clinical record revealed a FULL CODE Cardiopulmonary Resuscitation Advance Directive Statement dated (MONTH) 6, (YEAR) signed by the resident and a Registered Nurse. A physician order dated (MONTH) 6, (YEAR) revealed documentation that the resident was a 'DO NOT RESUSCITATE status. The care plan regarding Advance Directives dated (MONTH) 5, 2019 revealed Resident has Advance Directives- DNR- Do Not Resuscitate. The goal was the resident's Advance Directives will be honored. Interventions included Resident has signed Do Not Resuscitate (DNR). A review of the face sheet dated (MONTH) 18, 2019 revealed Advance Directive. Do Not Resuscitate. An interview was conducted with the Social Services Assistant (staff #78) on (MONTH) 18, 2019 at 8:26 a.m. Staff #78 stated that when a resident is admitted the resident and/or the family are asked what their advance directive wishes are and that either a Full Code form or DNR form is placed in the resident's clinical record. An interview was conducted with a Licensed Practical Nurse (LPN/staff #4) on (MONTH) 18, 2019 at 8:30 a.m. Staff #4 stated she would refer to her 24 hour report to determine the resident's advance directive wishes. The LPN stated that the 24 hour report revealed the resident is a full code but that the resident's electronic clinical record revealed the resident is a DNR. An interview was conducted with the Director of Nursing (DON/staff #41) on (MONTH) 18, 2019 at 8:40 a.m. Staff #41 stated that she could not provide a copy of the 24 hour report as it was not a facility form. Staff #41 stated that licensed nurses should refer to the resident's clinical record regarding advance directive wishes. Staff #41 stated that the resident's advance directive status is updated periodically in the resident's clinical record and there may be a DNR form that did not get placed in the resident's clinical record. The DON further stated that the resident's advance directives needed to be clarified because of the discrepancy in the clinical record. -Resident #74 was admitted to the facility on (MONTH) 22, (YEAR) with [DIAGNOSES REDACTED]. Review of the clinical record revealed an Advance Directive Statement signed by the resident with no date and signed by a witness dated (MONTH) 22, (YEAR) that the resident was a DNR status. Review of physician's orders revealed an order dated (MONTH) 8, (YEAR) that the resident was a DNR. Review of the care management progress note dated (MONTH) 10, 2019 revealed the resident requested to change her advance directive from a DNR to a full code and that the resident signed the new advance directive form. The note also included medical records were notified to make changes on the face sheets. Continued review of the clinical record revealed an Advance Directive Statement that the resident was a full code status signed by the resident dated (MONTH) 11, 2019 and signed by the witness, social service worker, dated (MONTH) 10, 2019. However, review of the advance directives care plan revised (MONTH) 12, 2019 revealed the resident was a DNR. The goal was the resident's advance directives will be honored. Interventions included the code status will be reviewed on a quarterly basis and as needed. Review of the electronic clinical record dashboard and the face sheet revealed the resident was a DNR. Further review of the clinical record revealed no physician order that the resident was a full code status. During an interview conducted with a LPN (staff #3) on (MONTH) 18, 2019 at 11:00 AM, the LPN stated that if a resident was unresponsive, without pulse or respirations, she would call for assistance and check the clinical record for advance directive and would check the dashboard in the electronic clinical record to determine whether or not to initiate CPR. The LPN also stated that if there was a discrepancy, she would follow the advance directive signed by the resident. In an interview conducted with the social worker (SW/staff #77) on (MONTH) 18, 2019 at 11:26 AM, the SW stated that when someone changes their advance directive, she documents the request, have the resident complete and sign a new advance directive statement, and notifies the nurse the resident changed their advance directive so that the nurse can obtain a physician order to reflect the change. An interview was conducted with the Minimum Data Status (MDS) coordinator (staff #45) on (MONTH) 19, 2019 at 8:10 AM. The MDS coordinator stated that care plan conferences with the resident in attendance includes a review of the resident's code status. She said if the resident requests a change in code status, the advance directive statement is updated and the provider is called for a new advance directive order. Staff #45 stated that there was a delay in updating the order and care plan for resident #74 due to missed communication. The facility's policy regarding Advance Directives effective (MONTH) 21, 2019 revealed residents have the right to self-determination regarding their medical care, including the right to execute an advance directive. An advance directive is a written document prepared by the resident which directs how medical decisions are to be made should he/she lose the ability to make decisions. Social Services should review the advance directive information for accuracy quarterly and as needed with the resident or legal representative and document the findings in the progress note. With written reversals, the physician is notified and the plan is permanently adjusted. The policy included the physician must give an order for [REDACTED].>",2020-09-01
731,PAYSON CARE CENTER,35117,107 EAST LONE PINE DRIVE,PAYSON,AZ,85541,2019-09-19,600,D,1,1,KLKQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, resident and staff interviews, and policy review, the facility failed to ensure that one of two sampled residents (#2) was free from verbal abuse by another resident (#71). The deficient practice could result in further incidents of resident to resident abuse. Findings include: -Resident #2 was admitted to the facility on (MONTH) 16, (YEAR) with [DIAGNOSES REDACTED]. A review of the quarterly MDS (Minimum Data Set) assessment dated (MONTH) 13, 2019 revealed the resident's BIMS (Brief Interview for Mental Status) score was a 15 indicating the resident had intact cognition. -Resident #71 was readmitted to the facility on (MONTH) 31, (YEAR) with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment dated (MONTH) 3, 2019 revealed a BIMS score of 15 which indicated the resident had intact cognition. Review of an Activity Participation Note dated (MONTH) 8, 2019 written by the activity director (staff #71) revealed Late entry: On Thursday (MONTH) 4, during the 4th of (MONTH) party, (resident #71) asked for a third helping of food. Not all of the residents had been served so (staff member's name) asked him to wait until all of the other residents had been served. It appeared to this writer, that because he wanted more food, and because he did not believe (staff member's name), he got angry, became belligerent and called her a liar and a 'b----.' This writer was serving food to others, but overheard this conversation as (resident #71) became loud. A second incident occurred at the same party with (resident #71). He raised his voice and began yelling at another resident (resident #2) and stated 'You should never eat in front of people, you are disgusting to watch. You should just leave.' The other resident (#2) appeared to be hurt, embarrassed and he did leave the party. An interview was conducted with the activity director (staff #71) on (MONTH) 17, 2019 at 1:36 p.m. Staff #71 stated that resident #2 had a [MEDICAL CONDITION] and was non-verbal. Staff #71 stated that resident #71 saw resident #2 eating and became upset and said the way resident #2 ate was disgusting. Staff #71 stated that resident #2 stopped eating, got up and walked out of the dining room. Staff #71 stated she told resident #2 to come back to the party and that nothing was wrong with the way he was eating. Staff #71 stated resident #2 was embarrassed and his feelings were hurt. Staff #71 further stated that she knew that resident #2's feelings were hurt but she did not think of the situation as abuse because it was verbal and not physical. An interview was conducted with the administrator (staff #129) on (MONTH) 17, 2019 at 2:18 p.m. Staff #129 stated that he was not notified about this incident and that it should have been reported to him immediately. An interview was conducted with resident #2 and his roommate on (MONTH) 17, 2019 at 2:37 p.m. The roommate stated that he was at the party with resident #2 and that resident #71 stated to resident #2 that he needed to take his tongue and stick it in his hole (referring to his [MEDICAL CONDITION] stoma). The roommate stated that resident #2's tongue comes out when he eats and resident #71 stated we do not need to see that kind of stuff around here. Resident #2 shook his head affirmatively to the roommate's statement. The roommate stated that he told resident #71 that he was really rude and what he said was unacceptable. The roommate stated that resident #71 told him to mind his own business. Resident #2 stated that it made him feel sad and mad. Resident #2 further stated that he left the party and did not come back. Review of the facility's policy Protection of Residents: Reducing the Threat of Abuse and Neglect dated (MONTH) (YEAR) revealed each resident has the right to be free from abuse. Residents must not be subjected to abuse by anyone. It is the policy and practice of this facility that all residents will be protected from all types of abuse. The policy also included .Verbal Abuse-The use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents .",2020-09-01
732,PAYSON CARE CENTER,35117,107 EAST LONE PINE DRIVE,PAYSON,AZ,85541,2019-09-19,607,D,0,1,KLKQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to implement their policy regarding reporting and investigating an allegation of abuse involving two residents (#2 and #71). The deficient practice could result in further incidents of resident to resident abuse not being reported and investigated. Findings include: -Resident #2 was admitted to the facility on (MONTH) 16, (YEAR) with [DIAGNOSES REDACTED]. A review of the quarterly MDS (Minimum Data Set) assessment dated (MONTH) 13, 2019 revealed the resident's BIMS (Brief Interview for Mental Status) score was a 15 indicating the resident had intact cognition. -Resident #71 was readmitted to the facility on (MONTH) 31, (YEAR) with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment dated (MONTH) 3, 2019 revealed a BIMS score of 15 which indicated the resident had intact cognition. A review of an Activity Participation Note dated (MONTH) 8, 2019 written by the activity director (staff #71) revealed Late entry: On Thursday (MONTH) 4, during the 4th of (MONTH) party, (resident #71) asked for a third helping of food. Not all of the residents had been served so (staff member's name) asked him to wait until all of the other residents had been served. It appeared to this writer, that because he wanted more food, and because he did not believe (staff member's name), he got angry, became belligerent and called her a liar and a 'b----.' This writer was serving food to others, but overheard this conversation as (resident #71) became loud. A second incident occurred at the same party with (resident #71). He raised his voice and began yelling at another resident (resident #2) and stated 'You should never eat in front of people, you are disgusting to watch. You should just leave.' The other resident (#2) appeared to be hurt, embarrassed and he did leave the party. Further review of the clinical record revealed no evidence that the incident was reported to the administrator or the State Survey Agency or investigated by the facility. An interview was conducted with the activity director (staff#71) on (MONTH) 17, 2019 at 1:36 p.m. Staff #71 stated that she did not think of the situation as abuse because it was verbal and not physical. Staff #71 stated that she did not report the incident because it occurred on a holiday. Staff #71 stated that although she did not document it, she reported the incident four days later to the former director of nursing. An interview was conducted with the administrator (staff #129) on (MONTH) 17, 2019 at 2:18 p.m. Staff #129 stated that if a staff member witnessed resident to resident abuse that it should be reported to himself or the director of nursing within 15 minutes. Staff #129 stated that he would then report the incident to the State Survey Agency within the required time frame of two hours. Staff #129 stated that he was not notified of this incident and that he expected staff to report something like this to him immediately. Review of the facility's policy Protection of Residents: Reducing the Threat of Abuse and Neglect, dated (MONTH) (YEAR), revealed .All associates are mandated to immediately report suspected resident abuse and/or neglect to their immediate supervisor and/or facility representative .The incident will be reported immediately to the administrator and the director of nursing .Facilities must ensure that all alleged violations involving abuse .are reported immediately, but not later than 2 hours after the allegation is made .to the administrator of the facility and to other officials (including the State Survey Agency) .It is the policy of this facility that reports of abuse are promptly and thoroughly investigated . The policy also revealed when an incident or suspected incident of resident abuse is reported, the administrator/designee will investigate the occurrence. The policy included if the investigation is being conducted by the designee, the administrator will be consulted daily concerning the progress of the investigation.",2020-09-01
733,PAYSON CARE CENTER,35117,107 EAST LONE PINE DRIVE,PAYSON,AZ,85541,2019-09-19,609,D,0,1,KLKQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, and policy review, the facility failed to ensure an allegation of verbal abuse involving two residents (#2 and #71) was reported to the administrator and the State Survey Agency. The deficient practice could result in further incidents of resident to resident abuse not being reported as required. Findings include: -Resident #2 was admitted to the facility on (MONTH) 16, (YEAR) with [DIAGNOSES REDACTED]. A review of the quarterly MDS (Minimum Data Set) assessment dated (MONTH) 13, 2019 revealed the resident's BIMS (Brief Interview for Mental Status) score was a 15 indicating the resident had intact cognition. -Resident #71 was readmitted to the facility on (MONTH) 31, (YEAR) with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment dated (MONTH) 3, 2019 revealed a BIMS score of 15 which indicated the resident had intact cognition. A review of an Activity Participation Note dated (MONTH) 8, 2019 written by the activity director (staff #71) revealed Late entry: On Thursday (MONTH) 4, during the 4th of (MONTH) party, (resident #71) asked for a third helping of food. Not all of the residents had been served so (staff member's name) asked him to wait until all of the other residents had been served. It appeared to this writer, that because he wanted more food, and because he did not believe (staff member's name), he got angry, became belligerent and called her a liar and a 'b----.' This writer was serving food to others, but overheard this conversation as (resident #71) became loud. A second incident occurred at the same party with (resident #71). He raised his voice and began yelling at another resident (resident #2) and stated 'You should never eat in front of people, you are disgusting to watch. You should just leave.' The other resident (#2) appeared to be hurt, embarrassed and he did leave the party. Further review of the clinical record revealed no evidence that the incident was reported to the administrator or the State Survey Agency. An interview was conducted with the activity director (staff#71) on (MONTH) 17, 2019 at 1:36 p.m. Staff #71 stated that she did not think of the situation as abuse because it was verbal and not physical. Staff #71 stated that she did not report the incident because it occurred on a holiday. Staff #71 stated that although she did not document it, she reported the incident four days later to the former director of nursing. An interview was conducted with the administrator (staff #129) on (MONTH) 17, 2019 at 2:18 p.m. Staff #129 stated that he was not notified of the incident and that it should have been reported to him immediately so that he could have reported the incident to the State Survey Agency within two hours. Review of the facility's policy Protection of Residents: Reducing the Threat of Abuse and Neglect, dated (MONTH) (YEAR), revealed .All associates are mandated to immediately report suspected resident abuse and/or neglect to their immediate supervisor and/or facility representative .The incident will be reported immediately to the administrator and the director of nursing .Facilities must ensure that all alleged violations involving abuse .are reported immediately, but not later than 2 hours after the allegation is made .to the administrator of the facility and to other officials (including the State Survey Agency) .",2020-09-01
734,PAYSON CARE CENTER,35117,107 EAST LONE PINE DRIVE,PAYSON,AZ,85541,2019-09-19,610,D,0,1,KLKQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interview, and policy review, the facility failed to ensure a thorough investigation was conducted for an allegation of abuse involving two residents (#2 and #71). The deficient practice could result in incidents of resident to resident abuse not being investigated. Findings include: -Resident #2 was admitted to the facility on (MONTH) 16, (YEAR) with [DIAGNOSES REDACTED]. A review of the quarterly MDS (Minimum Data Set) assessment dated (MONTH) 13, 2019 revealed the resident's BIMS (Brief Interview for Mental Status) score was a 15 indicating the resident had intact cognition. -Resident #71 was readmitted to the facility on (MONTH) 31, (YEAR) with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment dated (MONTH) 3, 2019 revealed a BIMS score of 15 which indicated the resident had intact cognition. A review of an Activity Participation Note dated (MONTH) 8, 2019 revealed Late entry: On Thursday (MONTH) 4, during the 4th of (MONTH) party, (resident #71) asked for a third helping of food. Not all of the residents had been served so (staff member's name) asked him to wait until all of the other residents had been served. It appeared to this writer, that because he wanted more food, and because he did not believe (staff member's name), he got angry, became belligerent and called her a liar and a 'b----.' This writer was serving food to others, but overheard this conversation as (resident #71) became loud. A second incident occurred at the same party with (resident #71). He raised his voice and began yelling at another resident (resident #2) and stated 'You should never eat in front of people, you are disgusting to watch. You should just leave.' The other resident (#2) appeared to be hurt, embarrassed and he did leave the party. Further review of the clinical record revealed no evidence that the facility conducted an investigation of this incident. An interview was conducted with the administrator (staff #129) on (MONTH) 17, 2019 at 2:18 p.m. Staff #129 stated that he was not notified of the incident involving resident #2 and resident #71 and that therefore the incident of resident to resident verbal abuse was not investigated by the facility. Review of the facility's policy Protection of Residents: Reducing the Threat of Abuse and Neglect, dated (MONTH) (YEAR), revealed .It is the policy of this facility that reports of abuse are promptly and thoroughly investigated . The policy also revealed when an incident or suspected incident of resident abuse is reported, the administrator/designee will investigate the occurrence. The policy included if the investigation is being conducted by the designee, the administrator will be consulted daily concerning the progress of the investigation.",2020-09-01
735,PAYSON CARE CENTER,35117,107 EAST LONE PINE DRIVE,PAYSON,AZ,85541,2019-09-19,641,E,0,1,KLKQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and the Resident Assessment Instrument (RAI), the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 2 of 20 sampled residents (#82 and #76). The deficient practice could result in inaccurate discharge tracking information and inaccurate crucial factors for care planning decisions. Findings include: -Resident #82 was admitted to the facility on (MONTH) 16, 2019 with [DIAGNOSES REDACTED]. Review of a nursing note dated (MONTH) 5, 2019 revealed the resident had been discharged to an assisted living facility. However, review of the discharge MDS assessment dated (MONTH) 5, 2019 revealed the resident had been discharged to a psychiatric hospital. An interview was conducted with the MDS Coordinator (staff #45) on (MONTH) 19, 2019 at 1:10 p.m. Staff #45 stated the MDS assessment coding was inaccurate because the resident was discharged to an assisted living facility and not a psychiatric hospital. She stated she was unsure of how the inaccuracy occurred. She also stated that the MDS assessment needed to be coded accurately. During an interview conducted with the Director of Nursing on (MONTH) 19, 2019 at 1:15 p.m., she stated it was important for the MDS assessment to be accurate for every resident. The DON stated they did not have a specific policy for MDS assessment that they use the RAI manual. The RAI manual instructs to review the clinical record including the discharge plan and discharge orders for documentation of a resident's location and code the discharge location. -Resident #76 was admitted to the facility on (MONTH) 26, (YEAR) with [DIAGNOSES REDACTED]. A review of the nursing progress note dated (MONTH) 27, (YEAR) revealed the resident was alert, confused, and unable to follow direction. A review of the provider's initial history and physical dated (MONTH) 27, (YEAR) revealed the resident was a poor historian. Review of the baseline care plan dated (MONTH) 27, (YEAR) revealed the resident had short and long term memory impairment. Interventions included allowing extra time to respond to questions and to face and speak clearly when communicating with the resident. However, review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 2, 2019 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. During an interview conducted with the MDS Coordinator (staff #45) on (MONTH) 19, 2019 at 11:36 AM, the MDS Coordinator stated that the BIMS score on the admission assessment is incorrect. She stated that she was unable to find any documentation in the clinical record that supports the BIMS score of 15. Staff #45 also stated that this error could have a negative impact on the care plan. The RAI manual instructs an attempt to conduct the BIMS should be conducted with all residents. Cognitive patterns are crucial factors in many care planning decisions. The RAI manual revealed the importance of accurately completing and submitting the MDS assessment cannot be over emphasized. The MDS assessment is the basis for the development of an individualized care plan.",2020-09-01
736,PAYSON CARE CENTER,35117,107 EAST LONE PINE DRIVE,PAYSON,AZ,85541,2019-09-19,658,E,0,1,KLKQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure services provided met professional standards of quality by failing to clarify the dosage of a medication for one of five sampled residents (#71). The deficient practice could result in residents being administered incorrect dosages of medications. Findings include: Resident #71 was readmitted to the facility on (MONTH) 31, (YEAR) with [DIAGNOSES REDACTED]. Review of the clinical record revealed a physician's orders [REDACTED]. Give 1 capsule by mouth two times a day for anxiety. Further review of the physician's orders [REDACTED]. A review of the (MONTH) 2019 Medication Administration Record [REDACTED]. An interview was conducted with a Licensed Practical Nurse (LPN/staff #4) on (MONTH) 18, 2019 at 8:30 a.m. Staff #4 stated that the dosage of the medication was not documented on the physician order [REDACTED]. The LPN further stated that she would clarify the dose with the resident's physician before it was administered again. An interview was conducted with the Director of Nursing (DON/staff #41) on (MONTH) 18, 2019 at 9:47 a.m. The DON stated that the order should have been clarified before it was administered to the resident. Review of the facility's policy Administration of Medications, dated (MONTH) 24, 2019, revealed a physician order [REDACTED]. The policy also included the nurse must clarify any order that is incomplete or unclear.",2020-09-01
737,PAYSON CARE CENTER,35117,107 EAST LONE PINE DRIVE,PAYSON,AZ,85541,2019-09-19,684,E,0,1,KLKQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff and resident interviews, the facility failed to ensure that one sampled resident (#65) received treatment and care in accordance with professional standards of practice relating to bowel status. The deficient practice could result in residents with diarrhea not being treated. Findings Include: Resident #65 was admitted to the facility on (MONTH) 30, 2019 with [DIAGNOSES REDACTED]. Review of the nursing admission/readmission note signed (MONTH) 31, 2019 revealed the resident was alert and oriented to person, place, time, and situation and was pleasant and cooperative. The note included the resident had burning/itching and redness to the perianal area related to [MEDICAL CONDITIONS] diarrhea. The note also revealed the resident was started on an antibiotic at the hospital for [MEDICAL CONDITION] and will finish the antibiotics at the facility. Review of the clinical record revealed physician orders dated (MONTH) 31, 2019 for [MEDICATION NAME] (antibiotic) suspension 125 milligrams (mg) by mouth every 6 hours for history [MEDICAL CONDITION] and [MEDICAL CONDITION] until (MONTH) 6, 2019, Lactobacillus (antidiarrheal agent) one capsule by mouth two times a day for antibiotic treatment, and strict isolation for [MEDICAL CONDITION] and contact isolation [MEDICAL CONDITION]. The nursing skilled progress note dated (MONTH) 31, 2019 revealed the resident was on strict precautions for [MEDICAL CONDITION]. The note included the resident was the only resident in the room. The note also included the resident needed one person assistance for bed mobility, transfers and activities of daily living (ADLs). Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 6, 2019 revealed a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate impaired cognition. The assessment also included the resident was occasionally incontinent of bowel. The Medication Administration Record [REDACTED]. Review of the care plan initiated (MONTH) 12, 2019 revealed the resident had occasional bowel incontinence. The goal was that the resident would have no skin breakdown related to bowel incontinence. Interventions included checking the resident every two hours and assisting with toileting as needed, observing pattern of incontinence and initiating toileting schedule if indicated, and providing pericare after each incontinent episode and as needed. Review of the provider progress note dated (MONTH) 14, 2019 revealed the resident was no longer having loose stools and that the resident had been taken off of contact precautions. The health status progress note dated (MONTH) 14, 2019 revealed the resident had not had loose stools for 3 days and the strict isolation precautions had been discontinued. The task documentation for bowel movements revealed boxes to check if the resident had formed, loose, hard, or putty like stools. The task documentation revealed the resident had loose stools on (MONTH) 21, 2019. A skin/wound note dated (MONTH) 28, 2019 revealed a wound culture was obtained and there were new orders for [MEDICATION NAME] and [MEDICATION NAME] for 10 days. Physician orders dated (MONTH) 28, 2019 revealed for [MEDICATION NAME] (antibiotic) 100 mg by mouth twice a day for infection for 10 days and [MEDICATION NAME] (antibiotic) 500 mg by mouth three times a day for infection for 10 days. The MAR for (MONTH) 2019 revealed the resident continued to receive the Lactobacillus for antibiotic treatment. The task documentation for bowel movements revealed the resident had loose stools on (MONTH) 29, 2019 and (MONTH) 1-3, 2019. The clinical record revealed the resident was sent to the hospital on (MONTH) 3, 2019 related to a fall injury. Review of a discharge MDS assessment dated (MONTH) 3, 2019 revealed the resident was frequently incontinent of bowel. The resident was readmitted to the facility on (MONTH) 7, 2019 with [DIAGNOSES REDACTED]. Readmission physician orders did not include antibiotics or Lactobacillus. Review of an admission/re-admission collection tool dated (MONTH) 7, 2019 revealed the box for bowel incontinence was checked but the box for diarrhea was not checked. The nursing progress notes from (MONTH) 9-11, 2019 revealed the resident was incontinent of bowel but did not include the resident was having diarrhea/loose stools. Review of the task documentation for bowel movements revealed the resident had loose stools on (MONTH) 11, 2019. The wound physician progress notes [REDACTED]. Physician orders dated (MONTH) 11, 2019 revealed for isolation precautions [MEDICAL CONDITION] and [MEDICATION NAME] (antibiotic) 1 gram intravenously every 24 hours for 21 days, pharmacy to follow [MEDICATION NAME] trough levels and adjust dose as needed. Review of the nursing progress notes from (MONTH) 12 to 18, 2019 revealed the resident was incontinent of bowel but did not include the resident was having diarrhea. The task documentation for bowel movements revealed the resident had loose stools on (MONTH) 13-14, 16-17, and 19, 2019. Review of the clinical record including the Order Summary Report for active physician's orders as of (MONTH) 19, 2019 revealed no documentation the diarrhea/loose stools were being addressed. An interview was conducted with resident #65 on (MONTH) 16, 2019 at 3:28 p.m. He stated that he had been having a problem with diarrhea. He stated that he had a diarrhea bowel movement today. Another interview was conducted with the resident on (MONTH) 19, 2019 at 8:47 a.m. He stated that the diarrhea had become kind of a constant thing and that it was happening daily. The resident stated that he told staff that he was having a problem with diarrhea. He stated that he did not know who or when he spoke with staff regarding the diarrhea. An interview was conducted with a Certified Nursing Assistant (CNA/staff #106) on (MONTH) 19, 2019 at 8:50 a.m. She stated that if a resident is constantly having loose stools that she would let the nurse know and keep the nurse updated. She stated that resident #65 has diarrhea and that his stools has always been loose. The CNA stated that she notified the nurse that resident #65 was having loose stools. An interview was conducted with a Registered Nurse (RN/staff #91) on (MONTH) 19, 2019 at 9:17 a.m. She stated that if she was notified that a resident was having loose stools she would document it, notify the practitioner, consult with dietary, and assess the consistency of the stools to rule out a blockage. The RN stated that she had not been notified by the CNA or the resident that the resident was having loose stools. She also stated that the resident had not requested any medication for loose stools. She stated that she would expect the CNA to let her know if a resident is having constant loose stools so that she could visualize the stool. The RN stated she would notify the physician and dietary if the loose stools continued over three days so that interventions could be implemented to resolve the loose stools. During an interview conducted with the Director of Nursing (DON/staff #41) on (MONTH) 19, 2019 at 1:43 p.m., the DON stated that if a resident was having constant diarrhea, she would expect the CNA to report it to the nurse. She stated that the nurse would then be expected to assess the stools and document it. The DON stated that if the nurse determines that the resident is having constant diarrhea, the nurse would need to notify the provider. She stated that having constant loose stools/diarrhea would put the resident at risk for skin breakdown, dehydration, altered nutrition, and weakness.",2020-09-01
738,PAYSON CARE CENTER,35117,107 EAST LONE PINE DRIVE,PAYSON,AZ,85541,2019-09-19,686,G,0,1,KLKQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, staff interviews, and policy review, the facility failed to ensure one of three sample residents (#65) was provided necessary treatment and services consistent with professional standards of practice regarding pressure ulcers. The deficient practice could result in the development of pressure ulcers, wound complications and delayed identification of new skin issues. Findings include: Resident #65 was admitted to the facility on (MONTH) 30, 2019, with [DIAGNOSES REDACTED]. Review of the nursing admission/readmission note dated (MONTH) 30, 2019 revealed the resident was alert and oriented to person, place, time, and situation and was pleasant and cooperative. The note included the resident was status [REDACTED]. The note included the resident stated that he had not ambulated in approximately 3 months. Review of an admission/readmission collection tool signed (MONTH) 31, 2019, revealed the resident had no feeling at all to the lower legs and is status [REDACTED]. The Tool included the resident had intermittent burning and tingling in the lower legs, heels, and toes and that there was a tiny scab at the tip of the remaining metatarsal of the left toe(s) but did not include what toes remained. The tool also included pressure ulcer(s) was a risk alert. However, review of the Braden Scale for predicting pressure ulcer risk signed (MONTH) 31, 2019 revealed a score of 16 which indicated the resident was at mild risk for pressure ulcers. A care plan initiated (MONTH) 31, 2019 revealed the resident was at risk for break in skin integrity related to a history of pressure ulcers to the heels/toes, [MEDICAL CONDITION], and being wheelchair bound. The goal was that the resident would maintain intact skin. Interventions included floating the heels while in bed and/or boots and weekly skin checks. Review of the clinical record revealed physician admission orders [REDACTED]. Nursing skilled progress notes dated (MONTH) 1, 4, 5, and 6, 2019 revealed the resident's heels were soft and boggy and there was a dry scab to the right great toe. The note included the resident declined major position changes. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 6, 2019 revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderate impaired cognition. The assessment included the resident required extensive assistance with bed mobility, toileting, and hygiene and had only transferred from the bed 1-2 times. The assessment also included the resident was at risk for pressure ulcers and had pressure reduction in place to the chair and bed. Review of the pressure ulcer Care Area Assessment (CAA) for the MDS assessment revealed weekly skin checks were ongoing and that a care plan would ensure measures were in place for prevention of complications due to decreased mobility. The nursing skilled progress notes dated (MONTH) 8 and 12, 2019 revealed the resident declined major position changes and that the resident's heels were soft and boggy A nursing skilled progress note dated (MONTH) 13, 2019 revealed the resident was able to ambulate in halls, cooperates as able with PT (physical therapy)/OT (occupational therapy), and that nursing continued to encourage and educate. The nursing skilled progress notes dated (MONTH) 16 and 17, 2019 revealed the resident was able to ambulate in the hall. The weekly skin integrity data collection tools conducted between (MONTH) 6, 2019 and (MONTH) 23, 2019 revealed the resident's skin was intact. However, review of the clinical record from (MONTH) 31, 2019 to (MONTH) 25, 2019, revealed no evidence the heels were floated and/or that boots were in place as indicated in the care plan. A nursing progress note dated (MONTH) 26 2019 revealed the wound care nurse was notified the resident had an open area to his left and right foot so that the wound nurse could obtain orders. The note included the resident was aware of the open areas. The note also included the foot board was removed since the resident slides in bed. The note did not include location, description, or measurements of the wounds to the feet. The physician orders [REDACTED]. Review of the Treatment Administration Record (TAR) dated (MONTH) 2019 revealed the treatment for [REDACTED]. The nursing skilled progress note dated (MONTH) 27, 2019 revealed the bilateral feet dressing were clean, dry and intact. The note included the wound nurse was following and to see the wound notes for details. Review of the Wound Observation Tool dated (MONTH) 27, 2019 revealed the resident acquired a right foot unstageable/deep tissue injury pressure ulcer on (MONTH) 26, 2019. The right foot 2nd to 5th toes are amputated and the ulcer is located on the lateral aspect of the amputated site. The wound measured 1 centimeter (cm) by 1 cm, no drainage, and no signs of infection, no pain, and was dark purple to black discoloration with skin intact. The current treatment plan is [MEDICATION NAME] gauze daily. The Tool included the ulcer may have been caused by the resident's feet against the foot board and that the footboard was removed. The Tool included the resident reported no feeling in his feet. The Tool revealed preventative measures included pressure reduction mattress, pressure reduction cushion in wheelchair, pillows to elevate bilateral lower extremities to float heels, and reposition every two hours. Review of a Wound Observation Tool dated (MONTH) 27, 2019 revealed the resident acquired an unstageable pressure ulcer to the plantar surface of the left foot on (MONTH) 26, 2019. The wound measured 2.5 cm by 2 cm, had 100% slough, a small amount of serous drainage, no signs of infection, and no pain. The current treatment plan is [MEDICATION NAME] Ag daily. The Tool revealed preventative measures included pressure reduction mattress, pressure reduction cushion in wheelchair, pillows to elevate and float heels, and reposition every two hours. The Tool also included the resident rests his feet against the foot board; the foot board was removed from the bed, and to educate the resident on pressure relief and positioning. Further review of the clinical record revealed no progress note for (MONTH) 28, 2019. A care plan initiated (MONTH) 28, 2019 revealed the resident had an unstageable pressure ulcer to the right foot and a stage 4 pressure ulcer to the left foot related to history of ulcers and immobility. The goal was that the pressure ulcers will show signs of healing and remain free from infection. Interventions included educating the resident/family/caregivers as to causes of skin breakdown, transfer/positioning requirements, importance of taking care during ambulating/mobility, good nutrition and frequent repositioning and treatments as ordered. A nutrition/dietary progress note dated (MONTH) 28, 2019 revealed the resident's nutrition intake by mouth was 25-50% and that the resident was likely not meeting increased needs for wound healing. The [MEDICATION NAME] was low at 3. The note included a recommendation will be made to increase ensure to three times a day and for prosource twice a day for wound healing. The wound physician progress notes [REDACTED]. The note included the unstageable right foot ulcer located to the lateral aspect of the foot had black eschar and was without odor. The note included the wounds to the left and the right feet were debrided. A skin/wound progress note dated (MONTH) 28, 2019 revealed the wound care physician saw the resident. The note revealed the left plantar wound was debrided and that the bone was exposed after debridement. The right foot wound was also debrided. A wound culture was obtained by the physician and the physician wrote new orders for treatment and for [MEDICATION NAME] and Keflex for 10 days. The note did not include measurements or descriptions of the wounds. Review of the physician's orders [REDACTED]., cover with dry 4 X 4 gauze, wrap with Kerlix and change daily and to cleanse the right foot unstageable pressure ulcer with wound cleanser, apply [MEDICATION NAME] gel, cover with [MEDICATION NAME] Ag dressing, cover with 4 X 4 gauze, wrap with [MEDICATION NAME], and change three times a week on Monday, Wednesday, and Friday. The TAR for (MONTH) 2019 revealed the treatment was provided to the left foot on (MONTH) 29 and 30. The TAR contained no documentation that the treatment was provided on (MONTH) 31. The (MONTH) 2019 TAR revealed the treatment was provided to the right foot on Friday, (MONTH) 30 as ordered. The nursing skilled progress note dated (MONTH) 2, 2019 revealed the resident was taking antibiotics [MEDICAL CONDITION] in the left foot wound and was on contact precautions [MEDICAL CONDITION]. Review of the clinical record revealed the resident was sent to the hospital on (MONTH) 3, 2019 related to a fall injury. The resident was readmitted to the facility on (MONTH) 7, 2019 with [DIAGNOSES REDACTED]. Review of the physician admission orders [REDACTED]. The Braden Scale for predicting pressure ulcer risk and risk factors with an effective date of (MONTH) 7, 2019 revealed a score of 13 which indicated the resident was at moderate risk for pressure ulcers. Continued review of the clinical record revealed no documentation that a thorough assessment of the left and right feet pressure ulcers was conducted upon admission. Review of the admission/readmission collection tool regarding the skin condition signed by the nurse on (MONTH) 9, 2019 revealed the resident had open area/wound. The documentation included the left foot was healing from amputated toes and that the dressing was clean, dry, and intact. The assessment did not include any information about the right foot. Review of the TAR for (MONTH) 2019 revealed the left foot pressure ulcer treatment from the previous admission (July 30, 2019) was provided to the resident on (MONTH) 8 and 9. Continued review of the (MONTH) 2019 TAR revealed the right foot pressure ulcer treatment from the previous admission (July 30, 2019) was provided to the resident on Monday, (MONTH) 9. The care plan regarding pressure ulcers was revised (MONTH) 9, 2019 to include the intervention to remove the footboard from the bed so that the resident does not rest/push his feet on it. Review of the physician's orders [REDACTED]. Cleanse the right foot unstageable ulcer with wound cleanser, apply silver foam dressing, pad with 4 x 4 gauze, wrap with rolled gauze, and change every three days. The physician order [REDACTED]. Review of the TAR for (MONTH) 2019 revealed the treatment was provided as ordered to the right and left foot. The (MONTH) 2019 TAR also revealed documentation that the waffle boots to bilateral feet were on at all times while in bed from (MONTH) 10-19, 2019. Review of the clinical record from the readmission on (MONTH) 7, 2019, revealed no thorough assessment of the left foot wound until (MONTH) 11, 2019 and no thorough assessment of the right foot until (MONTH) 12, 2019. Review of the wound observation tool dated (MONTH) 11, 2019 revealed documentation this was the first observation and that the stage 4 left foot plantar pressure ulcer measured 1.7 cm x 1 cm, 100% slough, a very small piece of bone was present in the wound bed, small amount of serous drainage, no tunneling or undermining, and no signs or symptoms of infection. Treatment was provided as ordered. The documentation revealed preventative measures included pressure reduction mattress, waffle boots to bilateral feet, pressure reduction cushion in wheelchair, and that the foot board was removed. The comments section of the wound observation tool included that prior to admission to the hospital the left foot wound had granulation and now has 100% slough and that no redness was noted. The resident [MEDICAL CONDITION] in the wound and is on contact precautions. The wound care physician is to see the resident today (September 11, 2019). Waffle boots were placed to bilateral feet. The comment section included the resident needs extensive assistance with 1-2 staff for ADL care, bed mobility, and transfers. Review of the wound physician progress notes [REDACTED]. Review of physician's orders [REDACTED]. Review of the wound observation tool dated (MONTH) 12, 2019 revealed documentation this was the first observation and that the right foot unstageable pressure ulcer measured 1 cm x 1 cm, 100% slough, small amount serous drainage, no tunneling and/or undermining, and no signs or symptoms of infection. Included was pressure reduction mattress, pressure reduction cushion in wheelchair, waffle boots to bilateral feet, and foot board removed as preventative measures. The comments section of the wound observation tool revealed the right foot pressure ulcer had dark brown eschar with no redness (conflicting information regarding wound bed) and a small amount of serous drainage. The resident saw the wound doctor yesterday (September 11, 2019) who debrided the wounds and changed the treatment. The comments included waffle boots to bilateral feet and foot board on bed removed. Review of the care plan regarding pressure ulcers revealed the interventions were updated (MONTH) 13, 2019 to include waffle boots to bilateral feet while in bed and pressure reduction mattress on the bed. Continued review of the clinical record from the readmission on (MONTH) 7, 2019, revealed a complete weekly skin assessment was not conducted until (MONTH) 17, 2019 on the weekly skin integrity data collection form. Review of the care plan regarding skin integrity revealed the interventions were revised on (MONTH) 17, 2019 to include pressure reducing mattress and alternating air mattress. An observation of the right and left foot pressure ulcer treatment was conducted on (MONTH) 18, 2019 at 12:42 p.m. with two wound nurses (Licensed Practical Nurse (LPN)/staff #96 ) and (staff #8). The right foot pressure ulcer measured 1cm x 1.2 cm x utd (unable to determine), had 50% dark eschar, 20-30 % slough, small amount granulation, no odor and the peri wound was intact. The left foot pressure ulcer measured 1.4 cm x 1 cm x 0.3 cm, slough removed, scant amount serosanguinous drainage, red granulation, and peri wound intact. Treatment was provided as ordered to the right and left foot pressure ulcers. An interview was conducted with a Registered Nurse (RN/staff #91) on (MONTH) 19, 2019 at 9:17 a.m. She stated that the nurse is to do a head to toe skin assessment within two hours of admission/re-admission and then weekly and as needed after that. She stated that if the resident is admitted with wounds the dressings should be adjusted enough to visualize and assess the wound unless there is a provider order to leave the dressing in place, the assessment/description of any wounds present should be documented in the admission nursing assessment, and the nurse should notify the wound nurse that the resident has wounds. She stated that if the wounds were present on admission/re-admission there should not be 4 to 5 days between admission/re-admission and documentation of wound assessments. She stated that a head to toe skin assessment completed over seven days from the prior assessment would be late. An interview was conducted with the wound nurse (LPN/staff #96) on (MONTH) 19, 2019 at 1:05 p.m. She stated skin assessments are to be conducted weekly. The wound nurse stated that if weekly skin assessments are late, new skin issues may be missed and/or there could be a delay in notification and treatment of [REDACTED]. The wound nurse stated that the wound observation tool is done once a week and that she does the staging of wounds. She stated that the wound assessments on resident #65 did not meet expectation as there was no documentation of an assessment of the wounds until 4 and 5 days after the re-admission. She stated that by not doing an initial assessment, they would not be able to identify if the wounds had changed or worsened. During an interview conducted with the Director of Nursing (DON/staff #41) on (MONTH) 19, 2019 at 1:43 p.m., the DON stated the expectation is that the admission nurse completes the skin status which would include any wounds on the admission/readmission collection tool. She stated that the 4 and 5 day delay of wound assessments increased the risk of unidentified wound deterioration that could have been present on admission. She stated that the nursing staff is expected to do a head to toe skin assessment on admission and weekly thereafter. The DON further stated that the skin assessment conducted on (MONTH) 17, 2019 was late which could increase the risk of missing new skin issues. Review of the facility's policy for pressure ulcer/injury prevention and management revealed that a comprehensive skin assessment on admission and re-admission may identify pre-existing signs of possible deep tissue damage already present. The policy stated that a skin assessment should be performed weekly by a licensed nurse. Measures to protect the resident against the adverse effects of external mechanical forces, such as pressure, friction, and shear are implemented in the plan of care: .heel protection/suspension should be implemented while the resident is in bed .",2020-09-01
739,PAYSON CARE CENTER,35117,107 EAST LONE PINE DRIVE,PAYSON,AZ,85541,2019-09-19,688,E,0,1,KLKQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, and policy review, the facility failed to provide treatment and services to prevent further reduction in range of motion (ROM) for one of two sampled residents (#17). The deficient practice could result in residents not being provided treatment and services to increase, maintain, or prevent further decrease in ROM. Findings include: Resident #17 was readmitted to the facility on (MONTH) 1, (YEAR) with [DIAGNOSES REDACTED]. A review of an Occupational Therapy Evaluation and Plan of Treatment dated (MONTH) 4, 2019 revealed the long term goal was for education/training to be completed for resident and staff for appropriate splinting/bracing and for contracture management. Review of an Occupational Therapy Discharge Summary dated (MONTH) 28, 2019 revealed .Use of palm guard and built up palm guard to increase digit extension. Unable to use resting splint due to current contracture. Continue with RNA (restorative nursing assistant) . Review of the care plan initiated (MONTH) 23, 2019 revealed the resident has [MEDICAL CONDITION] and that her ability to communicate is impaired but that she is able to communicate most needs. The goal was that the resident will communicate needs, wants using head nods, gestures, and pointing. Interventions included framing questions in yes/no format and giving the resident adequate time to communicate needs and wants in an unhurried and un-rushed atmosphere. Review of a Rehabilitation Services Multidisciplinary Screening Tool dated (MONTH) 29, 2019 revealed the resident was on level 1 maintenance for active range of motion, passive range of motion, splinting/braces, and omnicycle. A review of the care plan initiated (MONTH) 30, 2019 revealed the resident has an ADL (activities of daily living) self-care performance deficit related to musculoskeletal impairment and stroke. The goal was the resident will maintain current level of function in ADL's. Interventions included the resident has contractures of the right hand, provide skin care to keep clean and prevent skin breakdown and Nursing rehabilitation/restorative: Splint/Brace Program #1. Placement of palm guard and hand hygiene. Review of a Rehabilitation Services Multidisciplinary Screening Tool dated (MONTH) 29, 2019 revealed the resident was receiving restorative services but did not indicate what services were provided to the resident. Review of the quarterly MDS (Minimum Data Set) assessment dated (MONTH) 12, 2019 revealed a BIMS (Brief Interview for Mental Status) score of 13 which indicated the resident had intact cognition. The assessment also included that passive/active ROM and a splint or brace assistance was not performed in the last 7 days. An interview was conducted with the resident on (MONTH) 16, 2019 at 11:22 a.m. A splint or hand roll was not observed in her right hand. When asked if staff assisted her with range of motion for her contracted right hand, the resident shook her head no. Another interview was conducted with the resident on (MONTH) 18, 2019 at 3:51 p.m. When asked if staff had attempted range of motion to extend the fingers on her right hand, the resident shook her head no. When asked if staff had ever placed a hand roll or brace in her right hand the resident shook her head no. When asked if she wanted staff to provide range of motion for her right hand the resident shook her head yes. Again no splint or hand roll was observed in the resident's right hand. An interview was conducted with the Director of Therapy (staff #68) on (MONTH) 19, 2019 at 9:21 a.m. Staff #68 stated that the resident was on a restorative program for hand hygiene, range of motion, and contracture prevention. An interview was conducted with a Restorative Nursing Assistant (RNA/staff #104) on (MONTH) 19, 2019 at 9:30 a.m. Staff #104 stated that she believed the resident was still on the restorative nursing caseload. Staff #104 stated that the resident uses an omnicycle three times a week and never refuses to participate. Staff #104 stated that range of motion is provided to her right hand and that the resident wore a hand splint. Staff #104 stated that restorative nursing usually put the hand splint on the resident's right hand three times a week and nursing probably took it off at night. Staff #104 stated that they document in the computer when the resident participated in restorative nursing however she was unable to provide evidence of that. Staff #104 stated that the resident is not scheduled for restorative nursing on any particular day just as long as she participated three times a week. Staff #104 stated that range of motion is provided to the resident three times a week and a splint is put on the resident's right hand. Another interview was conducted with the resident on (MONTH) 19, 2019 at 9:50 a.m. A splint or hand roll was not observed in her right hand. When asked if staff had ever placed the hand roll in her right hand that staff #104 had located at the back of one of her dresser drawers, the resident shook her head no and then shook her head yes. When asked if staff placed the hand roll in her right hand three times a week, the resident shook her head no. An interview was conducted with a Certified Nursing Assistant (CNA/staff #109) on (MONTH) 19, 2019 at 9:59 a.m. Staff #109 stated that he never applied a splint or hand roll to the resident's right hand and did not document when he performed range of motion to the resident's right hand during care. An interview was conducted the Restorative Nurse (staff #45) on (MONTH) 19, 2019 at 10:33 a.m. Staff #45 stated that the splint and palm guard with hand hygiene was put on the resident's care plan on (MONTH) 9, 2019. Staff #45 stated that since the resident was on a level 1 restorative order, there was no physician's order. Staff #45 stated that since there was not a physician order for [REDACTED]. Review of the facility's policy Restorative Nursing revealed The facility is responsible for providing maintenance and restorative programs as indicated by the resident's comprehensive assessment to achieve and maintain the highest practicable outcome .Restorative Nursing Functions can be within one of the following categories: Range of Motion (Active and Passive. Splint or brace assistance .The trained CNA will document provided techniques per the restorative care plan in the medical record .Restorative Nursing does not require a physician order .",2020-09-01
740,HAVEN OF CAMP VERDE,35118,86 WEST SALT MINE ROAD,CAMP VERDE,AZ,86322,2018-02-02,658,D,0,1,KG8511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, facility documentation, staff interviews, manufacturer's instructions, and the Rules of the State Board of Nursing, the facility failed to ensure that a medication patch was applied and removed as ordered for one resident (#29). Findings include: Resident #29 was admitted on (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment dated (MONTH) 3, (YEAR) revealed the resident had a Brief Interview of Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Review of a physician's orders [REDACTED]. A review of the consulting pharmacist report dated (MONTH) 21, (YEAR) that was sent electronically to the Director of Nurses (staff #51) on (MONTH) 24, (YEAR), revealed a recommendation to provide a place on the electronic Medication Administration Report (eMAR) for nurses to document the removal of the patch in the evening. During a medication administration observation conducted on (MONTH) 31, (YEAR) at 8:10 a.m. with a Licensed Practical Nurse (LPN/staff #37), a [MEDICATION NAME] dated (MONTH) 30, (YEAR) was noted to be in place to the lower back of resident #29. Staff #37 removed the patch before applying the new [MEDICATION NAME]. A review of the eMAR dated (MONTH) (YEAR) revealed the last patch applied, prior to the medication administration observation, was (MONTH) 30, (YEAR) in the am. The eMAR also revealed no direction and no place to document the removal of the [MEDICATION NAME]. An interview was conducted on (MONTH) 1, (YEAR) at 9:17 a.m. with staff #37. She stated the expectation is that the staff will follow the physician's orders [REDACTED].#37 stated the nurse would be expected to read the directions for the medication before administering the medication. After reviewing the [MEDICATION NAME] package, staff #37 stated the patch is applied to the resident up to 12 hours in a 24 hour period. Staff #37 reviewed the electronic medication pass directions and stated the patch was to be on for 12 hours and off for 12 hours. She stated a patch was still in place when she was ready to apply a new patch on (MONTH) 31, (YEAR) and (MONTH) 1, (YEAR). Later at 10:18 a.m., staff #37 stated she should have notified staff #51 and the physician that the patch that was applied the day before was still on the resident (MONTH) 31, (YEAR) and (MONTH) 1, (YEAR). She also stated that she should have contacted the physician for clarification. An interview was conducted with staff #51 on (MONTH) 1, (YEAR) at 10:24 a.m. She stated the nurse should have should have clarified the order with the physician due to the directions on the [MEDICATION NAME] package when she noticed that the patch was still on the resident each morning. During an interview conducted on (MONTH) 1, (YEAR) at 2:54 p.m. with the Executive Director (staff #69), staff #69 stated the facility does not have a specific policy regarding Nursing Standards of Practice. The manufacturer's direction included applying the [MEDICATION NAME] Patch 5% to intact skin once for up to 12 hours within a 24 hour period. The Rules of the State Board of Nursing included .Implement aspects of a client's care consistent with the LPN scope of practice in a timely and accurate manner including: a. Following nurse and physician orders [REDACTED]. The Rules of the State Board of Nursing also included .Provide nursing care within the RN (Registered Nurse) scope of practice in which the nurse .b. Clarifies health care provider orders when needed .3. Supervise, monitor, and evaluate the care assigned to a LPN .",2020-09-01
741,HAVEN OF CAMP VERDE,35118,86 WEST SALT MINE ROAD,CAMP VERDE,AZ,86322,2018-02-02,689,G,1,1,KG8511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on closed clinical record review, facility and hospital documentation, and staff interviews, the facility failed to ensure that adequate supervision was provided to one resident (#245), who was at risk for aspiration. Findings include: Resident #245 was initially admitted on (MONTH) 1, (YEAR) and readmitted to the facility on (MONTH) 7, (YEAR), with [DIAGNOSES REDACTED]. Review of a Swallowing Ability and Function Evaluation dated (MONTH) 18, (YEAR), revealed the resident had mild to moderate dysphagia, experienced coughing after swallowing and had no teeth. Review of a hospital Modified [MEDICATION NAME] Swallow report dated (MONTH) 4, (YEAR) revealed the resident presented with moderate diffuse lingual residue, after swallows of thin, nectar-thick and puree consistencies. The report included that solids were not tried, due to poor dentition. Resident presents with tongue base and posterior pharyngeal wall weakness, as well as delayed swallowing initiation, which results in tongue base and pharyngeal residue with all consistencies. No penetration or aspiration occurred during this study. The report recommendations including the following: -mechanical soft-ground with thin liquids -small bites and sips -the patient should be monitored during meals to ensure she takes small bites and sips -the resident should be out of of bed and fully upright for all oral medications, and meds should be crushed and presented in puree form -aspiration precautions and for daily swallowing exercise regimen. The physician orders [REDACTED]. The order also included that the resident must be out of bed in chair, supervised and to take slow bites when eating meals or snacks, due to inhalation of solids and liquids. Another physician's orders [REDACTED]. Review of the ST evaluation and treatment notes dated (MONTH) 8, (YEAR), indicated the resident was referred to ST, due to exacerbation of cognitive impairment and risk for aspiration and [MEDICAL CONDITION]. The notes included for ST to assess/evaluate least restrictive oral intake and analyze the oral/pharyngeal function, improve cognitive-linguistic skills and develop and instruct in compensatory strategies. A nutritional care plan dated (MONTH) 8, (YEAR) indicated the resident had decreased intake related to aspiration. The approaches included that staff were to explain and reinforce the importance of maintaining the diet orders, encourage compliance, and staff were to serve the diet as ordered. Further review of the resident's care plans including the nutritional care plan revealed that none of the care plans addressed the resident's aspiration risk and difficulty with swallowing. The care plans also did not include that the resident required supervision with eating and must be out of bed in a chair, and for the resident to take slow bites when eating meals or snacks. A physician's orders [REDACTED]. Review of a nurses note dated (MONTH) 9, (YEAR) revealed that ST was teaching swallowing/chewing techniques and was waiting for endoscopy to be done. Review of the nurses notes dated (MONTH) 10, (YEAR) at 9:00 a.m., revealed the resident had a choking episode in the dining room during breakfast. A certified nursing assistant (CNA), yelled out to a Licensed Practical Nurse (LPN) that resident #245 was choking. The notes indicated that the resident was turning blue. Abdominal chest thrusts were initiated and the nurse removed a piece of toast the size of a golf ball. The resident was then able to cough and breath, and her color returned to normal. The physician was notified and ordered a pureed diet, nectar thick liquids and a ST evaluation. The notes further included that ST evaluated the resident that same day. According to the Speech Therapy treatment note dated (MONTH) 10, (YEAR), the resident required the [MEDICATION NAME] maneuver today. The note included the resident's diet and liquid texture were assessed with [REDACTED]. Instructions included alternating liquids/solids to increase pharyngeal clearance and to use small controlled sips and small bites. Review of the physician orders [REDACTED]. Review of a nurses notes dated (MONTH) 10, (YEAR) at 8:40 p.m., revealed the resident must be closely supervised during meal times and hydration times. Further review of the resident's care plans revealed they were not revised to reflect that the resident had a choking episode, nor of the need to provide supervision with eating or any additional interventions. An annual Minimum Data Set (MDS) assessment dated (MONTH) 14, (YEAR), included a Brief Interview for Mental Status (BIMS) score of 10, which indicated that the resident had moderate cognitive impairment. The MDS indicated the resident was wheelchair bound and required limited assistance of one staff for eating. The MDS also included that the resident had swallowing disorders of coughing or choking during meals or when swallowing medications. Per the MDS, the resident had no natural teeth and was receiving a mechanically altered diet. Nursing notes dated (MONTH) 14, (YEAR) included that the resident chokes easily and requires constant supervision with eating. Physician orders [REDACTED]. The order also included the following: must be in dining room for meals, assisted dining for cues to sip water/juice to clear oral residue every couple of bites, small bites and thorough chew related to pneumonitis, due to inhalation of other solids and liquids. Review of the nurses notes dated (MONTH) 26, (YEAR) at 11:10 p.m., revealed that the resident's diet was upgraded from a puree diet to a regular mechanical soft diet, with ground meat. The nurses notes also indicated that the resident continues to need supervision with eating, due to a history of choking. Continued review of the resident's care plans revealed they were still not revised to reflect that the resident was at risk for aspiration and choking, and required supervision with eating. Review of the nurses notes and the facility's investigative documentation dated (MONTH) 10, (YEAR), revealed the resident took a donut from the activity room, and then took it with her to the dining room and proceeded to eat the donut. Per the documentation, No staff was in dining room yet as it was not lunch time .This nurse arrived in dining room and found patient with her head upright and leaning back slightly gasping and unable to breath or cough A hospice nurse (who was not employed by the facility) was in the dining room and performed two [MEDICATION NAME] maneuvers and then went to get help. A LPN (licensed practicable nurse/staff #37) came to the dining room and also performed the [MEDICATION NAME] maneuver. The resident became unconscious and emergency procedures continued, including manual ventilation with oxygen, until emergency responders arrived. The resident was then transported to the hospital. Review of the hospital emergency room (ER) physician notes dated (MONTH) 10, (YEAR) revealed PT CHOKED ON A DONUT, [MEDICATION NAME] DIDN'T WORK, EMS ARRIVED AND INTUBATED W/GOOD CAPNOGRAPHY AND PT WENT INTO [MEDICAL CONDITION] ON WAY HERE. The resident had a right side pneumothorax and a chest tube was inserted. The resident was transferred to the intensive care unit. On (MONTH) 30, (YEAR) at 2:06 p.m., an interview was conducted with the Director of Nursing (DON/staff #51). The DON stated the resident was in the activity room, when the donut was given to her by activity staff (staff #7). The DON stated the resident was supposed to be supervised, when having snacks or meals. The DON further stated the activity staff were unaware that the resident had wrapped the donut into a napkin. An interview was conducted on (MONTH) 31, (YEAR) at 8:26 a.m., with the activity assistant (staff #7). Staff #7 stated that the resident was in the activity room for a church activity and at the end of the church service, she passed out donuts. Staff #7 said she asked the resident if she wanted her donut cut up into smaller pieces. She stated the resident told her that she wanted to take the donut to the dining room for lunch. She said the resident then propelled herself out of the activity room to the dining room. Staff #7 stated that later she was taking other residents to the dining room and she saw resident #245 sitting at table next to another resident, and the donut was still wrapped in the napkin. She said that sometimes the resident would wrap food up and take it out of the activity room, but nothing happened. Staff #7 stated that on the day of the incident, she gave the resident a donut and she was aware that the resident wrapped the donut in a napkin and took it to the dining room. She stated that during activities she watched the resident eat. Staff #7 stated that once the residents were in the dining room, the CNA's were responsible for supervising the residents with eating. On (MONTH) 31, (YEAR) at 11:39 a.m., an interview was conducted with the speech language pathologist/clinical fell owship (staff #66). Staff #66 stated that she saw resident #245 for cognition and swallowing problems. Staff #66 stated that the resident needed supervision with eating at all times, as she was a high risk for aspiration. She stated that having food without supervision would be putting the resident at high risk for choking. She said the resident should not have been allowed to take the donut with her. Staff #66 further stated that the resident needed supervision, as she had a tendency of eating at a fast rate, needed to be cued, and needed to be reminded to tuck her chin in, as that helped her swallow better. Staff #66 stated that she upgraded the resident's diet on (MONTH) 26, (YEAR), but the resident still needed to be cued and supervised with eating. On (MONTH) 31, (YEAR) at 12:46 p.m., an interview was conducted with a CNA (staff #6). Staff #6 stated that resident #245 was able to feed herself, but needed to be supervised, as she had a tendency to eat too fast. Staff #6 stated that they did not let her have food in her room, as she was a high choking risk. Staff #6 stated the resident was always monitored while eating in activities, and usually activity staff would make sure she did not take anything out of the activity room. An interview was conducted on (MONTH) 31, (YEAR) at 1:33 p.m. with a LPN (staff #37), who was the resident's nurse on the day of the incident on (MONTH) 10. Staff #37 stated the resident could feed herself, but needed to be supervised and that staff had to stay with her to make sure she took small bites. Staff #37 stated the resident would not finish chewing, and would take another bite. Staff #37 stated that as far as she knew, the activities staff were aware of the diet restrictions for every resident. She stated that she was in the hallway when the incident occurred, and then helped perform the [MEDICATION NAME] maneuver. On (MONTH) 1, (YEAR) at 8:53 a.m., an interview was conducted with the Unit Manager (registered nurse/staff #32). Staff #32 stated the resident was to be supervised while eating. She said the resident was not allowed to bring food out of the activity room, because of her swallowing deficits. Staff #32 stated that this was not uncommon for her to carry things around. She said the care plan should have included this and that the resident needed supervision with eating. Staff #32 stated that the resident's diet restrictions, the level of supervision and that the resident should not carry food on her, were all communicated to activity staff in care conferences and on the unit. An interview was conducted on (MONTH) 1, (YEAR) at 9:15 a.m., with the Nurse Practitioner (NP/staff #64). The NP stated that the resident was to be supervised while eating meals and snacks, secondary to dysphasia. The NP stated that supervision with eating would include eating snacks and any other kind of eating. Staff #64 stated that the resident could not have food anywhere without supervision for her safety, as she did not fully understand the risks. An interview was conducted on (MONTH) 1, (YEAR) at 3:01 p.m., with the hospice RN (staff #67). Staff #67 stated that she was in the dining room talking to another resident, when someone shouted choking. Staff #67 stated that she went over to the table where the resident was parked in her wheelchair and performed the [MEDICATION NAME] maneuver. Staff #67 stated the resident was still alert, but dusky and then went to the office next door to the dining room to tell staff that someone was choking. She said that she then ran back into the dining room and performed the [MEDICATION NAME] maneuver again, and then staff #37 came and helped. She further stated that when the resident choked, there were no staff in the dining room, so she had to go out of the dining room to get help.",2020-09-01
742,HAVEN OF CAMP VERDE,35118,86 WEST SALT MINE ROAD,CAMP VERDE,AZ,86322,2018-02-02,761,E,0,1,KG8511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, and facility policy, the facility failed to ensure that five expired medications and biologicals were not available for use and failed to ensure one medication had an expiration date. Findings include: During a medication storage observation conducted on (MONTH) 2, (YEAR) at 8:50 a.m. of the front hall medication cart, the following expired medications were observed: -One bottle of [MEDICATION NAME] (anti-hypertensive) 2.5 milligram (mg) tablets that expired on (MONTH) 23, (YEAR). -One bottle of Losartan (anti-hypertensive) 50 mg tablets that expired on (MONTH) 21, (YEAR). -One bottle of [MEDICATION NAME] (antacid) 20 mg [MEDICATION NAME] coated capsules with pharmacy labeled direction to discard after (MONTH) 14, (YEAR). -One bottle of [MEDICATION NAME] (anti-flatulent) 80 mg chewable tablets with pharmacy labeled direction to discard after (MONTH) 28, (YEAR). -One bottle of [MEDICATION NAME] (diuretic) 40 mg tablets with pharmacy labeled direction to discard after (MONTH) 13, (YEAR). Also observed was a bubble pack of [MEDICATION NAME] 20 mg (10 capsules) that had no expiration date. The bubble pack was not in the packaging it was delivered in. An interview was conducted with a Licensed Practical Nurse (staff #37) on (MONTH) 2, (YEAR) at 8:57 a.m. Staff #37 stated expired and discontinued medications are to be removed from the medication cart and placed into the return/disposal box in the medication storage room. She also stated there is a possibility available expired medications on the cart could be administered to a resident. During an interview conducted on (MONTH) 2, (YEAR) at 8:59 a.m. with the Director of Nursing (staff # 51), she stated expired medications are to be removed from the medication cart and given to her to return to the pharmacy or for disposal. Staff #51 further stated that the availability of expired medication on the medication cart increases the risk that an expired medication may be administered to a resident. The facility's policy Storage of Medications included the facility shall not use discontinued or outdated drugs or biologicals and that all such drugs shall be returned to the dispensing pharmacy or destroyed. The policy also included that drugs and biologicals shall be stored in the packaging in which they are received.",2020-09-01
743,HAVEN OF CAMP VERDE,35118,86 WEST SALT MINE ROAD,CAMP VERDE,AZ,86322,2019-03-28,580,G,0,1,M1SN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record review, staff interviews, facility documentation and policies and procedures, the facility failed to notify one resident's (#42) physician/practitioner in a timely manner regarding consistent refusals of medications and treatments. The deficient practice resulted in a delay of treatment and subsequent emergency transport to the hospital. Findings include: Resident #42 was admitted to the facility on (MONTH) 24, 2019, with [DIAGNOSES REDACTED]. Review of the admission nursing assessment dated (MONTH) 24, 2019 revealed the resident was admitted from the hospital and oxygen saturations (sats) were 91%. The resident was assessed to be alert, oriented, able to communicate her needs and required two person extensive assistance for all activities of daily living (ADL). The assessment also included the resident had wheezing and was on oxygen at 2 liters per minute. Review of the physician admission orders [REDACTED] -Breo Ellipta (corticosteroid) 100-250 micrograms (mcg) one puff, inhale one time daily for [MEDICAL CONDITION]. -[MEDICATION NAME] solution ([MEDICATION NAME][MEDICATION NAME]) 0.25 mg inhale only via nebulizer three times a day for [MEDICAL CONDITION]. -Oxygen at (0-5) liters per minute to keep sats above 89% and check every shift. -Apixaban (an anticoagulant) 2.5 mg two times daily. -[MEDICATION NAME] (antibiotic) 300 mg every 12 hours for a urinary tract infection. -[MEDICATION NAME] (antidepressant) 75 mg one daily for [MEDICAL CONDITION]. -[MEDICATION NAME] (multivitamin) 2000 units once daily as a supplement. -[MEDICATION NAME] suspension (nasal decongestant) one spray in each nostril once daily for allergies [REDACTED].>-[MEDICATION NAME] Aerosol (corticosteroid) 250/50 mcg one puff inhale orally two times daily for [MEDICAL CONDITION]. -[MEDICATION NAME] (anticonvulsant) 400 mg three times daily. -[MEDICATION NAME] (diuretic) 20 mg once daily for [MEDICAL CONDITION] and hypertension. -[MEDICATION NAME] (respiratory [MEDICATION NAME]) 600 mg every 12 hours for congestion. -Magnesium Chloride 64 mg two times daily as a supplement. A Nurse Practitioner (NP) note dated (MONTH) 25, 2019 revealed a detailed plan to treat the [MEDICAL CONDITION] which included the following: supplemental oxygen as needed to keep oxygen sats more than 90%, chest x-ray as clinically indicated, small volume equalizer ( SVN), monitor breathing and aggressive incentive spirometry. Also included was that the resident would undergo aggressive therapies and all disciplines to evaluate and treat as indicated. Progress would be reviewed weekly with the entire interdisciplinary team and all facets of care would be reviewed on an ongoing basis by the NP and medical director. Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. However, on (MONTH) 27, 28, and 29, the documentation showed that the resident refused the bedtime dose of [MEDICATION NAME]. Review of the resident's care plans dated (MONTH) 29, 2019 revealed a problem related to [MEDICAL CONDITION]. The goal was for the resident to display daily optimal breathing patterns. Interventions included to give the aerosol or [MEDICATION NAME] as ordered and document any side effects and/or effectiveness. Another care plan identified the resident had a mood problem related to a [DIAGNOSES REDACTED]. The goal was that the resident would have an improved and happier mood state. Interventions were to administer medications as ordered and monitor for effectiveness/side effects and behavioral health consults as needed. The care plan did not include any interventions related to the resident's refusal of medications. Review of an internal document provided by facility staff who identified this form as an informal communication system between the nursing staff and the physicians/medical providers. This form included documentation dated (MONTH) 30, 2019 that resident #42 was not eating, drinking or taking medications. Although there were sections for additional information such as new orders, the only documentation for resident #42 was a signature by the prescriber to indicate the communication note had been seen. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 31, 2019 revealed the resident scored a 12 on the brief interview for mental status, which indicated mild cognitive impairment. The MDS included the resident required extensive assistance of two staff with ADLs, was on oxygen therapy and that the resident did not display any behavioral symptoms, such as rejecting or refusing care and services. Review of the (MONTH) 2019 MAR indicated [REDACTED]. A nursing note dated (MONTH) 2, 2019 documented the resident refused all of the medications and that education was given to the resident about the importance of the medication and being compliant. Further documented was the nurse went through every medication with the resident and explained what it was for and the resident still refused. Continued review of the (MONTH) 2019 MAR indicated [REDACTED]. Review of the clinical record revealed no evidence that the resident refused the physician ordered oxygen. Review of the internal document communication form between physicians/providers and nursing staff revealed an entry dated (MONTH) 7, 2019. Although the resident continued to consistently refuse scheduled medications, the entry on the form made no mention of this. There was no documentation to indicate the physician had knowledge of the resident's refusal of multiple medications. Review of the MAR from (MONTH) 8-16, 2019 revealed documentation that the resident refused all doses of prescribed medications. Further review of the clinical record for this time period revealed no documentation that the physician/NP was notified of the resident's ongoing refusal of medications. In addition, there were no corresponding physician/NP notes from (MONTH) 8-16, 2019. A nursing note dated (MONTH) 16, 2019 documented the resident continued to refuse all medications and that education was given. Review of the internal document communication form between physicians/providers and nursing staff revealed an entry dated (MONTH) 17, 2019 regarding resident #42. Although the resident continued to consistently refuse all scheduled medications, the entry on the form made no mention of this. There was no documentation to indicate the physician/NP had knowledge of the resident's continued refusal of multiple medications. Review of the [MEDICAL CONDITION] medication review form dated (MONTH) 18, 2019 revealed the following staff had been in attendance to review the [MEDICATION NAME] (antidepressant) medication: the physician, consulting pharmacist, Director of Nursing and the Assistant Director of Nursing. Further documented was the resident's target behaviors of a sad mood had increased. Although there was discussion of the resident's depression and increased symptoms, there was no documentation regarding the resident's ongoing refusal of the [MEDICATION NAME]. Review of the (MONTH) 2019 MAR indicated [REDACTED]. A nursing note dated (MONTH) 20, 2019 included the resident continued to refuse medications and was given helpful advice regarding her health status. Review of the internal document communication form between physicians/providers and nursing staff revealed an entry dated (MONTH) 23, 2019 regarding resident #42. Although the resident continued to refuse scheduled medications, the entry on the form made no mention of this. Also, there was no documentation to indicate the physician/NP had knowledge of the resident's refusal of multiple medications. A monthly nursing summary dated (MONTH) 23, 2019 documented the resident now had a mental/behavioral status that included delusions related to being in a nursing home. However, there was no further documentation of the resident's delusions and no evidence that the physician/NP were notified. In the respiratory section, there was documentation that the resident used oxygen and lung sounds were diminished. A statement included that the resident refuses to get out of bed, eat or take medications. Continued review of the internal document communication form revealed an entry dated (MONTH) 25, 2019. The documentation included the resident had refused all medications. However, there was no evidence of a signature on the form to indicate the physician/NP had reviewed this entry. Review of the nursing notes through (MONTH) 25, 2019 revealed no evidence that the physician/NP had been notified, despite multiple entries of the resident's consistent refusals of medications. According to the MAR from (MONTH) 20-27, 2019, the resident continued to refuse medications. The MAR indicated [REDACTED]. Further review of the resident's care plans revealed no evidence that the care plans were revised since the initial date of (MONTH) 29, 2019, to reflect the resident's ongoing refusal of medications. In addition, there was no plan or interventions to address the resident's refusal of medications. A nursing note dated (MONTH) 27, 2019 with an entry time of 9:20 p.m., revealed the resident had a change of condition. The note included the resident refused all medications except one medication to help with nausea. After the resident had been administered the medication, she vomited within five minutes. Per the note, the resident had been refusing to wear her oxygen, even though she stated that she was having problems breathing. Staff assisted the resident in placing the nasal cannula back on and made sure the oxygen was set at 2 liters per minute. Staff left the room and when they returned the oxygen was again off of the resident. However, there was no documentation the physician/NP had been notified of the resident's change of condition and ongoing refusal of medications. Nursing notes dated (MONTH) 28, 2019 documented the following: 12:36 a.m: Resident able to sleep. 10:18 a.m: Resident refused ALL medications. 10:10 a.m: Change of condition summary: B/P = 130/92, pulse = 29-36, oxygen saturation 58-92% and oxygen was increased to 5 liters per minute. The family was notified and came to the facility to be with the resident. The resident initially refused to be evaluated at the hospital, however, upon a lot of encouragement from staff and family she agreed to be transported. Vital signs: B/P = 129/82, oxygen saturation at 56% and the resident refused the oxygen mask and oxygen via nasal cannula was in place. An order was obtained for transport to the hospital for acute care evaluation. A discharge assessment dated (MONTH) 2, (YEAR) documented the resident was transferred to the hospital on (MONTH) 28, 2019 via ambulance. The documentation included that vital signs were very poor and oxygen saturation levels were at 50-83%. Measures taken to stabilize resident prior to transfer was to increase the oxygen and elevate the head of bed. An interview was conducted with a Registered Nurse (Acting Director of Nursing/staff #36) on (MONTH) 28, 2019 at 2:15 p.m. Staff #36 stated the nursing staff use the informal communication system form, as a means to communicate and notify the medical provider. Staff stated the physician should have been notified that resident #42 had refused her medications on so many occasions. Staff #36 stated she thought she remembered that she had told the physician of the resident's refusals and was told the resident had the right to refuse. She stated she made an error in not having documentation to support this. She said physician notification for medication refusals would be considered a standard of nursing practice. An interview was conducted with a Licensed Practical Nurse (staff #64) on (MONTH) 28, 2019 at 2:36 p.m. Staff #64 stated if a resident refuses medications the physician has to be notified as some medications are more important than others, like breathing medications and treatments for a resident with [MEDICAL CONDITION]. Staff #64 stated she world notify the physician before the end of her shift and certainly if the resident kept on refusing the medications. An interview was conducted with a RN (staff #14) on (MONTH) 28, 2019 at 3:18 p.m. Staff #14 stated if a resident refused a medication, she would document and certainly notify the physician if the resident refused three or more times. Staff #14 stated physician notification would depend on the medical status of the resident and the severity of the symptoms. According to a facility policy regarding a resident change of condition the following was included: Our facility shall promptly notify the resident, the attending physician, and representative of changes in the resident's medical/mental status. The nurse will notify the resident's physician or physician on call when there is a significant change in the resident's mental and physical condition, and when there is refusal of medications on two or more consecutive times. A significant change of condition is a major decline that 1) Will not normally resolve itself without staff intervention by implementing standard clinical interventions. 2) Impacts more than one area of the resident's health status. 3) Requires interdisciplinary review and/or revision to the care plan. 4) Ultimately is based on judgement of the clinical staff. According to a facility policy regarding medication administration the following was included: Medications are administered in accordance with good nursing guidelines and practices. Medications are administered in accordance with the written orders of the prescriber. If a dose of regularly scheduled medication is refused the space provided on the front of the MAR indicated [REDACTED]. If two or more doses of a vital medication is refused, the physician is notified.",2020-09-01
744,HAVEN OF CAMP VERDE,35118,86 WEST SALT MINE ROAD,CAMP VERDE,AZ,86322,2019-03-28,600,G,1,1,M1SN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews, facility documentation and policy and procedures, the facility failed to ensure one resident (#292) was free from neglect, by staff performing an unsafe transfer causing a fall, which resulted in psychological harm to the resident. The facility also failed to ensure 4 out of 5 sampled residents (#'s 3, 16, 244 and 292) were free from abuse. The deficient practice resulted in one resident being fearful of falling, causing psychological distress and anxious behaviors, which resulted in an overall decline. The deficient practice also resulted in four residents being subjected to abuse. Findings include: -Resident #292 was admitted to the facility on (MONTH) 11, (YEAR), with [DIAGNOSES REDACTED]. The resident was discharged on (MONTH) 27, (YEAR). Regarding an incident of neglect: Review of the baseline care plan-admission evaluation dated (MONTH) 11, (YEAR) under the section for ADL's (activities of daily living), revealed that resident #292 was alert and oriented x 4 and was totally dependent on two staff with transfers. The documentation included the resident had severe impairment with movement to bilateral legs and hips. Review of the ADL care plan dated (MONTH) 13, (YEAR), revealed the resident had an ADL self-care performance deficit, related to deconditioning. One of the interventions included that staff participation was required for transfers. However, the care plan did not specify how many staff were required for transfers or if mechanical lifts should be used. According to the Physical Therapy Evaluation and Plan of Treatment dated (MONTH) 14, (YEAR), the resident was totally dependent with bed mobility and transfers and required maximum assistance. A nurses note dated (MONTH) 16, (YEAR), revealed the resident was a Hoyer lift for transfers and was totally dependent on two+ persons for assistance. Review of a psych progress note dated (MONTH) 22, (YEAR), revealed resident denies any feelings of anxiety and reports that she feels very stable on her current psychiatric medications, which included duloxetine (anti-depressant) and [MEDICATION NAME] (for [MEDICAL CONDITION]). The progress note also stated that staff report no agitation/anxiety symptoms and no aggression or bizarre behaviors since admission. According to a quarterly MDS (Minimum Data Set) assessment dated (MONTH) 25, (YEAR), the resident scored a 13 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Per the MDS, the resident required extensive assistance of two persons with bed mobility, transfers, dressing and toilet use, and was totally dependent on two persons with transfers. The MDS also noted that the resident did not have any behaviors. A physical therapy note dated (MONTH) 4, (YEAR), revealed the resident started therapy and had needed 100% assistance, but now has improved to 20 % assistance. The note included that for bed mobility and sit to stand, the resident was a moderate assist of two persons with a front wheel walker. A nurses note dated (MONTH) 5, (YEAR) included the resident required extensive assistance of two staff members for transfers, secondary to generalized weakness and size, and utilizes a mechanical lift as needed. Review of the nurse's notes from (MONTH) 11, (YEAR) to (MONTH) 6, (YEAR), revealed no documentation that the resident experienced any fearfulness, any anxiety type behaviors or ADL decline. Review of clinical record revealed that resident #292 did not have any falls, since admission. A nurses note dated (MONTH) 6, (YEAR) revealed that a CNA (certified nursing assistant/staff #18) transferred the resident alone by herself from the bed to the wheelchair, with the help of a walker. While attempting to sit into the wheelchair, the resident slid to the floor on her knees. The note included that two staff members (CNA #18 and nurse #56) with the help of a sit/stand Hoyer lift assisted the resident from the floor to the wheelchair. The resident had no injuries except for a right hip old superficial blister, which had popped and a dressing was applied. A IDT review note dated (MONTH) 7, (YEAR), revealed a non-injury fall related to weakness during transfer and resident placed on alert charting. Review of the nurses progress notes from (MONTH) 7, (YEAR) through Discharge (September 27, (YEAR)) revealed the following: September 7: Resident did not want to get out of bed this shift and also refused therapy this a.m. September 8: Resident hitting CNA's during brief changes, refusing to help transfer self, demonstrates anxious behaviors when receiving ADL assistance and yelling from the room. September 9: Resident did not get out of bed this shift or the evening shift. September 10: Resident demonstrates anxious behaviors when receiving ADL assistance. Resident non-compliant with transfers and repositioning. Refusing care such as toileting, repositioning, getting out of bed and physical and occupational therapy. September 11 and 12: Resident demonstrates anxious behaviors when receiving ADL assistance; refusing care such as toileting, repositioning and getting out of bed. September 15: An incident note by the nurse included that around 9 p.m., the resident became afraid and scared that she was going to fall during a brief change. The resident remained upset and asked the nurse to call the doctor for something to calm the nerves. The nurse obtained an order for [REDACTED]. September 17: Resident demonstrates anxious behaviors when receiving ADL assistance, non-compliant with transfer and repositioning. Patient refusing care such as toileting, repositioning, getting out of bed and refusing physical and occupational therapy. September 18: Resident still refusing to get out of bed and non-compliant with most ADL's. Refusing PT/OT. Nurse Practitioner (NP) notified regarding resident's statements of anxiousness and fearful thoughts of falling out of bed. September 19: Resident requesting PRN [MEDICATION NAME] due to anxiousness, agitation and fear of falling out of bed. Demonstrates anxious behaviors when receiving ADL assistance and non-compliant with transfers and repositioning. Refusing care such as toileting, repositioning and getting out of bed. [MEDICATION NAME] given as needed. September 20: Resident refused to get out of bed this shift, refused to take a shower and multiple attempts made to encourage out of bed activities. The majority of all meals were served in her room per resident's request. September 21: Resident demonstrates anxious behaviors when receiving ADL assistance, non-compliant with transfers and repositioning. Refusing care such as toileting, repositioning and getting out of bed, [MEDICATION NAME] as needed. September 22: Demonstrates anxious behaviors when receiving ADL assistance, non-compliant with transfers and repositioning. Refusing care such as toileting, repositioning, getting out of bed and PT/OT. [MEDICATION NAME] given as needed. September 24: Resident is alert and oriented, remained in bed all day per her request. Non-compliant with ADL's and PT/OT. September 25: Resident refusing brief changes with CNA's. Went in and spoke with resident and offered [MEDICATION NAME], which previously had been effective with fear of falling during brief changes. The resident continued to refuse. The night shift note stated the resident also feels like she is going to fall when rolled from back to side. Non-compliant with most ADL's, PT and OT. (MONTH) 26: Resident alert and oriented x 2 confused and anxious. Resident feels like she is going to fall when rolled from back to side. Non-compliant with most ADL's, PT and OT. Review of the therapy treatment notes from (MONTH) 6, (YEAR) to Discharge (September 27, (YEAR)) revealed the following: September 6, 7 and 10: Resident refused multiple attempts to participate in therapy in the therapy room or in the room. September 11: Resident is a Hoyer, tolerated sitting in wheelchair for lunch. Refused to go to the gym. Resident making very minimal progress at this time. Resident requires motivation and encouragement to participate. Resident fearful of falling, resistive with staff with rolling and changing brief. Resident was reassured she is safe and was not going to fall. September 12: Resident refused therapy services, refused to get out of bed. September 17: Making very minimal progress at this time due to lack of participation and missed visits. Resident requesting pain medications and [MEDICATION NAME]. She stated that she would like to follow up with her psychiatrist, as she is fearful of falling when being changed and is afraid that she will fall out of bed. Resisting care with CNA's. September 18: Straight leg raising was attempted during therapy but unable to complete. September 19, 20, 21 and 22: Resident making minimal progress, unmotivated and has fear of falling. Refused multiple attempts to participate in therapy and getting out of bed. September 24: Therapy discharge summary included resident has steadily declined. Refuses to get out of bed due to lack of motivation, effort. Resident is being discharged at this time from therapy. Review of the resident's care plans dated (MONTH) 17, (YEAR), revealed the resident uses anti-anxiety medication ([MEDICATION NAME]) related to an anxiety disorder. A goal included the resident will have decreased episodes of signs and symptoms of anxiety. Interventions included to give anti-anxiety medications as ordered, monitor side effects and track target behaviors of statements of anxiousness. A psych eval progress note dated (MONTH) 19, (YEAR) revealed staff reports that last week resident had a fall and it appears to have resulted in worsening depression and anxiety. The resident has anxiety symptoms of excessive worry/anxiety and being fearful. The recommendation was to continue [MEDICATION NAME] 0.5 mg every 12 hrs as needed for anxiety, as evidence by agitation and fearfulness. Further review of the clinical record revealed the resident was discharged on (MONTH) 27, (YEAR). The facility was unable to provide any evidence that the incident regarding a fall due to an unsafe transfer, which resulted in the resident experiencing psychological distress and overall decline was identified as neglect. In addition, there was no evidence that the incident was thoroughly investigated. An interview with a CNA (staff #18) was conducted on (MONTH) 26, 2019 at 11:47 a.m. She stated when the resident fell , she was transferring the resident with the help of a gait belt and walker. She said the resident slid out of the wheelchair and sat straight down on her knees. Staff #18 stated that she was told by therapy the day before that the resident was going to be an extensive assist of one person for transfers, instead of two. An interview was conducted on (MONTH) 26, 2019 at 12:05 p.m. with a licensed practical nurse (LPN/staff #56), who worked the day shift on (MONTH) 6, (YEAR) when the resident fell . She stated that she was going into the resident's room to give her medications and when she entered the room, the resident was on her knees on the floor in front of the wheelchair. She said the CNA was in the room and had tried to transfer the resident. Staff #56 stated that she asks therapy every day for any changes with the resident's ability and type of assistance needed with transfers, and then documents it in a progress note. She stated if she documented the resident needs two person extensive assistance, it means that she clarified this with therapy, prior to documenting it. An interview with a physical therapy assistant (PTA/staff #58) was conducted on (MONTH) 26, 2019 at 12:58 p.m. At this time, the therapy notes were reviewed with staff #58, who stated the resident was a two person transfer at the time of the fall. She said that since the resident was transferred from the bed to a standing position, it would require two persons. She stated the resident was making good progress, until the fall on (MONTH) 6, (YEAR). An interview with a registered nurse (RN/staff #83) was conducted on (MONTH) 26, 2019 at 4:10 p.m. Staff #83 stated that she usually works the night shift and that the resident was a two person Hoyer lift for transfers at all times. An interview with the Assistant Director of Nursing (ADON/staff #36) and the Executive Director(ED/staff #10) was conducted on (MONTH) 28, 2019 at 8:52 a.m. Staff #36 stated that staff should care plan the number of staff assistance which is needed for transfers in the care plan within 24 hours of admit, because the care plan also transfers to the kardex where the CNA's look to find out how much help a resident needs with transfers. She stated that it would be neglect if staff were not following the care plan or therapy orders for transfers. Staff #36 said she would expect the CNA's to follow what therapy recommends for transfers. She stated if therapy makes any changes in the transfer status, she expects them to document it in their notes. At this time, the fall documentation was reviewed with staff #36. She stated that during an IDT meeting (which included the Director of Nusing (DON), ADON, the Care Coordinator and therapy), it was not identified that the fall was an unsafe transfer. Staff #36 said that since they did not identify the incident as neglect, they did not report or investigate the incident. Staff #10 stated that he remembers the resident and that after the fall, the resident was scared to leave the room or get out of bed. According to the Lifting Machine policy, the use of a mechanical lift for resident transfers will be conducted with the assistance of at least two nursing assistants to safely move a resident. Types of mechanical lifts include sit to stand lifts. Regarding an allegation of abuse for resident #292: Review of a facility's investigation report revealed that on (MONTH) 27, (YEAR) on the night shift between 3-6 a.m., a CNA (staff #85) witnessed another CNA (staff #86) telling resident #292 to shut up and threaten to drop the resident if she did not stop swinging her arms around, while changing the resident's brief. Staff #85 reported the resident was reaching her arms out, because she was afraid of falling and wanted help. Staff #85 reported that staff #86 told the resident that if she hits her, I will drop you. The investigation included a written interview with staff #86 who said that on (MONTH) 27, (YEAR), she yelled at resident #292 because the resident was afraid of falling and she needed to calm down. Staff #86 stated that she told the resident that she might drop her if she did not calm down or if she hit her. The investigation report also included an interview with resident #292's roommate who stated that on (MONTH) 27, (YEAR), she heard resident #292 yelling because she was scared that she was going to fall out of bed. The roommate stated that she heard one of the staff tell the resident to shut-up or be quiet. The roommate stated that she was upset and did not like what was happening. -Resident #16 was admitted to the facility on (MONTH) 6, (YEAR), with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment dated (MONTH) 14, (YEAR), revealed a BIMS (Brief Interview for Mental Status) score of 14, which indicated the resident had intact cognition. Review of the facility's investigation report revealed that on (MONTH) 27, (YEAR) during the night shift between 3:00 a.m. and 6:00 a.m., a CNA (staff #85) witnessed another CNA (staff #86) swearing and handling resident #16 rough, when changing the resident's brief. The report included that staff #85 had asked staff #86 to help her change the resident's brief. Staff #85 reported that while changing the resident's brief, staff #86 said that she did not know why the resident waits so long to pee, while grabbing and yanking the resident towards her. Per the report, staff #86 also hurriedly turned the resident on her side, so she could change the resident's sheets. Staff #85 reported that she thought staff #86 intended to be mean and that staff #86 had been frustrated all night. The resident reported that she was awakened by staff and that staff #86 was saying damn it or God damn it because her bed was wet. The resident said that staff #86 shoved her hard to the side while changing her sheets and that she knew staff #86 was mad, because her bed sheets were wet. The investigation also included a written interview with staff #86 who stated that she was swearing while in the resident's room, because she was frustrated. Staff #86 reported that she said crap and may have said sh Staff #86 said that she could see how the resident may have thought that she was swearing at her and that she did not mean to shove and push the resident onto her side and back at medium speed, while changing the resident's sheets. An interview was conducted with resident #16 on (MONTH) 27, 2019 at 2:29 p.m., who stated that staff #86 came into her room on (MONTH) 27, (YEAR) and shoved her so hard that she hit the bedrail. The resident stated that she was not hurt, but she was humiliated. She said staff #86 was angry and swearing because her bed was wet. She also stated that another CNA (staff #85) was present, but did not say anything. An interview was conducted on (MONTH) 28, 2019 at 8:52 a.m., with the Assistant Director of Nursing (ADON/staff #36) and the Executive Director (ED/staff #10). The ADON said that their policy includes that abuse can be physical, mental, verbal or emotional. -Resident #244 was admitted on (MONTH) 24, (YEAR) and readmitted on (MONTH) 31, (YEAR), with [DIAGNOSES REDACTED]. The resident was discharged on (MONTH) 4, (YEAR). The admission MDS assessment dated (MONTH) 31, (YEAR) revealed a BIMS score of 3, which indicated the resident had severe impaired cognition. According to the resident's care plans, the resident did not exhibit any physical or verbal aggression towards others. Review of the facility's investigation report revealed that on (MONTH) 27, (YEAR) on the night shift between 3 a.m. - 6 a.m., staff #85 asked staff #86 to help her change resident #244's brief. Staff #85 was having difficulty because resident #244 pulled her pants up and said that she was cold. Staff #86 told staff #85 that she was going to show her a trick. Staff #86 then proceeded to pull the resident's pants down, tore open the brief, forced the resident to roll over, and pried the resident's legs apart. Staff #85 stated that she felt that staff #86 forced the resident to roll over. Staff #85 reported that staff #86 told the resident to open her legs and then told staff #85, I kind of forced her to open her legs. The resident then said that she wanted to be left alone. Staff #85 said she believed that staff #86 was trying to be mean, had been frustrated all night and forced resident #244 to open her legs. The investigation also included an interview with resident #244, but she was unable to remember anything that occurred on (MONTH) 27. -Resident #3 was readmitted to the facility on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment dated (MONTH) 18, (YEAR), revealed a BIMS score of 6, which indicated the resident had severe cognitive impairment. Review of the facility's investigation report revealed that on (MONTH) 27, (YEAR) on the night shift between 3:00 a.m. and 6:00 a.m., staff #85 reported that she and staff #86 woke resident #3 up to change his brief. Staff #85 said the resident was having trouble standing up, so staff #86 told the resident Fine, you don't get changed tonight and left the room. The investigation report included a written interview with staff #86, who reported that she yelled at the resident to get him to stand up. She stated that she was frustrated, because the resident was not helping her change his brief. The report included that staff #86 stated that she cannot control the volume or tone of her voice. Further review of the investigative findings regarding the allegations of abuse for resident #3, #16, #244 and #292, revealed they all occurred on the night shift on (MONTH) 27, (YEAR) sometime between 3 a.m. - 6 a.m. and involved staff #86. The documentation also included the following: Staff #86 was physically more forceful than needed when providing care, raised her voice and used profanity. Staff #86 was perceived by staff and residents as being angry and frustrated. Staff #86 was involuntary terminated. An interview was conducted on (MONTH) 28, 2019 at 8:52 a.m. with the Assistant Director of Nursing (ADON/staff #36) and the Executive Director (ED/staff #10). Staff #36 said that their policy includes that abuse can be physical, mental, verbal or emotional. She said that during new hire orientation, staff receive abuse training and that their first priority is to protect the residents. Staff #10 stated that the incidents of suspected abuse (for resident #3, #16, #244 and #292) occurred on the night shift on (MONTH) 27, (YEAR) between 3 a.m. - 6 a.m. He said abuse training is provided throughout the year and they have had several trainings on abuse in the past 6 months. Review of the Resident Rights policy revised (MONTH) (YEAR), revealed that employees shall treat all residents with kindness, respect and dignity. Residents have the right to be free from abuse and neglect. Review of the facility's Abuse policy dated (MONTH) (YEAR) revealed the facility strives to prevent the abuse of all residents. The objective is to provide a safe haven for residents through preventative measures which protect residents right to be free from abuse and neglect. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual of goods or services that are necessary to maintain physical, mental and psychosocial well-being. Instances of abuse cause physical harm, pain or mental anguish. Abuse includes verbal abuse, sexual abuse, physical abuse, mental abuse and neglect. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. If abuse/neglect is witnessed or suspected, the resident's safety will immediately be secured. Prompt reporting and investigation will be utilized to identify the validity of findings and reasonable measures will be implemented to deter further incidents of abuse/neglect.",2020-09-01
745,HAVEN OF CAMP VERDE,35118,86 WEST SALT MINE ROAD,CAMP VERDE,AZ,86322,2019-03-28,602,D,1,1,M1SN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews, facility documentation and policy review, the facility failed to ensure two sampled residents (#'s 33 and 16) were free from misappropriation of property. The deficient practice could result in other residents' narcotics being misappropriated. Findings include: -Resident #33 was admitted to the facility on (MONTH) 17, (YEAR) with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. Review of the controlled substance record for (MONTH) (YEAR) revealed 20 tablets of [MEDICATION NAME] 5 mg was delivered to the facility. The record also included that on (MONTH) 13, (YEAR), 16 tablets had been administered and 4 tablets were left. -Resident #16 was admitted to the facility on (MONTH) 6, (YEAR) with a [DIAGNOSES REDACTED]. The physician orders [REDACTED]. The MAR for (MONTH) (YEAR) included the above orders and the documentation showed the resident received [MEDICATION NAME] on multiple days. Review of the controlled substance record dated (MONTH) (YEAR) revealed the facility had received 30 tablets of [MEDICATION NAME] 2.5 mg from the pharmacy. The record also revealed that on (MONTH) 13, (YEAR), 17 tablets had been administered and 13 tablets were left. Review of the facility's investigation report with a reference date of (MONTH) 14, (YEAR), revealed a staff member discovered that one [MEDICATION NAME] blister packet for resident #33 was missing and one blister packet for resident #16 was missing. The report included that between the two residents, there were a total of 17 [MEDICATION NAME] tablets which were missing. The report also included a Registered Nurse (RN/staff #84) was identified as a suspect and eventually confessed to taking the 17 [MEDICATION NAME] tablets. The investigation report included a written statement from staff #20 dated (MONTH) 14, (YEAR). The RN had found the [MEDICATION NAME] controlled substance records for residents #33 and #16 hidden under the narcotic book which was on top of the medication cart. The [MEDICATION NAME] 5 mg controlled substance record for resident #33 revealed there should be 13 tablets left in the blister packet. The [MEDICATION NAME] 2.5 mg controlled substance record for resident #16 revealed there should be 4 tablets left in the blister packet. The statement further included that the [MEDICATION NAME] blister packets for residents #33 and #16 were not in the medication cart. Review of the personnel record for staff #84 revealed staff #84 was terminated on (MONTH) 17, (YEAR). The file also contained evidence that staff #85 had been provided training and education on abuse and misappropriation of personal property. Attempts to contact staff #84 via telephone were unsuccessful. An interview was conducted with staff #20 on (MONTH) 26, 2019 at 10:21 a.m. Staff #20 stated that he found the controlled substance records for residents #33 and #16 hidden in a binder on top of the medication cart. Staff #20 also stated that he was not able to find the [MEDICATION NAME] blister packets for the residents in the medication cart. He stated that he notified the Director of Nursing (DON/staff #31) and an investigation was initiated. During an interview conducted with staff #31 on (MONTH) 26, 2019 at 10:50 a.m., the DON stated that the missing narcotics were considered misappropriation of personal property. Staff #31 stated that staff #84 stole resident #33 and resident #16 [MEDICATION NAME]. The facility's policy regarding Abuse revealed the facility strives to prevent abuse of all residents. Per the policy, abuse includes misappropriation of personal property. The objective is to provide a safe haven for the residents through preventative measures that protect every resident's right to be free from abuse.",2020-09-01
746,HAVEN OF CAMP VERDE,35118,86 WEST SALT MINE ROAD,CAMP VERDE,AZ,86322,2019-03-28,607,E,1,1,M1SN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews, facility documentation and policy and procedures, the facility failed to implement their abuse policy, by failing to immediately report allegations of abuse to the administrator/designee, by failing to report the allegations of abuse to the State Agency within two hours, and by failing to protect residents from the potential for further abuse for 4 of 5 sampled residents (#3, #16, #244 and #292). The facility also failed to identify an incident of neglect for one resident (#292), failed to report the incident of neglect to the State Agency, failed to conduct a thorough investigation and failed to protect residents from the potential for further neglect. Findings include: -Resident #292 was admitted to the facility on (MONTH) 11, (YEAR), with [DIAGNOSES REDACTED]. The resident was discharged on (MONTH) 27, (YEAR). Regarding an incident of neglect: Review of the baseline care plan-admission evaluation dated (MONTH) 11, (YEAR) under the section for ADL's (activities of daily living), revealed that resident #292 was alert and oriented x 4 and was totally dependent on two staff with transfers. The documentation included the resident had severe impairment with movement to bilateral legs and hips. Review of the ADL care plan dated (MONTH) 13, (YEAR), revealed the resident had an ADL self-care performance deficit, related to deconditioning. One of the interventions included that staff participation was required for transfers. However, the care plan did not specify how many staff were required for transfers or if mechanical lifts should be used. According to the Physical Therapy Evaluation and Plan of Treatment dated (MONTH) 14, (YEAR), the resident was totally dependent with bed mobility and transfers, and required maximum assistance. A nurses note dated (MONTH) 16, (YEAR), revealed the resident was a Hoyer lift for transfers and was totally dependent on two+ persons for assistance. According to a quarterly MDS (Minimum Data Set) assessment dated (MONTH) 25, (YEAR), the resident scored a 13 on the BIMS, indicating intact cognition. Per the MDS, the resident required extensive assistance of two persons with bed mobility, transfers, dressing and toilet use, and was totally dependent on two persons with transfers. A physical therapy note dated (MONTH) 4, (YEAR), revealed the resident started therapy and had needed 100% assistance, but now has improved to 20 % assistance. The note included that for bed mobility and sit to stand, the resident was a moderate assist of two persons with a front wheel walker. A nurses note dated (MONTH) 5, (YEAR) included the resident required extensive assistance of two staff members for transfers, secondary to generalized weakness and size, and utilizes a mechanical lift as needed. Review of clinical record revealed that resident #292 did not have any falls, since admission. A nurses note dated (MONTH) 6, (YEAR) revealed that a CNA (certified nursing assistant/staff #18) transferred the resident alone by herself from the bed to the wheelchair, with the help of a walker. While attempting to sit into the wheelchair, the resident slid to the floor on her knees. The note included that two staff members (CNA #18 and nurse #56) with the help of a sit/stand Hoyer lift assisted the resident from the floor to the wheelchair. The resident had no injuries except for a right hip old superficial blister, which had popped and a dressing was applied. Review of the IDT review note dated (MONTH) 7, (YEAR), revealed a non-injury fall related to weakness during transfer and resident placed on alert charting. The facility was unable to provide any evidence that the incident regarding the fall was identified as neglect, that the incident was investigated or reported to the State Agency within two hours. There was also no evidence that staff #18 was removed from providing direct care to residents, pending an investigation. An interview was conducted on (MONTH) 26, 2019 at 12:05 p.m. with a licensed practical nurse (LPN/staff #56), who worked the day shift on (MONTH) 6, (YEAR) when the resident fell . She stated that she was going into the resident's room to give her medications and when she entered the room, the resident was on her knees on the floor in front of the wheelchair. She said the CNA was in the room and had tried to transfer the resident. Staff #56 stated that she asks therapy every day for any changes with the resident's ability and type of assistance needed with transfers, and then documents it in a progress note. She stated if she documented the resident needs two person extensive assistance, it means that she clarified this with therapy, prior to documenting it. An interview with a physical therapy assistant (PTA/staff #58) was conducted on (MONTH) 26, 2019 at 12:58 p.m. At this time, the therapy notes were reviewed with staff #58, who stated the resident was a two person transfer at the time of the fall. She said that since the resident was transferred from the bed to a standing position, it would require two persons. During an interview with a RN (staff #83) conducted on (MONTH) 26, 2019 at 4:10 p.m., the RN said that she usually works the night shift and that the resident was a two person Hoyer lift for transfers at all times. An interview was conducted with the Assistant Director of Nursing (ADON/staff #36) and the Executive Director (ED/staff #10) on (MONTH) 28, 2019 at 8:52 a.m. Staff #36 stated that staff should care plan the number of staff assistance which is needed for transfers in the care plan within 24 hours of admit, because the care plan also transfers to the kardex where the CNA's look to find out how much help a resident needs with transfers. She stated that it would be neglect if staff were not following the care plan or therapy orders for transfers. Staff #36 said she would expect the CNA's to follow what therapy recommends for transfers. She stated if therapy makes any changes in the transfer status, she expects them to document it in their notes. At this time, the fall documentation was reviewed with staff #36. She stated that during an IDT meeting (which included the Director of Nusing (DON), ADON, the Care Coordinator and therapy), it was not identified that the fall was an unsafe transfer. Staff #36 said that since they did not identify the incident as neglect, they did not report the incident to the State Agency or investigate the incident. Regarding an allegation of abuse for resident #292: Review of a facility's investigation report revealed that on (MONTH) 27, (YEAR) on the night shift between 3-6 a.m., a CNA (staff #85) witnessed another CNA (staff #86) telling resident #292 to shut up and threaten to drop the resident if she did not stop swinging her arms around, while changing the resident's brief. Staff #85 reported the resident was reaching her arms out, because she was afraid of falling and wanted help. Staff #85 reported that staff #86 told the resident that if she hits her, I will drop you. The investigation included a written interview with staff #86, who said that on (MONTH) 27, (YEAR), she yelled at resident #292 because the resident was afraid of falling and she needed to calm down. Staff #86 stated that she told the resident that she might drop her if she did not calm down or if she hit her. The investigation report also included an interview with resident #292's roommate, who stated that on (MONTH) 27, (YEAR) she heard resident #292 yelling, because she was scared that she was going to fall out of bed. The roommate stated that she heard one of the staff tell the resident to shut-up or be quiet. The roommate stated that she was upset and did not like what was happening. Further review of the investigation report revealed that the allegation of abuse was not reported immediately to the administrator/designee, and that the State Agency was not notified of the allegation of abuse until (MONTH) 27, (YEAR) at 8:54 a.m. In addition, there was no documentation that staff #85 was immediately removed from providing care to residents, pending the investigation. -Resident #16 was admitted to the facility on (MONTH) 6, (YEAR), with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment dated (MONTH) 14, (YEAR), revealed a BIMS score of 14, which indicated the resident had intact cognition. Review of the facility's investigation report revealed that on (MONTH) 27, (YEAR) during the night shift between 3:00 a.m. and 6:00 a.m., a CNA (staff #85) witnessed another CNA (staff #86) swearing and handling resident #16 rough, when changing the resident's brief. The report included that staff #85 had asked staff #86 to help her change the resident's brief. Staff #85 reported that while changing the resident's brief, staff #86 said that she did not know why the resident waits so long to pee, while grabbing and yanking the resident towards her. Per the report, staff #86 also hurriedly turned the resident on her side, so she could change the resident's sheets. Staff #85 reported that she thought staff #86 intended to be mean and that staff #86 had been frustrated all night. The resident reported that she was awakened by staff and that staff #86 was saying damn it or God damn it because her bed was wet. The resident said that staff #86 shoved her hard to the side while changing her sheets and that she knew staff #86 was mad, because her bed sheets were wet. The investigation also included a written interview with staff #86 who stated that she was swearing while in the resident's room, because she was frustrated. Staff #86 reported that she said crap and may have said sh Staff #86 said that she could see how the resident may have thought that she was swearing at her and that she did not mean to shove and push the resident onto her side and back at medium speed, while changing the resident's sheets. Further review of the investigation report revealed there was no evidence that the Administrator/designee was immediately notified at the time of the incident or that staff #85 was immediately removed from providing care to residents, pending the investigation. Further review revealed that the State Agency was not notified of the allegation of abuse until (MONTH) 27, (YEAR) at 8:54 a.m., which was over the two hour timeframe for reporting. An interview was conducted with resident #16 on (MONTH) 27, 2019 at 2:29 p.m., who stated that staff #86 came into her room on (MONTH) 27, (YEAR) and shoved her so hard that she hit the bedrail. The resident stated that she was not hurt, but she was humiliated. She said staff #86 was angry and swearing because her bed was wet. She also stated that another CNA (staff #85) was present, but did not say anything. -Resident #244 was admitted on (MONTH) 24, (YEAR) and readmitted on (MONTH) 31, (YEAR) with [DIAGNOSES REDACTED]. The resident was discharged on (MONTH) 4, (YEAR). The admission MDS assessment dated (MONTH) 31, (YEAR) revealed a BIMS score of 3, which indicated the resident had severe impaired cognition. Review of the facility's investigation report revealed that on (MONTH) 27, (YEAR) on the night shift between 3 a.m. - 6 a.m., staff #85 asked staff #86 to help her change resident #244's brief. Staff #85 was having difficulty because resident #244 pulled her pants up and said that she was cold. Staff #86 told staff #85 that she was going to show her a trick. Staff #86 then proceeded to pull the resident's pants down, tore open the brief, forced the resident to roll over, and pried the resident's legs apart. Staff #85 stated that she felt that staff #86 forced the resident to roll over. Staff #85 reported that staff #86 told the resident to open her legs and then told staff #85, I kind of forced her to open her legs. The resident then said that she wanted to be left alone. Staff #85 said she believed that staff #86 was trying to be mean, had been frustrated all night and forced resident #244 to open her legs. Further review of the investigation report revealed there was no evidence that the Administrator/designee was immediately notified at the time of the incident or that staff #85 was immediately removed from providing care to residents, pending the investigation. Further review revealed that the State Agency was not notified of the allegation of abuse until (MONTH) 27, (YEAR) at 8:54 a.m., which was over the two hour timeframe for reporting. -Resident #3 was readmitted to the facility on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment dated (MONTH) 18, (YEAR), revealed a BIMS score of 6, which indicated the resident had severe cognitive impairment. Review of the facility's investigation report revealed that on (MONTH) 27, (YEAR) on the night shift between 3:00 a.m. and 6:00 a.m., staff #85 reported that she and staff #86 woke resident #3 up to change his brief. Staff #85 said the resident was having trouble standing up, so staff #86 told the resident Fine, you don't get changed tonight and left the room. The investigation report included a written interview with staff #86, who reported that she yelled at the resident to get him to stand up. She stated that she was frustrated, because the resident was not helping her change his brief. The report included that staff #86 stated that she cannot control the volume or tone of her voice. Further review of the investigative findings regarding the allegations of abuse for resident #3, #16, #244 and #292, revealed they all occurred on the night shift on (MONTH) 27, (YEAR) sometime between 3 a.m. - 6 a.m. and involved staff #86. The documentation also included the following: Staff #86 was physically more forceful than needed when providing care, raised her voice and used profanity. Staff #86 was perceived by staff and residents as being angry and frustrated. Staff #86 was involuntary terminated. Continued review of the investigation report revealed there was no evidence that the Administrator/designee was immediately notified at the time of the incident or that staff #85 was immediately removed from providing care to residents, pending the investigation. Further review revealed that the State Agency was not notified of the allegation of abuse until (MONTH) 27, (YEAR) at 8:54 a.m., which was over the two hour timeframe for reporting. An interview was conducted on (MONTH) 28, 2019 at 8:52 a.m. with the Assistant Director of Nursing (ADON/staff #36) and the Executive Director (ED/staff #10). Staff #36 said that their policy includes that abuse can be physical, mental, verbal or emotional. She said that during new hire orientation, staff receive abuse training and that their first priority is to protect the residents. Staff #10 stated that the incidents of suspected abuse (for resident #3, #16, #244 and #292) occurred on the night shift on (MONTH) 27, (YEAR) between 3 a.m. - 6 a.m., and the alleged perpetrator (staff #86) worked until the end of her shift, which ended at 6:00 a.m. He stated that staff #85 reported the allegations of abuse to the day shift CNA's and that he was notified of the allegations around 8:00 a.m. on (MONTH) 27. He said that staff #85 was formally disciplined and re-educated for not reporting the suspected abuse immediately. He said the regulation requires the facility to call and report abuse within two hours from the point of notification and defined notification as the time the suspected abuse happened. He said abuse training is provided throughout the year and they have had several trainings on abuse in the past 6 months. Staff #36 stated that all staff have been told to call the ED, the DON or ADON right away if they can't find the charge nurse to report the abuse. Staff #36 said they have told staff to call until they get a hold of somebody. She said that staff who witness an allegation of abuse is expected to ask the alleged perpetrator to leave the building. Review of the facility's abuse policy dated (YEAR), revealed that the facility strives to prevent the abuse of all residents. The objective is to provide a safe haven for residents through preventative measures which protect residents right to be free from abuse and neglect. If abuse/neglect is witnessed or suspected, the resident's safety will immediately be secured. If staff is suspected of being the abuser, they will be suspended until the investigation is complete. The policy also included that if abuse is witnessed or suspected, the Executive Director will be notified, and the ED and the witness who is reporting will notify the State Survey Agency in accordance with timeframes and standards required by the State Agency. Prompt reporting and investigation will be utilized to identify the validity of findings and reasonable measures will be implemented to deter further incidents of abuse. The policy also included the ED will begin an investigation immediately and will complete the investigation within 5 days using the abuse investigation packet. A minimum of 3 residents will be interviewed in order to determine if there is a trend. Staff members will document their own statements and sign and date them. The policy included that all abuse investigation information will be documented and kept in an abuse investigation binder.",2020-09-01
747,HAVEN OF CAMP VERDE,35118,86 WEST SALT MINE ROAD,CAMP VERDE,AZ,86322,2019-03-28,609,E,1,1,M1SN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews, facility documentation and policy and procedures, the facility failed to immediately report allegations of abuse to the administrator/designee and failed to report the allegations of abuse to the State Agency within two hours for 4 of 5 sampled residents (#3, #16, #244 and #292). The facility also failed to report an incident of neglect within 2 hours to the State Agency involving one resident (#292). A delay in reporting resulted in residents being subjected to further abuse and a delay in initiating the investigative process. Findings include: -Resident #292 was admitted to the facility on (MONTH) 11, (YEAR), with [DIAGNOSES REDACTED]. The resident was discharged on (MONTH) 27, (YEAR). Regarding an incident of neglect: Review of the baseline care plan-admission evaluation dated (MONTH) 11, (YEAR) under the section for ADL's (activities of daily living), revealed that resident #292 was alert and oriented x 4 and was totally dependent on two staff with transfers. The documentation included the resident had severe impairment with movement to bilateral legs and hips. Review of the ADL care plan dated (MONTH) 13, (YEAR), revealed the resident had an ADL self-care performance deficit, related to deconditioning. One of the interventions included that staff participation was required for transfers. However, the care plan did not specify how many staff were required for transfers or if mechanical lifts should be used. According to the Physical Therapy Evaluation and Plan of Treatment dated (MONTH) 14, (YEAR), the resident was totally dependent with bed mobility and transfers, and required maximum assistance. A nurses note dated (MONTH) 16, (YEAR), revealed the resident was a Hoyer lift for transfers and was totally dependent on two+ persons for assistance. According to a quarterly MDS (Minimum Data Set) assessment dated (MONTH) 25, (YEAR), the resident scored a 13 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Per the MDS, the resident required extensive assistance of two persons with bed mobility, transfers, dressing and toilet use, and was totally dependent on two persons with transfers. A physical therapy note dated (MONTH) 4, (YEAR), revealed the resident started therapy and had needed 100% assistance, but now has improved to 20 % assistance. The note included that for bed mobility and sit to stand, the resident was a moderate assist of two persons with a front wheel walker. A nurses note dated (MONTH) 5, (YEAR) included the resident required extensive assistance of two staff members for transfers, secondary to generalized weakness and size, and utilizes a mechanical lift as needed. Review of clinical record revealed that resident #292 did not have any falls, since admission. A nurses note dated (MONTH) 6, (YEAR) revealed that a CNA (certified nursing assistant/staff #18) transferred the resident alone by herself from the bed to the wheelchair, with the help of a walker. While attempting to sit into the wheelchair, the resident slid to the floor on her knees. The note included that two staff members (CNA #18 and nurse #56) with the help of a sit/stand Hoyer lift assisted the resident from the floor to the wheelchair. The resident had no injuries except for a right hip old superficial blister, which had popped and a dressing was applied. Review of the IDT review note dated (MONTH) 7, (YEAR), revealed a non-injury fall related to weakness during transfer and resident placed on alert charting. Review of the State Agency data base revealed the allegation of neglect was not reported. An interview was conducted on (MONTH) 26, 2019 at 12:05 p.m. with a licensed practical nurse (LPN/staff #56), who worked the day shift on (MONTH) 6, (YEAR) when the resident fell . She stated that she was going into the resident's room to give her medications and when she entered the room, the resident was on her knees on the floor in front of the wheelchair. She said the CNA was in the room and had tried to transfer the resident. Staff #56 stated that she asks therapy every day for any changes with the resident's ability and type of assistance needed with transfers, and then documents it in a progress note. She stated if she documented the resident needs two person extensive assistance, it means that she clarified this with therapy, prior to documenting it. An interview with a physical therapy assistant (PTA/staff #58) was conducted on (MONTH) 26, 2019 at 12:58 p.m. At this time, the therapy notes were reviewed with staff #58, who stated the resident was a two person transfer at the time of the fall. She said that since the resident was transferred from the bed to a standing position, it would require two persons. She stated the resident was making good progress, until the fall on (MONTH) 6, (YEAR). An interview with a registered nurse (RN/staff #83) was conducted on (MONTH) 26, 2019 at 4:10 p.m. Staff #83 stated that she usually works the night shift and that the resident was a two person Hoyer lift for transfers at all times. An interview with the Assistant Director of Nursing (ADON/staff #36) and the Administrator (ED/staff #10) was conducted on (MONTH) 28, 2019 at 8:52 a.m. Staff #36 stated that staff should care plan the number of staff assistance which is needed for transfers in the care plan within 24 hours of admit, because the care plan also transfers to the kardex where the CNA's look to find out how much help a resident needs with transfers. She stated that it would be neglect if staff were not following the care plan or therapy orders for transfers. Staff #36 said that she would expect the CNA's to follow what therapy recommends for transfers. She further stated that she expects staff to report abuse or suspicion of abuse to the Executive Director, Director of Nursing or the ADON immediately. She stated that they have two hours to report allegations of abuse to the officials. She stated that they did not identify the transfer for resident #292 as unsafe or as neglect/abuse, therefore they did not report the incident to the State Agency. Regarding an abuse allegation for resident #292: Review of a facility's investigation report revealed that on (MONTH) 27, (YEAR) on the night shift between 3 a.m.- 6 a.m., CNA (staff #85) witnessed another CNA (staff #86) telling resident #292 to shut up and threaten to drop the resident if she did not stop swinging her arms around, while changing the resident's brief. Staff #85 reported the resident was reaching her arms out, because she was afraid of falling and wanted help. Staff #85 reported that staff #86 told the resident that if she hits her, I will drop you. The investigation included a written interview with staff #86, who said that on (MONTH) 27, (YEAR) she yelled at resident #292, because the resident was afraid of falling and she needed to calm down. Staff #86 stated that she told the resident that she might drop her if she did not calm down or if she hit her. The investigation report also included an interview with resident #292's roommate who stated that on (MONTH) 27, (YEAR) she heard resident #292 yelling, because she was scared that she was going to fall out of bed. The roommate stated that she heard one of the staff tell the resident to shut-up or be quiet. The roommate stated that she was upset and did not like what was happening. Further review of the investigation report revealed that the allegation of abuse was not reported immediately to the administrator/designee, and that the State Agency was not notified of the allegation of abuse until (MONTH) 27, (YEAR) at 8:54 a.m., which is over the two hour timeframe for reporting. -Resident #16 was admitted to the facility on (MONTH) 6, (YEAR), with [DIAGNOSES REDACTED]. Review of the facility's investigation report revealed that on (MONTH) 27, (YEAR) during the night shift between 3:00 a.m. and 6:00 a.m., a CNA (staff #85) witnessed another CNA (staff #86) swearing and handling resident #16 rough, when changing the resident's brief. The report included that staff #85 had asked staff #86 to help her change the resident's brief. Staff #85 reported that while changing the resident's brief, staff #86 said that she did not know why the resident waits so long to pee, while grabbing and yanking the resident towards her. Per the report, staff #86 also hurriedly turned the resident on her side, so she could change the resident's sheets. Staff #85 reported that she thought staff #86 intended to be mean and that staff #86 had been frustrated all night. The resident reported that she was awakened by staff and that staff #86 was saying damn it or God damn it because her bed was wet. The resident said that staff #86 shoved her hard to the side while changing her sheets and that she knew staff #86 was mad, because her bed sheets were wet. The investigation also included a written interview with staff #86 who stated that she was swearing while in the resident's room, because she was frustrated. Staff #86 reported that she said crap and may have said sh Staff #86 said that she could see how the resident may have thought that she was swearing at her and that she did not mean to shove and push the resident onto her side and back at medium speed, while changing the resident's sheets. An interview was conducted with resident #16 on (MONTH) 27, 2019 at 2:29 p.m., who stated that staff #86 came into her room on (MONTH) 27, (YEAR) and shoved her so hard that she hit the bedrail. The resident stated that she was not hurt, but she was humiliated. She said staff #86 was angry and swearing because her bed was wet. She also stated that another CNA (staff #85) was present, but did not say anything. Further review of the investigation report revealed that the allegation of abuse was not reported immediately to the administrator/designee, and that the State Agency was not notified of the allegation of abuse until (MONTH) 27, (YEAR) at 8:54 a.m., which is over the two hour timeframe for reporting. -Resident #244 was admitted on (MONTH) 24, (YEAR) and readmitted on (MONTH) 31, (YEAR), with [DIAGNOSES REDACTED]. The resident was discharged on (MONTH) 4, (YEAR). Review of the facility's investigation report revealed that on (MONTH) 27, (YEAR) on the night shift between 3 a.m.- 6:00 a.m., staff #85 asked staff #86 to help her change resident #244's brief. Staff #85 was having difficulty because resident #244 pulled her pants up as she was cold. Staff #86 told staff #85 that she was going to show her a trick. Staff #86 then proceeded to pull the resident's pants down, tore open the brief, forced the resident to roll over, and pried the resident's legs apart. Staff #85 stated that she felt that staff #86 forced the resident to roll over. Staff #85 reported that staff #86 told the resident to open her legs and then told staff #85, I kind of forced her to open her legs. The resident then said that she wanted to be left alone. Staff #85 said she believed that staff #86 was trying to be mean, had been frustrated all night and forced resident #244 to open her legs. Further review of the investigation report revealed that the allegation of abuse was not reported immediately to the administrator/designee, and that the State Agency was not notified of the allegation of abuse until (MONTH) 27, (YEAR) at 8:54 a.m., which is over the two hour timeframe for reporting. -Resident #3 was readmitted to the facility on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. Review of the facility's investigation report revealed that on (MONTH) 27, (YEAR) on the night shift between 3:00 a.m. and 6:00 a.m., staff #85 reported that she and staff #86 woke resident #3 up to change his brief. Staff #85 said the resident was having trouble standing up, so staff #86 told the resident Fine, you don't get changed tonight and left the room. The investigation report included a written interview with staff #86, who reported that she yelled at the resident to get him to stand up. She stated that she was frustrated, because the resident was not helping her change his brief. The report included that staff #86 stated that she cannot control the volume or tone of her voice. Further review of the investigation report revealed that the allegation of abuse was not reported immediately to the administrator/designee, and that the State Agency was not notified of the allegation of abuse until (MONTH) 27, (YEAR) at 8:54 a.m. Continued review of the investigative findings regarding the allegations of abuse for resident #3, #16, #244 and #292, revealed they all occurred on the night shift on (MONTH) 27, (YEAR) sometime between 3 a.m. - 6 a.m. and involved staff #86. The documentation also included the following: Staff #86 was physically more forceful than needed when providing care, raised her voice and used profanity. Staff #86 was perceived by staff and residents as being angry and frustrated. Staff #86 was involuntary terminated. An interview with the Assistant Director of Nursing (ADON/staff #36) and the Administrator (ED/staff #10) was conducted on (MONTH) 28, 2019 at 8:52 a.m. Staff #36 stated that she expects staff to report abuse or suspicion of abuse to the Executive Director, Director of Nursing (DON) or the ADON immediately. She said that all staff have been told to call the ED, DON or ADON right away if the CNA can't find the charge nurse to report abuse, and that they have been told to call until they get a hold of somebody. She stated that they have two hours to report allegations of abuse to the officials. Staff #10 stated that the allegations of abuse occurred on (MONTH) 27, (YEAR) on the night shift between 3 a.m. - 6 a.m. He stated that staff #85 reported the allegations of abuse to the day shift CNA's and that he was notified of the allegations around 8:00 a.m. The ED stated that abuse allegations are required to be reported within two hours from the point of notification, and defined notification as the time the suspected abuse happened. Review of the facility's abuse policy dated (YEAR), revealed that the facility strives to prevent the abuse of all residents. The objective is to provide a safe haven for residents through preventative measures which protect residents right to be free from abuse and neglect. The policy included that if abuse is witnessed or suspected, the ED will be notified, and the ED and the witness who is reporting will notify the State Survey Agency in accordance with timeframes and standards required by the State Agency. Prompt reporting and investigation will be utilized to identify the validity of findings and reasonable measures will be implemented to deter further incidents of abuse.",2020-09-01
748,HAVEN OF CAMP VERDE,35118,86 WEST SALT MINE ROAD,CAMP VERDE,AZ,86322,2019-03-28,610,E,1,1,M1SN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews, facility documentation and policy and procedures, the facility failed to prevent the potential for further abuse of residents, by failing to remove a staff member from providing direct care to residents regarding allegations of abuse for 4 of 5 sampled residents (#3, #16, #244, and #292), and failed to conduct a thorough investigation regarding an incident of neglect for 1 sampled resident (#292) and failed to protect residents from the potential for further neglect. The deficient practice resulted in residents being subjected to further abuse/neglect. The deficient practice also resulted in an incident of neglect regarding an unsafe transfer not being identified or investigated, in order to determine possible causes of the fall and implement corrective action. Findings include: -Resident #292 was admitted to the facility on (MONTH) 11, (YEAR), with [DIAGNOSES REDACTED]. The resident was discharged on (MONTH) 27, (YEAR). Regarding an incident of neglect: Review of the baseline care plan-admission evaluation dated (MONTH) 11, (YEAR) under the section for ADL's (activities of daily living), revealed that resident #292 was alert and oriented x 4 and was totally dependent on two staff with transfers. The documentation included the resident had severe impairment with movement to bilateral legs and hips. Review of the ADL care plan dated (MONTH) 13, (YEAR), revealed the resident had an ADL self-care performance deficit, related to deconditioning. One of the interventions included that staff participation was required for transfers. However, the care plan did not specify how many staff were required for transfers or if mechanical lifts should be used. According to the Physical Therapy Evaluation and Plan of Treatment dated (MONTH) 14, (YEAR), the resident was totally dependent with bed mobility and transfers, and required maximum assistance. A nurses note dated (MONTH) 16, (YEAR), revealed the resident was a Hoyer lift for transfers and was totally dependent on two+ persons for assistance. According to a quarterly MDS (Minimum Data Set) assessment dated (MONTH) 25, (YEAR), the resident scored a 13 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Per the MDS, the resident required extensive assistance of two persons with bed mobility, transfers, dressing and toilet use, and was totally dependent on two persons with transfers. A physical therapy note dated (MONTH) 4, (YEAR), revealed the resident started therapy and had needed 100% assistance, but now has improved to 20 % assistance. The note included that for bed mobility and sit to stand, the resident was a moderate assist of two persons with a front wheel walker. A nurses note dated (MONTH) 5, (YEAR) included the resident required extensive assistance of two staff members for transfers, secondary to generalized weakness and size, and utilizes a mechanical lift as needed. Review of clinical record revealed that resident #292 did not have any falls, since admission. A nurses note dated (MONTH) 6, (YEAR) revealed that a CNA (certified nursing assistant/staff #18) transferred the resident alone by herself from the bed to the wheelchair, with the help of a walker. While attempting to sit into the wheelchair, the resident slid to the floor on her knees. The note included that two staff members (CNA #18 and nurse #56) with the help of a sit/stand Hoyer lift assisted the resident from the floor to the wheelchair. The resident had no injuries except for a right hip old superficial blister, which had popped and a dressing was applied. Review of the IDT review note dated (MONTH) 7, (YEAR), revealed a non-injury fall related to weakness during transfer and resident placed on alert charting. Further review of the clinical record revealed the resident was discharged on (MONTH) 27, (YEAR). The facility was unable to provide any evidence that the incident of neglect was thoroughly investigated or that staff #18 was removed from providing direct care to residents, pending an investigation. An interview with a physical therapy assistant (PTA/staff #58) was conducted on (MONTH) 26, 2019 at 12:58 p.m. At this time, the therapy notes were reviewed with staff #58, who stated the resident was a two person transfer at the time of the fall. She said that since the resident was transferred from the bed to a standing position, it would require two persons. An interview with the Assistant Director of Nursing (ADON/staff #36) and the Executive Director (ED/staff #10) was conducted on (MONTH) 28, 2019 at 8:52 a.m. She stated that it would be neglect if staff were not following the care plan or therapy orders for transfers. Staff #36 said she would expect the CNA's to follow what therapy recommends for transfers. At this time, the fall documentation was reviewed with staff #36. She stated that during an IDT meeting (which included the DON, ADON, the Care Coordinator and therapy), it was not identified that the fall was an unsafe transfer. Staff #36 said that since they did not identify the incident as neglect, and they did not report the incident or investigate it. The ADON also stated that when there is an allegation of abuse/neglect, the first priority is to protect the resident by removing the alleged perpetrator. She stated that if the alleged perpetrator is a staff member, the staff is asked to leave the building. Regarding an allegation of abuse for resident #292: Review of a facility's investigation report revealed that on (MONTH) 27, (YEAR) on the night shift between 3-6 a.m., a CNA (staff #85) witnessed another CNA (staff #86) telling resident #292 to shut up and threaten to drop the resident if she did not stop swinging her arms around, while changing the resident's brief. Staff #85 reported the resident was reaching her arms out, because she was afraid of falling and wanted help. Staff #85 reported that staff #86 told the resident that if she hits her, I will drop you. The investigation included a written interview with staff #86, who said that on (MONTH) 27, (YEAR) she yelled at resident #292, because the resident was afraid of falling and she needed to calm down. Staff #86 stated that she told the resident that she might drop her if she did not calm down or if she hit her. The investigation report also included an interview with resident #292's roommate, who stated that on (MONTH) 27, (YEAR) she heard resident #292 yelling, because she was scared that she was going to fall out of bed. The roommate stated that she heard one of the staff tell the resident to shut-up or be quiet. The roommate stated that she was upset and did not like what was happening. Further review of the facility's report revealed there was no evidence that staff #86 was immediately removed from providing care to residents. -Resident #16 was admitted to the facility on (MONTH) 6, (YEAR), with [DIAGNOSES REDACTED]. Review of the facility's investigation report revealed that on (MONTH) 27, (YEAR) during the night shift between 3:00 a.m. and 6:00 a.m., a CNA (staff #85) witnessed another CNA (staff #86) swearing and handling resident #16 rough, when changing the resident's brief. The report included that staff #85 had asked staff #86 to help her change the resident's brief. Staff #85 reported that while changing the resident's brief, staff #86 said that she did not know why the resident waits so long to pee, while grabbing and yanking the resident towards her. Per the report, staff #86 also hurriedly turned the resident on her side, so she could change the resident's sheets. Staff #85 reported that she thought staff #86 intended to be mean and that staff #86 had been frustrated all night. The resident reported that she was awakened by staff and that staff #86 was saying damn it or God damn it because her bed was wet. The resident said that staff #86 shoved her hard to the side while changing her sheets and that she knew staff #86 was mad, because her bed sheets were wet. The investigation also included a written interview with staff #86 who stated that she was swearing while in the resident's room, because she was frustrated. Staff #86 reported that she said crap and may have said sh Staff #86 said that she could see how the resident may have thought that she was swearing at her and that she did not mean to shove and push the resident onto her side and back at medium speed, while changing the resident's sheets. An interview was conducted with resident #16 on (MONTH) 27, 2019 at 2:29 p.m., who stated that staff #86 came into her room on (MONTH) 27, (YEAR) and shoved her so hard that she hit the bedrail. The resident stated that she was not hurt, but she was humiliated. She said staff #86 was angry and swearing because her bed was wet. She also stated that another CNA (staff #85) was present, but did not say anything. Further review of the facility's report revealed there was no evidence that staff #86 was immediately removed from providing care to residents. -Resident #244 was admitted on (MONTH) 24, (YEAR) and readmitted on (MONTH) 31, (YEAR), with [DIAGNOSES REDACTED]. The resident was discharged on (MONTH) 4, (YEAR). Review of the facility's investigation report revealed that on (MONTH) 27, (YEAR) on the night shift between 3:00 a.m. and 6:00 a.m., staff #85 asked staff #86 to help her change resident #244's brief. Staff #85 was having difficulty because resident #244 pulled her pants up and said that she was cold. Staff #86 told staff #85 that she was going to show her a trick. Staff #86 then proceeded to pull the resident's pants down, tore open the brief, forced the resident to roll over, and pried the resident's legs apart. Staff #85 stated that she felt that staff #86 forced the resident to roll over. Staff #85 reported that staff #86 told the resident to open her legs and then told staff #85, I kind of forced her to open her legs. The resident then said that she wanted to be left alone. Staff #85 said she believed that staff #86 was trying to be mean, had been frustrated all night and forced resident #244 to open her legs. The report included an interview with resident #244, but she was unable to remember anything that occurred on (MONTH) 27. The facility was unable to provide any documentation that staff #86 was immediately removed from providing care to residents. -Resident #3 was readmitted to the facility on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. Review of the facility's investigation report revealed that on (MONTH) 27, (YEAR) on the night shift between 3:00 a.m. and 6:00 a.m., staff #85 reported that she and staff #86 woke resident #3 up to change his brief. Staff #85 said the resident was having trouble standing up, so staff #86 told the resident Fine, you don't get changed tonight and left the room. The investigation report included a written interview with staff #86, who reported that she yelled at the resident to get him to stand up. She stated that she was frustrated, because the resident was not helping her change his brief. The report included that staff #86 stated that she cannot control the volume or tone of her voice. Further review of the investigative report revealed no evidence that staff #86 was immediately removed from providing care to residents. Continued review of the investigative findings regarding the allegations of abuse for resident #3, #16, #244 and #292, revealed they all occurred on the night shift on (MONTH) 27, (YEAR) sometime between 3 a.m. - 6 a.m. and involved staff #86. The documentation also included the following: Staff #86 was physically more forceful than needed when providing care, raised her voice and used profanity. Staff #86 was perceived by staff and residents as being angry and frustrated. Staff #86 was involuntary terminated. An interview was conducted on (MONTH) 28, 2019 at 8:52 a.m. with the Assistant Director of Nursing (ADON/staff #36) and the Executive Director (staff #10). Staff #10 stated that the allegations of abuse occurred on (MONTH) 27, (YEAR) on the night shift between 3 a.m. - 6 a.m. Staff #10 stated that the alleged perpetrator worked until the end of her shift, which ended at 6:00 a.m. He stated that staff #85 reported the allegations of abuse to the day shift CNA's and that he was notified of the allegations around 8:00 a.m. The ADON stated that during new hire orientation, staff receive abuse training and the first priority is to protect the resident, by removing the staff member involved. She said that the staff who witness an allegation of abuse is expected to ask the alleged perpetrator to leave the building. Review of the facility's abuse policy dated (YEAR), revealed that the facility strives to prevent the abuse of all residents. The objective is to provide a safe haven for residents through preventative measures which protect residents right to be free from abuse and neglect. If abuse/neglect is witnessed or suspected, the resident's safety will immediately be secured and the ED will be notified. If staff is suspected of being the abuser, they will be suspended until the investigation is complete. Prompt reporting and investigation will be utilized to identify the validity of findings and reasonable measures will be implemented to deter further incidents of abuse. The policy also included the ED will begin an investigation immediately and will complete the investigation within 5 days using the abuse investigation packet. A minimum of 3 residents will be interviewed in order to determine if there is a trend. Staff members will document their own statements and sign and date them. The policy included that all abuse investigation information will be documented and kept in an abuse investigation binder. -",2020-09-01
749,HAVEN OF CAMP VERDE,35118,86 WEST SALT MINE ROAD,CAMP VERDE,AZ,86322,2019-03-28,658,E,0,1,M1SN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy review, the facility failed to meet professional standards of quality, by failing to administer a medication according to the physician ordered parameters for one sampled resident (#9). The deficient practice could result in complications related to [MEDICAL CONDITION] and [MEDICAL CONDITION]. Findings include: Resident #9 was admitted on (MONTH) 20, (YEAR), with a [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 28, (YEAR), revealed a score of 11 on the Brief Interview for Mental Status, which indicated the resident had intact cognition. Physician orders [REDACTED]. This order had an original order date of (MONTH) 4, (YEAR). A care plan for hypertension included a goal that the resident will remain free of complications related to hypertension. Interventions included administering medications as ordered and to monitor for side effects such as orthostatic [MEDICAL CONDITION] and increased heart rate and for effectiveness. According to the Medication Administration Record (MAR) for (MONTH) 2019 revealed [MEDICATION NAME] was administered daily to the resident. However, further review of the (MONTH) 2019 MAR and of the clinical record revealed documentation of only one blood pressure and pulse for the month of March. The resident's blood pressure was 113/54 and the pulse was 85. Further review of the clinical record revealed no evidence that the resident's blood pressure and heart rate were obtained in (MONTH) 2019, prior to the administration of [MEDICATION NAME]. During a medication administration observation conducted on (MONTH) 27, 2019 at 7:41 am., a Registered Nurse (RN/staff #41) was observed to administer [MEDICATION NAME] to resident #9, without obtaining the resident's blood pressure or pulse. An interview was conducted with staff #41 immediately following the observation. The RN stated that the Certified Nursing Assistants (CNA's) have a list of residents that need to have their vital signs taken and that the CNA's are the ones that obtain residents' blood pressures. She stated that she did not have a blood pressure reading for this resident, because [MEDICATION NAME] does not require a blood pressure reading prior to administration. After reviewing the physician's orders [REDACTED].#41 stated that the last blood pressure and pulse for this resident was obtained on (MONTH) 1, 2019 and the blood pressure was 113/54 and the pulse was 85. At this time, the resident's blood pressure and pulse were obtained. The resident's blood pressure was 143/73 and the pulse was 93. The RN stated that the resident's blood pressure and pulse should be obtained before administering the blood pressure medication, as ordered by the physician. An interview was conducted on (MONTH) 28, 2019 at 8:52 p.m., with the Assistant Director of Nursing (ADON/staff #36). The ADON stated that the expectation is that the nurses administer medications according to the physician orders. She stated that her expectation is that the nurses obtain resident #9's blood pressure and pulse, prior to administering the [MEDICATION NAME] as ordered by the physician. Review of a facility's policy regarding Medication Administration dated 2007, revealed that medications are to be administered in accordance with the written orders of the prescriber. The policy also included obtaining and recording vital signs as necessary prior to medication administration.",2020-09-01
750,HAVEN OF CAMP VERDE,35118,86 WEST SALT MINE ROAD,CAMP VERDE,AZ,86322,2016-12-16,154,D,0,1,J4JN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and a review of facility policies, the facility failed to ensure that an informed consent was obtained prior to the use of an anti-anxiety medication for one resident (#49) and failed to ensure the responsible party was informed of a test result for one resident (#95). Findings include: -Resident #49 was readmitted on (MONTH) 29, (YEAR), with [DIAGNOSES REDACTED]. A review of the (MONTH) and (MONTH) recapitulation of physician's orders [REDACTED]. A review of the (MONTH) (YEAR), MAR (Medication Administration Record) revealed documentation that the prn [MEDICATION NAME] had been administered four times from (MONTH) 5 through 8, (YEAR). However, a review of a [MEDICAL CONDITION] medication informed consent revealed that the explanation of the risk and benefits and signed consent for the use of the [MEDICATION NAME] had not been obtained until (MONTH) 9, (YEAR), which was nine days after initiation of the [MEDICATION NAME]. An interview was conducted on (MONTH) 14, (YEAR) at 8:15 a.m., with the DON (staff #20). Following a review of the physician's orders [REDACTED].#20 stated that the informed consent should have been obtained from the resident or the resident's responsible party prior to the administration of the [MEDICATION NAME]. A facility policy titled, Behavior Management Program, included the following: Consent and Tracking All [MEDICAL CONDITION] medications require the following: 1. ADON (Assistant Director of Nursing) ensures that an informed consent is obtained from the resident and/or responsible party. Another facility policy titled, Medication Administration, included the following: 9. Medications requiring consent before administration of medication will have consent signed or verbal consent obtained within 48 hours of the physician order. -Resident #95 was admitted to the facility on (MONTH) 25, (YEAR), with [DIAGNOSES REDACTED]. In a review of the clinical record there was documentation of a physician's orders [REDACTED]. Further review of the clinical record revealed a chest x-ray was completed on (MONTH) 31, (YEAR). The chest x-ray results were noted by the physician and the form of the results was placed in the resident's clinical record. In a review of physician and nursing progress notes for (MONTH) and June, (YEAR), there was no evidence that the resident or responsible party was informed of the x-ray results. An interview was conducted with a Licensed Practical Nurse (LPN/staff 355) on (MONTH) 14, (YEAR) at 12:31 p.m. He stated he could not locate any documentation that the resident or responsible party was informed of the chest x-ray results. He stated the licensed staff have a place in the computerized charting system to confirm that the resident or responsible party have been notified of test results and stated this documentation was not located in the computerized system. He further stated it was facility practice and standard nursing practice that residents or responsible parties be notified of test results. According to a facility policy regarding physician services the following was included: Statement: The medical care is under the supervision of a Licensed Physician. 3. The physician will provide timely information about the resident's condition and medical needs. An additional facility policy regarding a change in condition or status included: Statement: Our facility shall promptly notify the resident or representative of changes in the resident's medical condition or status. 3. Unless otherwise instructed by the resident the Charge Nurse will notify the resident's family or representative when there has been a significant change in the resident's status. 6. The Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical condition.",2020-09-01
751,HAVEN OF CAMP VERDE,35118,86 WEST SALT MINE ROAD,CAMP VERDE,AZ,86322,2016-12-16,281,D,0,1,J4JN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, and review of facility policies, the facility failed to ensure that an anti-anxiety medication order included the frequency of administration for one resident (#49), that one resident (#2) was not administered a medication without a physician's order, and that one resident (#97) was administered the physician ordered treatment. Findings include: Resident #49 was readmitted on (MONTH) 29, (YEAR), with [DIAGNOSES REDACTED]. A review of the (MONTH) and (MONTH) (YEAR) recapitulation of physician's orders revealed an order for [REDACTED]. A review of the (MONTH) (YEAR) MAR (Medication Administration Record) revealed documentation of the prescribed [MEDICATION NAME] and documentation that the medication had been administered multiple times. However, the physician's order did not include the frequency of the prn [MEDICATION NAME]. An interview was conducted on (MONTH) 14, (YEAR) at 8:15 a.m., with the DON (staff #20). Following a review of the prescribed [MEDICATION NAME] order, staff #20 stated that the licensed staff should have clarified the [MEDICATION NAME] order regarding the frequency of the administration. Another interview was conducted on (MONTH) 14, (YEAR) at 8:50 a.m., with a Licensed Practical Nurse (Staff #37). Following a review of the [MEDICATION NAME] order, she stated that she would not have administered the [MEDICATION NAME] without first clarifying the order with the physician regarding the frequency of administration. A facility policy titled Medication and Treatment Orders, included Orders for medications and treatments will be consistent with principles of safe and effective order writing. The policy also included the following: 9. Orders for medications must include: c. Dosage and frequency of administration. -Resident #2 was admitted to the facility on (MONTH) 23, (YEAR), with [DIAGNOSES REDACTED]. Per physician's orders dated (MONTH) 23, (YEAR), the resident was to be administered [MEDICATION NAME] (an anti-hypertensive) 5 milligrams (mg) one time daily. Per physician orders dated (MONTH) 29, (YEAR), the [MEDICATION NAME] was to be discontinued. Per the (MONTH) (YEAR) Medication Administration Record (MAR) there was evidence that the [MEDICATION NAME] was to be discontinued on (MONTH) 29, (YEAR). Per the October, November, and (MONTH) (YEAR) MARs there was no evidence of the [MEDICATION NAME] 5 mg documented on the MARs. During a medication administration observation conducted on (MONTH) 14, (YEAR) at 7:40 a.m., a Licensed Practical Nurse (LPN/staff #1) was observed to pull a blister pack of [MEDICATION NAME] 5 mg from the medication cart. The card of [MEDICATION NAME] had the name of resident #2 with instructions to administer 5 mg one time daily. The staff was then observed to place one of the [MEDICATION NAME] into a medication cup and administer it to the resident. The resident was observed to place the medication in his mouth and swallow the medication. In a review of the clinical record there was no evidence of a physician's order for the resident to be administered [MEDICATION NAME] 5 mg daily. The [MEDICATION NAME] had been discontinued on (MONTH) 29, (YEAR), and there were no additional orders to re-start the [MEDICATION NAME]. An interview was conducted with a Registered Nurse (RN/staff #58) on (MONTH) 14, (YEAR) at 9:03 a.m. She stated she reviewed the physician's orders and located the (MONTH) 29, (YEAR), discontinuation order. She also stated she could not locate a current physician's order for the [MEDICATION NAME]. An interview was conducted with staff #1 on (MONTH) 14, (YEAR) at 9:05 a.m. She located the [MEDICATION NAME] blister pack in the medication cart with the name of resident #2 listed. She stated she had administered the [MEDICATION NAME] 5 mg to the resident that morning. She further stated she administered it despite not having documentation on the December, (YEAR), MAR to indicate it was a current order. Continued in the interview with staff #1 the blister package of the [MEDICATION NAME] for resident #2 was viewed and included the following information: -Date: Refill: (MONTH) 2, (YEAR) Issue Date (MONTH) 2, (YEAR) -Amlodopine ([MEDICATION NAME]) 5 mg -Take one tab by mouth daily -Order after (MONTH) 28, (YEAR) There were 30 enclosed spaces and there were a total of 9 pills in the enclosed spaces. Staff #1 stated the blister package started out with 30 pills and now there were only 9 left. She stated it was obvious the pills were gone and stated the nurses must have been giving the [MEDICATION NAME] to resident #2 without an order. She also stated she was not sure why the pharmacy sent the new package on (MONTH) 2, (YEAR), since there were physician's order to discontinue the medication. An interview was conducted with the Director of Nursing (DON/staff #20) on (MONTH) 14, (YEAR) at 9:11 a.m. She stated there was no current order for the [MEDICATION NAME] and that staff #1 should not have administered the medication without documentation on the MAR to indicate it was a current order. She further stated the Nurse Practitioner would be notified of the medication error and staff #1 would be written up for a medication error. Continued in the interview with the DON/staff #20 she stated that the [MEDICATION NAME] blister package for resident #2 may have been sent in error from the pharmacy as the [MEDICATION NAME] had been discontinued in September, (YEAR). She stated the usual procedure is to inform the pharmacy of the medication changes and enter the changes in the computerized system and that order is directly forwarded to the pharmacy. The licensed staff should then remove the discontinued medication from the medication cart and note the discontinued order on the MAR. An interview was conducted with the contracted pharmacist on (MONTH) 14, (YEAR) at 9:29 a.m. She reviewed the system and stated the pharmacy had received the physician's order to discontinue the [MEDICATION NAME] on (MONTH) 29, (YEAR). She stated the pharmacy the pharmacy did not fill an order for [REDACTED].#2 in October, (YEAR). She then stated that on (MONTH) 1, (YEAR), there was a facility request to fill the [MEDICATION NAME] so a blister package with 30 [MEDICATION NAME] was sent to the facility despite not having a current physician's order. She stated she was unsure of how or why this error was made. A facility policy regarding medication administration included the following: 1. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe medications. 3. Drug orders must be recorded on the Physician's order sheet in the resident's chart. An additional facility policy regarding Medication administration included: 3. All current drugs must be recorded on the resident's Medication Administration Record. The seven rights of medication administration are as follows in order to ensure safety and accuracy of medication. 3. Right Medication-Medications are checked against the order before they are given. An additional facility policy regarding the ordering and receiving on non-controlled medications the following was included: Statement: Medications are received from the provider pharmacy on a timely basis. The nursing care center maintains accurate records of medication order and receipt. 1. Ordering medications from provider pharmacy: d. All medication order changes or discontinuations must be communicated to the pharmacy timely in order to provide quantities and accurate labeling when doses or administration are modified. 2. Receiving medications from the pharmacy: a. A licensed nurse as required by law: a. Receives medications delivered to the nursing care center from the pharmacy and documents delivery on the medication delivery receipt. Verifies medications received with the physician orders. Promptly reports discrepancies to the issuing pharmacy and charge nurse/supervisor. -Resident #97 was admitted (MONTH) 8, (YEAR), with [DIAGNOSES REDACTED]. A physician's order dated (MONTH) 8, (YEAR), revealed an order for [REDACTED]. A physician's order dated (MONTH) 8, (YEAR), revealed an order for [REDACTED]. A physician's order dated (MONTH) 8, (YEAR), revealed an order for [REDACTED]. Review of the TAR (Treatment Administration Record) for October, November, and (MONTH) of (YEAR) revealed there were multiple days that the above treatments were not documented administered as ordered. An interview was conducted with the corporate nurse (staff #58) on (MONTH) 14, (YEAR) at 3:00 p.m. Staff #58 reviewed the copies of the TAR for October, November, and (MONTH) of (YEAR). She confirmed there were several days on the TAR which did not document whether the resident received physician ordered treatments. Staff #58 stated she did not know why the prescribed physician ordered treatments were not documented.",2020-09-01
752,HAVEN OF CAMP VERDE,35118,86 WEST SALT MINE ROAD,CAMP VERDE,AZ,86322,2016-12-16,323,D,0,1,J4JN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, staff interviews, and a review of facility policy, the facility failed to ensure that a fall care plan intervention was implemented for one resident (#83). Findings include: Resident #83 was admitted on (MONTH) 20, (YEAR), with [DIAGNOSES REDACTED]. A fall risk assessment dated (MONTH) 20, (YEAR), identified that the resident was a high fall risk. A nursing admission evaluation also dated (MONTH) 20, (YEAR), documented that the resident was alert and oriented, required extensive assistance with activities of daily living, that a wheelchair was required for mobility, and that the resident's gait was unsteady. The evaluation also included documentation that the resident's Power of Attorney, had reported that the resident had early dementia and that when she awakes at night, she is disoriented. At that time, he requested that an alarm be placed on the resident. A fall report dated (MONTH) 29, (YEAR), included that at 12:40 p.m. the resident was found on the floor in her room next to her wheelchair. Per the documentation, the resident had reported that she slid out of her chair onto the floor. The resident had sustained a bruise on the left antecubital area and on the right elbow. The fall report did not include any documentation that the personal alarm had been provided or that it was functional at the time of this fall. A post fall investigative report dated (MONTH) 30, (YEAR), included that dycem would be placed in the resident's chair to prevent the resident from sliding. A review of a risk for falls care plan included documentation that a bed alarm was in place to alert staff of unassisted transfers and that dycem was placed in the wheelchair to prevent sliding from the wheelchair. However, neither the use of the bed alarm or the dycem in the wheelchair was included on the resident's MARs/TARs (Medication and Treatment Administration Records). A review of the resident's plan of care, used by the CNAs (Certified Nursing Assistants) in order to implement specific care needs, also did not include documentation for the use of a bed alarm or the dycem. A resident observation was conducted on (MONTH) 14, (YEAR) at 9:40 a.m. At this time, the resident was observed in bed without a bed alarm in place and the dycem was located on the resident's bedside table. An interview was conducted on (MONTH) 14, (YEAR) at 9:45 a.m. with a CNA (staff #6), who confirmed that a bed alarm was not on the resident. At this time, staff #6 reviewed the resident's plan of care and stated that the bed alarm was not on the resident's plan of care. Following this interview, staff #6 obtained a bed alarm and placed it on the resident. Another interview was conducted on (MONTH) 14, (YEAR) at 9:55 a.m. with the DON (staff #20). Staff #20 stated that a physician's orders [REDACTED]. A facility policy titled, Using the Care Plan, included The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who responsibility for providing care or services to the resident. The policy also included the following: 2. The Nurse Supervisor uses the care plans to complete the CNA's daily, weekly work assignment sheets and/or flow sheets.",2020-09-01
753,MI CASA NURSING CENTER,35120,330 SOUTH PINNULE CIRCLE,MESA,AZ,85206,2017-07-27,278,D,0,1,2EQE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, review of the RAI (Resident Assessment Instrument) manual and policy review, the facility failed to ensure that MDS (Minimum Data Set) assessments were accurate for three residents (#'s 16, 153 and 338). Findings include: -Resident #16 was admitted on (MONTH) 25, (YEAR), with [DIAGNOSES REDACTED]. According to the weight record documentation, the resident's admission weight was 228 lbs. The weight record also included the following: -Day 15: the resident's weight was 210 lbs, which was an 18 lb weight loss or 7.9%. -Day 30: the resident's weight was 205 lbs, which was a 23 lb weight loss or 10%. -Day 60: the resident's weight was 196 lbs, which was a 32 lbs weight loss or 14%. A review of the nutritional progress notes from (MONTH) 16, through (MONTH) 1, (YEAR), revealed documentation that although a gradual weight loss was beneficial, the resident had a significant weight loss from (MONTH) 25, to (MONTH) 26, (YEAR). However, review of a 60 day MDS assessment dated (MONTH) 26, (YEAR), revealed the significant weight loss had not been coded on the MDS assessment. An interview was conducted on (MONTH) 26, (YEAR) at 12:30 p.m., with MDS staff (staff #4 and #6). Following a review of the 60 day MDS assessment, staff #4 stated that it should have been coded to reflect the significant weight loss and that it was an error. Staff #6 stated that the dietary manager, who usually completes the weight section of the MDS assessment was on vacation at the time when the 60 day MDS assessment was completed. Staff #6 also stated he completed that section and he missed the documentation which indicated the resident had a significant weight loss. -Resident #338 was admitted on (MONTH) 11, (YEAR), with [DIAGNOSES REDACTED]. A review of the clinical record, inclusive of nursing notes and admission physician orders, revealed that the resident was to have four [MEDICAL TREATMENT] fluid exchanges per day. However, review of a 5 day MDS assessment revealed that [MEDICAL TREATMENT] had not been coded on the MDS. An interview was conducted on (MONTH) 26, (YEAR) at 12:00 p.m., with MDS staff (staff #4). Following a review of the 5 day MDS assessment, she stated that she should have coded it for [MEDICAL TREATMENT] and that it was a data entry error. -Resident #153 was admitted to the facility on (MONTH) 15, (YEAR), with [DIAGNOSES REDACTED]. Review of the Incontinence Care Plan initiated on (MONTH) 15, (YEAR), revealed a problem of Alteration in elimination as evidence by incontinent of bowel and bladder related to [MEDICAL CONDITION], does not recognize the urge to void or defecate. An intervention included to monitor for episodes of incontinence. According to the CNA (Certified Nursing Assistant) documentation from (MONTH) 15 through (MONTH) 22, (YEAR), the resident had multiple episodes of bladder incontinence, and had no episodes of bladder continence. Review of the admission MDS assessment dated (MONTH) 22, (YEAR), revealed the resident had a Brief Interview for Mental Status score of 9, which indicated the resident had moderate cognitive impairment. Review of the bowel and bladder section of the MDS revealed the resident was assessed as always being continent of bladder. In an interview conducted with a Licensed Practical Nurse (MDS Coordinator/staff #5) on (MONTH) 22, (YEAR) at 11:11 a.m., staff #5 stated that resident #153 has never been continent. Staff #5 stated that the admission MDS was coded incorrectly. In an interview conducted with the Director of Nursing (DON/staff #1) on (MONTH) 27, (YEAR) at 12:06 p.m., the DON stated the MDS was coded incorrectly and that the facility has a regional resource that comes and reviews the MDS assessments for accuracy. A facility policy titled, Certification of Accuracy of the MDS included that the signature on the MDS is a legal attestation that to the best of the knowledge of the signer, the information entered on the MDS accurately reflects the patient's status. The policy also included that the primary responsibility for accuracy, lies with the person selecting the MDS item response. Review of the RAI manual for the MDS revealed the importance of accurately completing and submitting the MDS assessment cannot be over - emphasized. The MDS assessment is the basis for the development of an individualized care plan.",2020-09-01
754,MI CASA NURSING CENTER,35120,330 SOUTH PINNULE CIRCLE,MESA,AZ,85206,2017-07-27,309,D,0,1,2EQE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the clinical record, staff and resident interviews and policy and procedures, the facility failed to ensure physician orders were in place for the care and treatment for one resident (#338) with a PD (Peritoneal [MEDICAL TREATMENT]) catheter. Findings include: Resident #338 was admitted on (MONTH) 11, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident was alert, with memory intact. The documentation also included the resident had a PD catheter in the abdomen. A care plan for the potential for complications related to peritoneal [MEDICAL TREATMENT] was developed on (MONTH) 11, (YEAR). The goal was for the resident to receive [MEDICAL TREATMENT] as ordered with minimal complications through the next review. Interventions included to administer/observe effectiveness of medications as ordered, check PD site for signs or symptoms of infection, pain or bleeding, daily and as needed. A review of the physician admission orders [REDACTED]. A physician's order dated (MONTH) 12, (YEAR) included the following: -May keep PD supplies including Alcavis, Except, [MEDICATION NAME] and [MEDICATION NAME] in resident's room. -Clarification order-Manual PD exchanges four times a day with 2,500 ml (milliliters) of 2.5% [MEDICATION NAME]. Another physician's order dated (MONTH) 12, (YEAR) included the following: -Discontinue all previous PD orders. -[MEDICAL TREATMENT] everyday with four exchanges per day. Fill volume 3,000 cc (cubic-centimeter), dwell four hours and no night exchanges. However, this physician's order did not include the percent or concentration of [MEDICATION NAME] to use. In addition, there were no physician orders for the care of the PD catheter or the catheter site. Although the (MONTH) (YEAR) TAR (Treatment Administration Record) included the (MONTH) 12 orders, it did not include the percent of [MEDICATION NAME] to be used or for the care of the catheter or catheter site. According to the admission MDS (Minimum Data Set) assessment dated (MONTH) 18, (YEAR), the resident had a BIMS (Brief Interview for Mental Status) score of 15, which indicated no cognitive deficits. The MDS also included the resident was receiving [MEDICAL TREATMENT]. Further review of the clinical record revealed there was only one entry which documented that the PD site dressing was changed. There was no documentation regarding the care which was provided to the PD site and catheter. A resident interview was conducted on (MONTH) 26, (YEAR) at 9:15 a.m. The resident stated that sometimes she does her own PD site treatment and at other times the nurses do it. She stated that all of the needed supplies are kept in her room. The resident further stated that the Except and [MEDICATION NAME] ointment is used at the PD site and the Alcavis is used to clean the PD catheter tubing. Following this interview, an interview was conducted with the ADON (Assistant Director of Nursing/staff #2). After reviewing the clinical record, she stated that she was unable to locate a physician's order for the care of the PD site and the catheter. Staff #2 stated that she would need to contact the physician to obtain orders. Immediately following this interview, an interview was conducted with the RN (Registered Nurse/Unit Manager/staff #24). Following a review of the clinical record, she stated that the admission orders [REDACTED]. Staff #24 confirmed that the TAR did not include any treatments for the catheter or the PD site. On (MONTH) 26, (YEAR) at 11:15 a.m., an interview was conducted with the DON (Director of Nursing/staff #1). She stated that the physician's order for the PD exchanges should have included the percent of [MEDICATION NAME] to use and that the PD site care and catheter care orders should have been obtained, transcribed and documented when administered by the licensed staff. A facility policy titled Continuous Ambulatory Peritoneal [MEDICAL TREATMENT] included, The purpose of this procedure is to provide continuous ambulatory peritoneal [MEDICAL TREATMENT] that is safe and consistent with physician orders and instructions from the [MEDICAL TREATMENT] facility. The policy also included the following: 2. Review all existing orders and instructions for care pertaining to the resident's [MEDICAL TREATMENT]. Verify the following: a. [MEDICATION NAME] solution/concentration This policy further included a section regarding the PD site care, which stated to provide catheter care and site observation as ordered. Another facility policy titled, Physician Order Processing Procedure-New Admission included that admission orders [REDACTED].",2020-09-01
755,MI CASA NURSING CENTER,35120,330 SOUTH PINNULE CIRCLE,MESA,AZ,85206,2017-07-27,431,D,0,1,2EQE11,"Based on observations, staff interviews, facility documentation and policy review, the facility failed to ensure that glucose control solutions were dated when opened, that two IV (Intravenous) solutions bags were not expired and that three syringes of sodium chloride were not expired. Findings include: An observation was conducted on (MONTH) 24, (YEAR) at 10:28 a.m., of a medication cart on the 100 nursing unit. During this observation, a box containing two opened glucose control solution bottles did not have the date when opened on the box or on the bottles. An interview was conducted at this time with a Registered Nurse (staff #24), who stated that the glucose control solution box should have the date of opening on it, because it would expire 90 days after it was opened. Staff #24 also stated that without the date of opening documented, she would not know when it would expire. Another observation was conducted on (MONTH) 27, (YEAR) at 11:00 a.m., of the emergency cart located on the 500 nursing unit. Inside the cart were two 1,000 cc (cubic centimeter) bags of IV solution. One IV bag of Sodium Chloride 0.9% had an expiration date of (MONTH) (YEAR), and the other IV bag of Dextrose 5%/0.45% Sodium Chloride had an expiration date of (MONTH) (YEAR). An interview was conducted on (MONTH) 27, (YEAR) at 11:15 a.m., with the Corporate Nurse (staff #191), who stated that the emergency carts are checked nightly to ensure that the list of contents are in the emergency cart, and the expiration dates should also have been checked. At this time, the DON (Director of Nursing/staff #1) stated the licensed staff should check the expiration dates before using any medication. According to the glucose control solution package insert the following was included: -The solutions are stable for 90 days after opening. -When you open a new bottle, write the date of opening on the bottle label. -Discard the solution 3 months after opening or the expiration date printed on the bottle, whichever comes first. A facility policy titled, Glucose Control Testing included 6. Write the date of opening on the white section of the label on the control solution. Open vial stability is 90 days or until the manufacturer's expiration date, whichever comes first.",2020-09-01
756,MI CASA NURSING CENTER,35120,330 SOUTH PINNULE CIRCLE,MESA,AZ,85206,2018-10-26,552,D,0,1,QPRH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility failed to ensure one resident (#117) was informed of and participated in the treatment plan that included the indication for and the risks and benefits of the use of [MEDICAL CONDITION] medications. Findings include: Resident #117 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. The admission Minimum Data Set assessment dated [DATE] revealed the resident was unable to complete the Brief Interview for Mental Status, however the staff assessment included the resident had memory problems and had moderate cognitive impairment. Review of the physician's orders [REDACTED]. Review of the clinical record revealed a psychoactive medication informed consent form for the use of [MEDICATION NAME] as a sedative/hypnotic medication, a psychoactive medication informed consent form for the use of [MEDICATION NAME] as an antidepressant medication, and a psychoactive medication informed consent form for the use of [MEDICATION NAME] as an antianxiety medication. All three forms were signed on 10/03/18 by the resident. However, the areas of the psychoactive medication informed consent forms designated to document the non-drug approaches that had been proven to be ineffective, the reason why the medication was prescribed, the expected benefits to the resident, and the proposed course of the medication were blank. The physician's orders [REDACTED]. However, further review of the clinical record revealed no documented evidence the resident was informed of the risks and benefits of [MEDICATION NAME]. An interview was conducted on 10/25/18 at 11:42 AM with the Registered Nurse/Director of Nursing (RN/DON/staff #122). The DON stated that the informed consents for the use of [MEDICAL CONDITION] medications are obtained prior to administering the medications from the resident or their representative. The DON stated that the informed consent form has to be completed before having the resident or their representative sign the form. The DON also stated that the psychoactive medication informed consent forms for resident #117 should have been completed with all the information prior to the resident signing to ensure the resident was fully informed. During an interview conducted on 10/25/18 at 03:09 PM with a RN (staff #1), the RN stated the admitting nurse will complete the consent for the use of any [MEDICAL CONDITION] medications and that all of the sections of the form should be completed prior to having the resident or their representative sign the form. The facility's policy titled Psychopharmacological Medication management did not address informing the resident of the risks and benefits of psychoactive medications.",2020-09-01
757,MI CASA NURSING CENTER,35120,330 SOUTH PINNULE CIRCLE,MESA,AZ,85206,2018-10-26,600,D,1,1,QPRH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, facility documentation, and policy and procedure, the facility failed to ensure one resident (#223) was free from neglect by failing to ensure one licensed staff member (#191) did not leave a potentially harmful solution at the resident's bedside. Findings include: Resident #223 was admitted to the facility on (MONTH) 18, (YEAR) with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Apply half-strength Dakin's soaked gauze and dry dressing for 10 days then reevaluate. Topical three times daily. The admission MDS (Minimum Data Set) assessment dated (MONTH) 25, (YEAR) revealed a BIMS (Brief Interview for Mental Status) score of 15 which indicated the resident was cognitively intact. Review of an Incident/Accident Data Entry Questionnaire dated (MONTH) 29, (YEAR) revealed At 3:00 a.m. resident reported to CNA (certified nursing assistant) that he drank approximately 45 cubic centimeters of something that did not taste like water. CNA brought out a plastic cup with a drop left in bottom of cup that smelled like Dakin's solution. Nurse spoke to resident shortly after and he was eating a sandwich and almond milk. Wound treatment done to right ischium and abdomen at 3:30 a.m .At 7:00 a.m. therapy asked nurse to speak with resident about what he drank. Nurse explained to resident that an incident report was started, poison control for the State of Arizona was notified, Dr . his nurse practitioner, and the facility director of nursing was notified of the incident .Supplies not to be left in resident's room . However, review of the clinical record did not reveal documentation by the nurse regarding this incident. A SLP (speech language pathology) Evaluation and Plan of Treatment dated (MONTH) 29, (YEAR) revealed the Patient seen for modified bedside swallow evaluation. Patient reported difficulty and pain with swallowing. Patient reported pain in mouth due to recent burn. Patient reported that softer foods are easier to swallow. Oral motor examination indicated lingual strength within normal limits. Speech therapist educated patient on need to change diet and utilize speech swallow study. Speech therapist recommends mechanical soft and thin liquids with training in speech swallow study . A physician's orders [REDACTED]. Review of an undated facility documentation by the DON (director of nursing/staff #122) revealed An investigation into a potential quality of care concern with regard to the placement of a caustic chemical in an unmarked container within reach of the aforementioned patient (resident #223) was immediately initiated upon knowledge of the occurrence .It was reported to this director of nursing services by (staff #191, a registered nurse) the aforementioned resident may have drank a solution believed to be Dakin's, a dilute solution of sodium hypochlorite (bleach) used for cleaning wounds which was left in an unmarked cup on the patient's bedside table .Interview with the registered nurse (staff #191) assigned to (resident's name) revealed the following: Approximately 3:00 a.m. on (MONTH) 29, (YEAR) (resident's name) reported to the night aide that he drank approximately 45 cubic centimeters of something that did not taste like water. The aide brought out an unmarked cup that had approximately a drop of an unknown clear solution inside. (Staff #191) stated she smelled the cup and she recognized it to be Dakin's, the solution used to cleanse his wound during dressing changes. (Staff #191) then spoke to the resident and noted him eating a sandwich and drinking almond milk. According to (staff #191) after (resident's name) finished his sandwich she completed a dressing change .(Staff #191) stated she notified (physician's name) and his nurse practitioner who instructed her to call poison control. Per poison control, the patient was to be monitored and the 'typically the first hour after ingestion is when nausea, vomiting, stomach upset, or adverse reactions should happen.' Poison control further suggest resident increase fluid intake and rinse his mouth for any residue . Further review of the facility documentation revealed that the registered nurse, staff #191 was terminated from the facility for risky nursing practice. A Termination Form dated (MONTH) 31, (YEAR) revealed .Although the resident remains unharmed, this associate (staff #191) shows continual risky nursing practice with the potential for resident harm .the decision has been made to terminate the working relationship with this associate for the safety of current and future residents . An interview was conducted with the RN (registered nurse/staff #191) on (MONTH) 24, (YEAR) at 8:07 a.m. Staff #191 stated that she left the Dakin's solution in the resident's room on his nightstand. She stated that she wondered why the resident drank the Dakin's solution as it was not near his water. Staff #191 stated that she left about 30 cubic centimeters of Dakin's solution in the resident's room after she did a dressing change to the resident's wounds. When asked why she did not document the incident in the resident's clinical record, staff #191 stated that she had worked in another state and they did not talk about mistakes they made in the resident's clinical record. Staff #191 stated that the incident occurred at approximately 3:00 a.m. She stated that she talked to the resident and that he stated that he was hungry and wanted some milk so we got him some. When asked if she did any type of assessment after the resident drank the Dakin's solution, staff #191 stated that she did not because the resident stated that he was fine. Staff #191 stated that she thought Dakin's solution was safe to swallow but was not 100% sure. Staff #191 stated that the incident occurred at 3:00 a.m. and the first person she notified was the DON around 4:00 a.m. or 5:00 a.m. Staff #191 stated that she called the physician and poison control after she had contacted the director of nursing. Staff #191 stated that in hindsight she should have called the physician immediately at 3:00 a.m. rather than allowing the resident to eat or drink anything and prior to calling the director of nursing one to two hours after the incident. An interview was conducted with the DON (staff #122) on (MONTH) 24, (YEAR) at 9:23 a.m. The DON stated that staff #191 should have documented in the resident's clinical record regarding a possible change of condition. The DON stated that staff #191 should have contacted the physician first. The DON further stated that staff #191 was terminated for not following the nurse practice act and putting other residents at risk. Review of the facility's policy Protection of Residents Reducing the Threat of Abuse and Neglect revealed .Neglect - means the failure of the facility, its employees .to provide goods and services to a resident that are necessary to avoid physical harm, pain .Neglect .may be the result of one or more failures involving one resident and one staff person .",2020-09-01
758,MI CASA NURSING CENTER,35120,330 SOUTH PINNULE CIRCLE,MESA,AZ,85206,2018-10-26,655,E,0,1,QPRH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff and resident interviews, and policy and procedure, the facility failed to ensure a summary of the baseline care plan was provided to 6 residents (#'s 1, 61, 72, 87, 117, and 223) and their representative. Findings include: -Resident #87 was admitted to the facility on (MONTH) 23, (YEAR) with [DIAGNOSES REDACTED]. Review of the Baseline Care Plan and Initial Discharge Plan dated (MONTH) 23, (YEAR), revealed the resident was to have rehabilitation services, be educated on medications, and needed assistive devices. The baseline care plan was signed by a registered nurse and a dietary employee. However, the field for the resident or representative's signature was blank. Further review of the clinical record revealed no evidence that the care plan had been discussed with the resident or the resident's representative, or that the resident or the resident's representative was provided a summary of the care plan. -Resident #223 was admitted to the facility on (MONTH) 18, (YEAR) with [DIAGNOSES REDACTED]. Review of the Baseline Care Plan and Initial Discharge Plan dated (MONTH) 18, (YEAR) revealed the resident was to have rehabilitation services and be educated on medications. The baseline care plan was signed by a registered nurse and a dietary employee. The field for the resident or representative's signature was blank. Further review of the clinical record revealed no evidence that the care plan had been discussed with the resident or the resident's representative, or that the resident or the resident's representative was provided a summary of the care plan. -Resident #72 was admitted to the facility on (MONTH) 10, (YEAR) with [DIAGNOSES REDACTED]. Review of the Baseline Care Plan and Initial Discharge Plan dated (MONTH) 11, (YEAR), revealed the resident was to have rehabilitation services and be educated on medications. The baseline care plan was signed by a registered nurse, CNA (certified nursing assistant), and a dietary employee. The field for the resident or representative's signature was blank. Further review of the clinical record revealed no evidence that the care plan had been discussed with the resident or the resident's representative, or that the resident or the resident's representative was provided a summary of the care plan. An interview was conducted with resident #72 on (MONTH) 23, (YEAR) at 1:45 p.m. The resident stated that nursing did not review her plan of care with her. The resident stated they do not have time. The resident further stated that physical therapy asked her what her goals were. An interview was conducted with the DON (director of nursing/staff #11) on (MONTH) 24, (YEAR) at 8:30 a.m. The DON stated that the baseline care plan should be signed by the resident within 48 hours of admission. The DON stated that the facility currently has a performance improvement plan in place because this was not being done. The DON stated that the admitting nurse now has the responsibility of reviewing the baseline care plan with the resident within 48 hours of admission to the facility. During an interview conducted with a RN (registered nurse/staff #126) on (MONTH) 24, (YEAR) at 11:40 a.m., staff #126 stated that the admitting nurse completes the baseline care plan and has the resident or family member sign within 48 hours of admission to the facility. An interview was conducted with an LPN (licensed practical nurse/staff #75) on (MONTH) 24, (YEAR) at 2:10 p.m. Staff #75 stated that the baseline care plans are completed and reviewed with the resident within 48 hours of admission by the charge nurse who admitted the resident. -Resident #117 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's clinical record revealed a Baseline Care Plan and Initial Discharge Plan dated 10/03/18. The baseline care plan was signed by a registered nurse and a dietary employee. The field for the resident or representative's signature was blank. Further review of the clinical record revealed no evidence that the care plan had been discussed with the resident or the resident's representative, or that the resident or the resident's representative was provided a summary of the care plan. -Resident #1 was admitted to the facility on (MONTH) 10, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed a Baseline Care Plan and Initial Discharge Plan dated (MONTH) 10, (YEAR) that the resident was to receive rehabilitation services and was at risk for breaks in skin integrity. The baseline care plan contained signature lines for nursing staff, the resident, and the resident's representative. All signature lines were blank. Further review of the clinical record revealed no evidence that the care plan had been discussed with the resident or the resident's representative, or that the resident or the resident's representative was provided a summary of the care plan. -Resident #61 was readmitted to the facility on (MONTH) 31, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed a Baseline Care Plan and Initial Discharge Plan dated (MONTH) 2, (YEAR) that the resident was at risk for falls and was to receive rehabilitation services. The baseline care plan was signed by a registered nurse and a dietary employee. The space for the resident or the resident representative's signature was blank. Further review of the clinical record revealed no evidence that the care plan had been discussed with the resident or the resident's representative, or that the resident or the resident's representative was provided a summary of the care plan. An interview was conducted with the Director of Nursing (DON/staff #11) on (MONTH) 24, (YEAR), at 8:30 AM. The DON stated that the baseline care plan should be signed by the resident within 48 hours of admission. She stated that the facility currently has a performance improvement plan in place because this was not being done. The DON stated that the admitting nurse now has the responsibility of reviewing the baseline care plan with the resident within 48 hours of admission to the facility. Review of the facility's policy Baseline Care Plan revealed .A baseline care plan will be developed for every resident within 48 hours of admission to provide an initial set of instructions needed to provide effective and person-centered care of the resident that meets professional standards of care . The policy further included that the care plan would be reviewed with the resident or the resident's representative, and that they would be provided copies of the care plan.",2020-09-01
759,MI CASA NURSING CENTER,35120,330 SOUTH PINNULE CIRCLE,MESA,AZ,85206,2018-10-26,657,D,0,1,QPRH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy and procedure, the facility failed to ensure a care plan was revised to reflect current code status and the use of an indwelling catheter for one resident (#45). Findings include: Resident #45 was admitted on (MONTH) 16, (YEAR) with [DIAGNOSES REDACTED]. An advanced directive dated (MONTH) 16, (YEAR) revealed the resident was a full code status. Review of the care plan dated (MONTH) 16, (YEAR) revealed the resident was a full code. The care plan also included the resident was experiencing incontinent episodes. An advanced directive dated (MONTH) 1, (YEAR) revealed the resident signed for a DNR (do not resuscitate) status. A physician's orders [REDACTED].>A physician's orders [REDACTED]. Size: 16F, Bulb: 10ml. Change for blockage or obstruction, but no more often than once per month unless MD is notified. However, review of the resident's care plan did not reveal the care plan was revised to reflect the current code status or the use of an indwelling catheter. An interview was conducted on (MONTH) 25, (YEAR) at 8:33 a.m. with the RN MDS Coordinator (Registered Nurse/Minimum Data Set Coordinator/staff #86). Staff #86 stated that care plans are updated when the MDS nurses are made aware of the changes by the nursing staff. The MDS coordinator stated that resident information is obtained from the morning meetings and that care plan are updated as needed. Staff #86 stated that the staff nurses update the care plans in the paper chart and the MDS nurses update the care plan in the electronic record. The MDS coordinator stated that the indwelling catheter should be care planned. During an interview conducted on (MONTH) 25, (YEAR) at 8:41 a.m. with a MDS LPN (Licensed Practical Nurse/staff #43), staff #43 stated that the MDS nurses attend the morning staff meeting and that during the new order review, they will update care plans in the electronic record at that time. Staff #43 stated that the unit managers will update the care plan in the paper chart as they receive new orders. An interview was conducted on (MONTH) 25, (YEAR) at 10:31 a.m. with the DON (Director of Nursing/staff #122). The DON stated that the policy is to update each care plan as needed, but no less than quarterly, and that if an order is missed the MDS nurses would update the care plan on the next quarterly review. The facility's policy titled Care Planning and Interventions revealed the interdisciplinary team meets on a scheduled basis and develops an individualized care plan to provide the greatest benefit to the resident. The policy included the care plan is updated as needed, but no less than quarterly as conditions change or interventions are determined to be ineffective or need to be revised.",2020-09-01
760,MI CASA NURSING CENTER,35120,330 SOUTH PINNULE CIRCLE,MESA,AZ,85206,2018-10-26,755,D,0,1,QPRH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, and policy and procedure, the facility failed to ensure that drug records were in order and that an account of all controlled drugs was maintained for two residents (#'s 19 and 25). Findings include: -Resident #19 was admitted to the facility on (MONTH) 1, (YEAR) with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. A reconciliation of the resident's narcotic medications was conducted with a LPN (licensed practical nurse/staff #119) on (MONTH) 25, (YEAR) at 12:55 p.m. The resident's Individual Resident's Controlled Substance Record revealed that 8 [MEDICATION NAME] should be available. However, the bubble pack of [MEDICATION NAME] revealed that there were only 6 [MEDICATION NAME] available. An interview was immediately conducted with staff 119. Staff #119 stated that she administered two [MEDICATION NAME] to the resident on (MONTH) 25, (YEAR) at 10:00 a.m. but forgot to document on the Individual Resident's Controlled Substance Record and the Pain Flow Sheet. Staff #119 stated that when she administered the medication she should have documented that it was administered but that she would have caught the error at shift change. An interview was conducted with the DON (director of nursing/staff #122) on (MONTH) 25, (YEAR) at 1:20 p.m. The DON stated that narcotics should be documented when administered on the narcotic record and the Pain Flow Sheet. The DON further stated that staff #119 will make a late entry that the medication was administered. -Resident #25 was admitted to the facility on (MONTH) 8, (YEAR) with [DIAGNOSES REDACTED]. Review of a physician order [REDACTED]. A reconciliation of the resident's narcotic medications was conducted with a LPN (staff #75) on (MONTH) 25, (YEAR) at 1:40 p.m. The resident's Individual Resident's Controlled Substance Record revealed that 23 [MEDICATION NAME] should be available. The bubble pack of [MEDICATION NAME] revealed that there were only 22 [MEDICATION NAME] available. An interview was conducted immediately with staff #75. Staff #75 stated that she administered the resident [MEDICATION NAME] in the morning but forgot to document that it was administered. The facility's policy General Dose Preparation and Medication Administration revealed Document necessary medication administration .when medications are administered .",2020-09-01
761,MI CASA NURSING CENTER,35120,330 SOUTH PINNULE CIRCLE,MESA,AZ,85206,2018-10-26,757,D,0,1,QPRH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy and procedure, the facility failed to ensure one resident's (#99) drug regimen was free from unnecessary drugs, by failing to ensure that pain medication was administered per the physician orders. Findings include: Resident #99 was admitted to the facility on (MONTH) 19, (YEAR) with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED] -September 10: [MEDICATION NAME] 5/325 mg 1 tablet was administered for a pain level of 6. -September 13: [MEDICATION NAME] 5/325 mg 1 tablet was administered for a pain level of 6. -September 29: [MEDICATION NAME] 5/325 mg 1 tablet was administered for a pain level of 6. -September 30: [MEDICATION NAME] 5/325 mg 1 tablet was administered for a pain level of 6. -October 11: [MEDICATION NAME] 5/325 mg 1 tablet was administered for a pain level of 6. -October 12: [MEDICATION NAME] 5/325 mg 1 tablet was administered for a pain level of 6. -October 23: [MEDICATION NAME] 5/325 mg 1 tablet was administered for a pain level of 6. During an interview conducted on (MONTH) 25, (YEAR) at 8:04 a.m. with a Licensed Practical Nurse (LPN/staff #14), the LPN stated that the resident is able to verbalize and request pain medication when he has pain. Staff #14 stated that the Tylenol and [MEDICATION NAME] pain medication has a specific pain scale and that she would administer the medication according to the ordered pain scale. An interview was conducted on (MONTH) 25, (YEAR) at 10:26 a.m. with the Director of Nursing (DON/staff #122). Staff #122 stated that the expectation is that non-pharmacological interventions would be implemented or medications would be administered according to the physician's orders [REDACTED]. The DON also stated that the expectation is that as needed pain medication would be administered according to the ordered pain level. The facility's policy titled Pain Management revealed that the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice.",2020-09-01
762,MI CASA NURSING CENTER,35120,330 SOUTH PINNULE CIRCLE,MESA,AZ,85206,2018-10-26,842,B,0,1,QPRH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy, the facility failed to ensure the medical record was accurately documented for one resident (#12) regarding advance directives. Findings include: Resident #12 was admitted to the facility on (MONTH) 25, (YEAR), with a [DIAGNOSES REDACTED]. Review of the clinical record revealed a Pre-Hospital Medical Care Directive Do Not Resuscitate (DNR) signed by the resident and dated (MONTH) 29, (YEAR). The physician's orders [REDACTED]. Review of the care plan regarding advance directives revealed the resident was a DNR. Interventions included to verify the presence of the DNR in the clinical record and to verify the presence of a physician's orders [REDACTED]. However, further review of the clinical record revealed recapitulations of physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. An interview was conducted with a Licensed Practical Nurse (staff #142) on (MONTH) 25, (YEAR) at 2:11 p.m. He stated that he would review the chart or the MAR indicated [REDACTED]. After reviewing the MAR, he stated that if he found the resident not breathing without a heartbeat, he would start CPR (Cardiopulmonary Resuscitation). Staff #142 further stated that there needs to be an order for [REDACTED].>During an interview conducted with a Certified Nursing Assistant (CNA/staff #175) on (MONTH) 25, (YEAR) at 2:19 p.m., the CNA stated that if she found a resident unresponsive, she would get the nurse. The CNA also stated that she would have to review the chart to find out if the resident was a full code or a DNR. An interview was conducted with the Director of Nursing (DON/staff #122) on (MONTH) 26, (YEAR) at 8:48 a.m. The DON stated that a resident's code status is found in the chart. She stated that the code status should be consistent throughout the clinical record. The facility's policy regarding Advance Directives revealed residents may revise an advance directive either orally or in writing. The policy included that the physician must give an order for [REDACTED].",2020-09-01
763,MI CASA NURSING CENTER,35120,330 SOUTH PINNULE CIRCLE,MESA,AZ,85206,2018-10-26,880,D,0,1,QPRH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, facility documents, and policy and procedure, the facility failed to ensure contact isolation precautions were followed. Findings include: During an observation conducted on 10/22/18 at 11:58 AM, the following was observed: -A Certified Nursing Assistant (CNA/staff #15) gathered the disposable lunch containers and placed them on top of the isolation cart outside of an isolation room for a resident on contact isolation for [MEDICAL CONDITION] (MRSA) wound infection. -The CNA then donned an isolation gown, but no gloves. Gloves were available in the cart. -The CNA took several disposable containers of food into the resident's room and placed them on the bedside table. -The CNA then returned to the door of the room, obtained a pair of gloves from the box mounted on the wall inside the room and then retrieved the remaining containers of food from the top of the isolation cart outside of the room. -The CNA placed the containers of food on the resident bedside table, then donned the gloves, set up the resident's meal, and assisted the resident into a position to eat. -The CNA then returned to the door of the room to get some salt and pepper packets from another CNA waiting outside the room. -The CNA removed her gloves and placed them in the isolation bin inside the room, and then the CNA removed her gown, rolled it, and placed it inside the same isolation bin inside the room. -The CNA then exited the room without washing or sanitizing her hands, went down the hall to the pantry, opened the door using the door handle, and washed her hands in the pantry sink. An interview was conducted on 10/22/18 at 12:09 PM with CNA #15. The CNA stated that a gown and gloves are to be put on before entering an isolation room. She stated that she knew she went into the room without donning gloves and that she did not put on gloves until after she had put down the first set of disposable dishes. The CNA also stated that the process for removing the gown and gloves is to remove the gloves and then the gown. She further stated that she did not think about contaminating the handle of the pantry door. During an interview conducted on 10/22/18 at 12:16 PM with a Registered Nurse (RN/staff #180), the RN stated that a gown and gloves need to be donned before entering an isolation room. Staff #180 stated that before exiting the room, remove the gown with the gloves and that the gloves are the last to come off. The RN stated that she leaves the room and goes to the soiled utility room to wash her hands. Staff #180 then stated that the handle of the soiled utility room would be contaminated and that she had never wiped the handle. An interview was conducted on 10/22/18 at 12:57 PM with the RN/Director of Nursing (DON/staff #122). The DON stated that when a resident is on contact isolation, staff are to gown and glove before entering the room. She stated that the policy is to remove the gown with the gloves, wrap them together, and toss them into the isolation bin. The DON also stated that the staff should wash their hands with soap and water in the room before leaving the room. A sign posted on the resident's door instructed those entering the room to see the nurse before entering and to Turn Over the sign for PPE Information. The back of the sign contained the following information:Contact Precautions Instruct visitors to wash hands when entering and leaving the room .Gown and gloves are required; Gloves required at all times .Hand hygiene required prior to leaving room. Hand sanitizer is not acceptable. The facility's policy titled Transmission-based Precautions and Isolation Procedures revealed the purpose is to minimize the risk of spread of infections between patient and/or associates and to control the spread of infection by intercepting its method of transmission from person to person. The policy included contact precautions are used for diseases transmitted by contact with the patient or the patient's environment by direct or in-direct contact.",2020-09-01
764,MI CASA NURSING CENTER,35120,330 SOUTH PINNULE CIRCLE,MESA,AZ,85206,2019-12-19,637,D,0,1,W0SY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that a significant change Minimum Data Set (MDS) assessment was completed for one resident (#50). Findings include: Resident #50 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan initiated 03/03/2019 revealed the resident had a nutritional problem or potential nutritional problem related to receiving hospice services. Review of the clinical record revealed the resident was admitted to hospice care on 3/10/19. However, review of the MDS assessments did not reveal a significant change MDS assessment was conducted. During an interview conducted with the MDS nurse (staff #142) on 12/17/19 at 12:56 PM, she stated the resident was started on hospice care on 3/10/19 and that a significant change MDS assessment should have been completed by 3/24/19. In an interview conducted with the Director of Nursing (staff #161) on 12/17/19 at 12:58 PM, she stated resident #50 should have had a significant change MDS assessment done when she started hospice on 3/10/19. Review of the RAI manual dated 10/2019 revealed a significant change in status assessment is required to be performed when a resident enrolls in a hospice program. The assessment reference date (ARD) must be within 14 days from the effective date of the hospice election. The manual also revealed this is to ensure a coordinated plan of care between hospice and nursing home is in place.",2020-09-01
765,MI CASA NURSING CENTER,35120,330 SOUTH PINNULE CIRCLE,MESA,AZ,85206,2019-12-19,640,D,0,1,W0SY11,"Based on clinical record review, staff interviews, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that the discharge Minimum Data Set (MDS) assessment was transmitted to the Centers for Medicare and Medicaid Services (CMS) system within 14 days after completion for one resident (#79). The deficient practice could result in lack of resident specific information for quality measure purposes. Findings include: Resident #79 was admitted to the facility on (MONTH) 2, 2019 and discharged from the facility on (MONTH) 17, 2019. Review of the discharge MDS assessment dated (MONTH) 17, (YEAR) revealed the resident was discharged to the community on (MONTH) 17, 2019. The assessment also revealed the Registered Nurse assessment coordinator signed the assessment as complete on (MONTH) 22, 2019. However, review of the CMS system revealed the discharge MDS assessment had not been transmitted. An interview was conducted with two MDS nurses (staff #13 and #142) on (MONTH) 17, 2019 at 3:08 p.m. Staff #142 said when an MDS assessment is marked completed, that meant the assessment is finished. She said when an MDS assessment is marked accepted, that means it had been transmitted to the CMS system. She stated some assessments are transmitted to the CMS system, and some assessments are not transmitted because they were created for insurance and billing purposes. Staff #142 stated all discharge assessments should be transmitted to the CMS system. She said the electronic health record provides a checkpoint that gives instructions on whether or not to submit a MDS assessment to the CMS system. Staff #142 stated the software had given instructions to not submit the discharge assessment, which was why it was not submitted. During an interview conducted with the Director of Nursing (DON/staff # 161) on (MONTH) 18, 2019 at 2:52 p.m., she stated her expectation is that the MDS assessment be completed and submitted in accordance with the regulations. Review of the RAI manual revealed a discharge MDS assessment must be submitted electronically and accepted into the CMS system, within 14 days after completion.",2020-09-01
766,MI CASA NURSING CENTER,35120,330 SOUTH PINNULE CIRCLE,MESA,AZ,85206,2019-12-19,657,E,0,1,W0SY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure the care plan was revised for 3 out of 23 sampled residents (#21, #32 and #58). The deficient practice could result in inaccuracies regarding resident care. Findings include: -Resident #32 was admitted to the facility on (MONTH) 7, 2019, with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 14, 2019, revealed a Brief Interview for Mental Status score of 13, which indicated the resident was cognitively intact. The assessment included the resident required extensive assistance for bed mobility, transfers and toilet use. The assessment also included that the resident did not have an indwelling urinary catheter and was occasionally incontinent of urine. A care plan for urinary incontinence dated (MONTH) 1, 2019, included a goal that the resident would have no skin breakdown related to urinary incontinence. Interventions included assisting with toileting as needed, providing incontinence briefs to maintain dignity and providing perineal care as needed. A physician's orders [REDACTED]. Review of a nursing progress note dated (MONTH) 5, 2019, revealed a Foley catheter was inserted. A significant change MDS assessment dated (MONTH) 5, 2019, revealed the resident had an indwelling catheter. The assessment included urinary incontinence and indwelling catheter was triggered and would be addressed in the care plan. However, review of the clinical record revealed no evidence the care plan was updated with goals and interventions for the resident's use of an indwelling urinary catheter. An interview was conducted with a Licensed Practical Nurse (LPN/staff #124) on (MONTH) 18, 2019 at 11:16 a.m. She stated when a nurse receives a new order, that nurse would be expected to update the resident's care plan accordingly. She said the MDS nurse could also update the resident's care plan. An interview was conducted with the Director of Nursing (DON/staff #161) on (MONTH) 18, 2019 at 2:52 p.m. She said updating care plans was an interdisciplinary effort. She said whoever found the change that needed to be made to the care plan could create the update, or they could notify someone who was able to make the update. The DON stated clinical records were routinely audited for certain things such as skin conditions, falls or catheters. She said when a change is identified during the audits; the appropriate care plan would be updated. The DON also stated she expected care plans to be updated after completion of the MDS assessment, or within approximately two weeks of completion of the MDS assessment. Review of the facility's policy for the Resident Assessment Instrument and Care Plan reviewed (MONTH) 29, 2019, revealed the MDS assessment would be completed at a minimum upon admission, quarterly, annually, and with a significant change in resident status. The care area process would begin with the care area triggers in the MDS assessment. The information identified using the MDS and Care Area Assessment process would be used to develop an individualized, person-centered care plan. -Resident #21 was admitted to the facility on (MONTH) 12, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed a physician order [REDACTED]. Review of the care plan initiated (MONTH) 27, (YEAR), revealed the resident was receiving oxygen therapy related to ineffective gas exchange. The goal was that the resident would have no signs or symptoms of poor oxygen absorption. Interventions included oxygen via nasal cannula continuously at 2 liter per minute. The quarterly MDS assessment dated (MONTH) 12, 2019 revealed the resident was receiving oxygen therapy. Continued review of the care plan regarding oxygen revealed an intervention initiated (MONTH) 20, 2019 for oxygen via nasal cannula at 4 liters per minute continuously. However, review of the physician's orders [REDACTED]. An interview was conducted on (MONTH) 18, 2019 at 10:14 a.m. with the DON (staff #161). The DON stated the care plan for oxygen would be revised as needed including when the orders for oxygen are changed. She stated the care plan should match the order for oxygen settings. The DON stated they complete regular audits to ensure the care plans are accurate and up to date. -Resident #58 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the care plan initiated 2/9/19 revealed the resident was at risk for falls related to poor safety awareness and impulsive behaviors. The goal was that the resident would not sustain serious injury requiring hospitalization . Interventions were assisting with activities of daily living as needed, keeping the call light within reach and orienting the resident to the room. A review of the clinical record revealed a progress note dated 12/15/19 at 7:05 PM that the resident was found lying on the floor at 6:45 PM. The note included the resident stated I was trying to go to the bathroom when I stood up and fell . The note also included the resident was assessed and had no signs or symptoms of new injuries. However, further review of the care plan did not reveal the care plan was revised to include the fall on 12/15/19 and/or if new interventions were implemented. During an interview conducted with a LPN (staff #185) on 12/19/19 at 9:29 AM, she stated that a resident who has a fall is assessed and neuro checks may be initiated if the fall is unwitnessed. The LPN stated that the next day they make rounds and decide what interventions should be implemented. Staff #185 also stated that an administration staff would update the care plan. After reviewing resident #58's care plan, the LPN confirmed the care plan had not been updated for the fall on 12/15/19. Review of the facility's policy for fall management reviewed (MONTH) 15, 2019, revealed residents will be assessed for fall indicators with any fall event. The interdisciplinary team will review and revise the care plan, if indicated, upon completion of each comprehensive, significant change and quarterly MDS assessment, upon a fall event and as needed thereafter.",2020-09-01
767,MI CASA NURSING CENTER,35120,330 SOUTH PINNULE CIRCLE,MESA,AZ,85206,2019-12-19,677,D,0,1,W0SY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, resident and staff interviews and policy review, the facility failed to ensure that one out of four sampled residents (#55) received showers according to the care plan. The deficient practice could result in hygiene needs not being met. Findings include: Resident #55 was admitted to the facility on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. Review of a care plan dated (MONTH) 29, 2019, revealed the resident had Activities of Daily Living (ADL) self-care performance deficit related to [MEDICAL CONDITION]. The care plan included the resident was totally dependent on staff to provide showers twice weekly and as necessary. A quarterly Minimum Data Set (MDS) assessment dated (MONTH) 30, 2019, revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The assessment included the resident required extensive assistance for transfers, toileting and personal hygiene, and was totally dependent on staff for bathing. Review of the nurse aide documentation for bathing for (MONTH) 2019, revealed no evidence the resident was offered or refused bathing assistance. The documentation included the code NA on (MONTH) 2, 5, 9, 12, 16, 19, 23, 26 and 30. Review of the nurse aide skin check and/or shower sheets for (MONTH) 2019, revealed the resident received a shower on (MONTH) 4 and 25, and the resident refused a shower due to back pain on (MONTH) 21. Review of the nurse aide documentation for bathing for (MONTH) 2019, revealed the code NA on (MONTH) 6, and that the resident refused bathing assistance on (MONTH) 9, 13 and 16. An interview was conducted with the resident on (MONTH) 16, 2019 at 10:14 a.m. He stated that he had not received a shower in over a month. He said that showers were the only time he received assistance shaving his face, and his beard was getting long. The resident's beard was observed to be approximately 0.5 inches long. The resident said he was supposed to receive showers twice a week, but no one came to offer him a shower. He stated that staff would automatically come to take his roommate for a shower twice a week, but no one came for him. Review of the nurse aide skin check/shower sheets for (MONTH) 2019, revealed the resident received a shower on (MONTH) 17, 2019. An interview was conducted with a Certified Nursing Assistant (CNA/staff #65) on (MONTH) 19, 2019 at 10:04 a.m. She said there was a shower schedule that evenly divided shower assignments between the day and evening shifts and allowed each resident to receive a shower twice a week. She said the schedule was based on residents' room numbers. She stated the CNA who provided the shower would fill out a skin check/shower sheet with any observed skin issues and give it to the nurse for review. A follow-up observation and interview was conducted with the resident on (MONTH) 19, 2019 at 10:48 a.m. He stated that he had received his shower and his face had been shaved. The resident was observed to be clean-shaven with a trimmed mustache. He said no one had offered him a shower and he had not refused a shower that week. He said the head nurse came to see him and asked why he did not receive a shower the previous day. He said he told her he did not know it was his shower day, and no one had told him about a shower that day. The resident stated after that conversation he received a shower. He said the only time recently that he remembered refusing a shower was once when he had received a lot of physical therapy and he was tired. An interview was conducted with the Director of Nursing (DON/staff #161) on (MONTH) 19, 2019 at 1:17 p.m. She said the standard routine for residents to receive showers included a schedule where rooms were assigned certain days and times each week for showers. She said the standard frequency for showers was twice a week, but the frequency and shower schedule could be altered based on resident preferences or requests. She said if a resident refused a shower, she would expect staff to re-approach the resident, then notify the nurse and have the nurse re-approach the resident as well. She said if the resident continued to refuse, she might re-approach the resident also. The DON stated that if the resident had a pattern of refusals, there would be a discussion between the resident, staff, and family members as applicable to find out the reason. She stated documentation of resident refusals of showers would be found in the electronic CNA documentation or on the skin check/shower sheets. She said sometimes the nurse or the interdisciplinary team would also write a progress note. The DON stated there was no official audit process for reviewing CNA shower documentation. She said for this resident, his room had been changed in the last few months, and therefore his shower schedule had changed. She also stated the shower schedule had not been updated in the electronic record for the nurse aides to document. Review of the facility's policy regarding ADLs reviewed (MONTH) 22, 2019, revealed the purpose was to ensure the facility identified and provided needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice to meet each resident's needs. The policy included residents would receive assistance as needed to complete ADLs.",2020-09-01
768,MI CASA NURSING CENTER,35120,330 SOUTH PINNULE CIRCLE,MESA,AZ,85206,2019-12-19,686,D,1,1,W0SY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#316) who developed a pressure ulcer received treatment and services consistent with professional standards of practice. The deficient practice could result in care not being provided to residents with pressure ulcers. Findings include: Resident #316 was readmitted on (MONTH) 25, 2019, with [DIAGNOSES REDACTED]. The Braden Scale for predicting pressure ulcer risk and risk factors dated (MONTH) 25, 2019 revealed a score of 12 which indicated the resident was at high risk for pressure ulcers. Review of the clinical record revealed a physician order [REDACTED]. The weekly skin integrity data collection form dated (MONTH) 29, 2019 revealed the resident skin was not intact, there was blanchable redness to the coccyx area, and barrier cream was applied as ordered. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 2, 2019 revealed the resident was independent regarding cognitive skills for daily decision making. The assessment included the resident did not have any pressure ulcers but was at risk for developing pressure ulcers. A weekly skin integrity data collection form dated (MONTH) 6, 2019 revealed the resident's skin was intact. The document included the resident had some redness on the coccyx area, barrier cream was applied, and no open areas were observed. The weekly skin integrity data collection form dated (MONTH) 13, 2019 revealed the skin was intact and that there were no new skin issues. Review of the physician orders [REDACTED]. The skin integrity data collection forms dated (MONTH) 19, 20, and 27, 2019 revealed the resident's skin was not intact, and that there was an open area/wound on the resident's right buttock. The notes also included a treatment was in place. Review of the Treatment Administration Record (TAR) dated (MONTH) 2019 revealed the treatment was provided as ordered to the open area. However, further review of the clinical record revealed no documentation that the right buttock wound was ever thoroughly assessed to include a description of the wound, staging, and measurements. Additional review of the clinical record revealed there was no care plan developed which addressed the pressure ulcer to the right buttock. There was also no intervention on any care plans regarding the care and treatment for [REDACTED]. The discharge MDS assessment dated (MONTH) 30, 2019 revealed the resident was discharged to an acute hospital and had no unhealed pressure ulcers at Stage 1 or higher. An interview was conducted with the Licensed Practical Nurse (LPN/staff #96) who is the wound nurse on (MONTH) 18, 2019 at 2:47 p.m. Staff #96 stated that once she is notified a resident has a break in skin integrity, she assesses the area, initiates a Wound Observation Tool, obtains an order for [REDACTED]. Regarding resident #316, the LPN stated she was not notified the resident had a wound. She stated information regarding skin status is supposed to be passed on during report. However, the LPN stated that she was aware [MEDICATION NAME] was being used for the resident's wound. She also stated that [MEDICATION NAME] is used for pressure ulcers stage 2 and above. On (MONTH) 18, 2019 at 3:20 p.m., an interview was conducted with the Director of Nursing (DON/staff #161). For a resident that has developed a wound, the DON stated her expectation would be for nursing to document the wound on a nursing progress note or complete a skin integrity assessment and notify the physician to obtain a treatment order. The DON stated she would expect the wound care nurse to be notified. She said her expectation would be for the wound care nurse to assess the wound, ensure the appropriate treatment and determine whether or not she would follow the wound. Review of the facility's policy titled Skin Integrity and Pressure Ulcer/Injury Prevention and Management effective (MONTH) 3, 2019, revealed a comprehensive skin inspection/assessment is conducted on admission and re-admission to the facility. The policy included the facility will utilize the Lippincott procedures for pressure injury management, long term care. The Lippincott procedure for pressure injury management, long term care revealed documentation should include the size, location, depth, and stage of the pressure injury; the condition of the wound bed, the presence of eschar, and the status of the peri-wound area. The procedure included the presence and signs of infection and pain, wound care provided and the resident's response to the interventions should be documented. The procedure also included teaching should be provided to the resident and/or family members and their understanding of the teaching, and whether they require follow-up teaching should be documented as well.",2020-09-01
769,MI CASA NURSING CENTER,35120,330 SOUTH PINNULE CIRCLE,MESA,AZ,85206,2019-12-19,695,D,0,1,W0SY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, and policy reviews, the facility failed to ensure oxygen therapy was provided to one resident (#21) consistent with professional standards of practice. The deficient practice could result in respiratory complications. Findings include: Resident #21 was admitted to the facility on (MONTH) 12, (YEAR) with [DIAGNOSES REDACTED]. The physician order [REDACTED]. Review of the care plan initiated on (MONTH) 27, (YEAR) revealed the resident was receiving oxygen therapy related to ineffective gas exchange. The goal was that the resident would have no signs or symptoms of poor oxygen absorption. Interventions included observing for signs and symptoms of respiratory distress and reporting to the physician as needed: respirations, pulse oximetry, increased heart rate, restlessness, diaphoresis, headaches, lethargy, confusion, and accessory muscle use and cough. Further review of the care plan, revealed an intervention initiated (MONTH) 27, (YEAR) for oxygen via nasal cannula at 2 liters per minute continuously and an intervention initiated (MONTH) 20, 2019 for oxygen via nasal cannula at 4 liters per minute continuously However, review of the physician's orders [REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated (MONTH) 30, 2019 revealed a score of 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. The MDS assessment also included the resident was receiving oxygen therapy. Review of the Medication Administration Record [REDACTED]. An observation was conducted of resident #21 on (MONTH) 16, 2019 at 9:22a.m. One prong of the nasal cannula was observed in the resident's her left nostril and the other prong was resting on her face to the left of her nose. The oxygen concentrator was set at 3 liters per minute. The tubing on the concentrator and the nasal cannula were not labeled with a date which would indicate when they had been changed. A Certified Nursing Assistant (CNA/staff #183) entered the resident's room during this observation and was not observed to check the resident's oxygen concentrator or tubing, and or adjust the resident's nasal cannula. Another observation was conducted of resident #21 on (MONTH) 17, 2019 at 9:26a.m. The resident was observed holding the nasal cannula in her hand. The oxygen concentrator was set at 3 liters per minute. The tubing on the concentrator and the nasal cannula were not labeled with a date to indicate when they were last changed. During this observation, the resident stated the nasal cannula was abrasive to her nostril and she did not like to wear it. An interview was conducted with resident #21 on (MONTH) 18, 2019 at 9:12 a.m. The tubing on the concentrator and the nasal cannula were labeled with the date (MONTH) 18. The resident stated that her oxygen concentrator was changed that morning, about an hour prior to this interview. She stated that when the machine was changed, no one checked to make sure it was working. The resident stated she had not been receiving oxygen since the machine was changed. The concentrator was observed and appeared to be working and was set at 2 liters per minute. The resident stated the tubing is incorrect and that is why she is not getting oxygen. Resident #21 also stated she had not alerted staff to the issue as she waved the nasal cannula around. At 9:35a.m., a CNA (staff #48) entered resident #21's room to provide care to resident #21's roommate. Resident #21 was heard telling staff #48 that she had a headache but did not need anything. After exiting the room, staff #48 was heard asking staff #183 to check on resident #21 when staff #183 had a chance. At 9:37a.m., resident #21 turned on her call light. A Licensed Practical Nurse (LPN/staff #74) responded and resident #21 told staff #74 that her oxygen was not working. Resident #21 stated to staff #74 that she had a bad headache but declined pain medication. Staff #74 checked the oxygen machine and informed the resident the machine was working fine. Staff #74 then checked the tubing and found it was twisted and blocking the oxygen flow. Staff #74 fixed the tubing and resident #21 stated she was able to breathe. An interview was conducted with the LPN (staff #74) on (MONTH) 18, 2019 at 9:56 a.m. Staff #74 stated that each time she enters resident #21's room, she checks the oxygen. She stated resident #21 does not like to wear the nasal cannula, but that they encourage her to keep it on. Staff #74 said she did not know how many liters of oxygen were ordered and that she needed to look it up. After reviewing the order, she said the order is for 2-4 liters per minute and that she usually keeps it at 2 liters per minute unless the resident is in distress. She stated the night shift changes the tubing once a week, and that the tubing is be labeled with the date it was changed. Staff #74 stated that when the tubing is changed, the tubing should be checked to make sure it is not twisted or bent to prevent the oxygen flow. Review of the physician orders [REDACTED]. An interview was conducted with the Director of Nursing (DON/ staff #161) on (MONTH) 18, 2019 at 10:14a.m. The DON stated the order for oxygen is usually a range so that the oxygen can be titrated to meet the residents' needs and comfort. Another interview was conducted with the DON on (MONTH) 18, 2019 at 12:46p.m. The DON stated the tubing on the oxygen concentrators is changed weekly, on Sunday. She stated the tubing should be labeled with the date it was changed. The DON stated that she expects staff to check oxygen equipment as they make their rounds and each time they enter the room and to make adjustments as needed. The facility's policy titled Oxygen Administration/ Safety/ Storage/ Maintenance reviewed (MONTH) 15, 2019, revealed oxygen supplies should be changed weekly and when visibly soiled. Equipment should be labeled with the resident name and dated when set up or changed out. The facility's policy regarding physician orders [REDACTED].",2020-09-01
770,MI CASA NURSING CENTER,35120,330 SOUTH PINNULE CIRCLE,MESA,AZ,85206,2019-12-19,732,D,0,1,W0SY11,"Based on observation, review of nurse staffing information, and staff interview, the facility failed to ensure the nurse staffing information was posted on a daily basis. Findings include: During an observation conducted on (MONTH) 16, 2019 at 8:17a.m., the daily nurse staff posting form was in a frame on the desk of the front receptionist. The daily staff posting form was dated (MONTH) 13, 2019. The posted nurse staffing information included the facility census, the number of Registered Nurses (RN), Licensed Practical Nurses (LPN), Certified Nursing Assistants (CNA) and the actual hours worked for each shift. Review of the daily staff postings forms for (MONTH) 2019 conducted on (MONTH) 18, 2019 at 1:12p.m., revealed there were daily staff posting forms which had been completed from (MONTH) 1 through (MONTH) 14. An interview was conducted with the Director of Nursing (DON/Staff #161) on (MONTH) 18, 2019 at 2:17p.m. The DON stated she is responsible for posting the daily staffing form. The DON stated that on the weekends, the receptionist is responsible for posting the form. She said in the past, the staffing coordinator would make sure the form was posted, but that staff member has been on leave and she has taken on the responsibility. The DON stated she posts a new staffing form every morning at the beginning of the shift. She stated she has two hours from the start of the morning shift to post a new staffing form. Regarding the staff posting dated (MONTH) 13 that was posted on (MONTH) 16, 2019, the DON stated she would expect the weekend staff to change the posting daily.",2020-09-01
771,MI CASA NURSING CENTER,35120,330 SOUTH PINNULE CIRCLE,MESA,AZ,85206,2019-12-19,761,E,0,1,W0SY11,"Based on observations, staff interviews and policy review, the facility failed to ensure expired medical supplies were not available for resident use. The deficient practice could result in inaccurate laboratory results and increased risk for infection. Findings include: During an observation of station 1 medication storage room conducted with a Registered Nurse (staff #64) on (MONTH) 19, 2019 at 11:38 a.m., the following were observed: -approximately thirty blood collection tubes with an expiration date of (MONTH) 30, 2019, which were stored in a cupboard with other blood collection tubes that were not expired. -Four expired culture swab kits which were stored in a drawer with other culture swab kits that were not expired. One culture swab kit had an expiration date of (MONTH) (YEAR), two kits had expiration dates of (MONTH) (YEAR), and another kit had an expiration date of (MONTH) 2019. An interview was conducted with staff #64 during this observation. She stated that she was responsible for auditing the medication room. She said she checks the room about every two weeks for expired products. During an observation of station 3 medication storage room conducted with a Licensed Practical Nurse (staff #176) on (MONTH) 19, 2019 at 11:56 a.m., the following were observed: -One PICC (peripherally inserted central catheter) line dressing change kit with an expiration date of (MONTH) 30, 2019, which was stored in a cupboard with other dressing change kits that were not expired. -Another PICC line dressing change kit with an expiration date of (MONTH) 31, 2019, which was stored in a cupboard with other dressing change kits that were not expired. The packaging of the kit was partially opened. -Two IV (intravenous) insertion kits with expiration dates of (MONTH) (YEAR) which were stored in a drawer with other IV insertion kits that were not expired. The packaging of one of the kits was partially opened. An interview was conducted with staff #176 during this observation. She stated she was responsible for auditing the medication room. She said the room contained a separate bin for expired medications and items that were to be returned to the pharmacy. An interview was conducted with the Director of Nursing (staff #161) on (MONTH) 19, 2019 at 1:41 p.m. She stated her expectation is that there should not be expired medications or supplies in the medication storage rooms. Review of the facility's policy titled: Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles revised (MONTH) 28, 2019, revealed the following: -The facility should ensure that medications and biologicals that have an expired date on the label, have been retained longer than recommended by manufacturer or supplier guidelines, or have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier. -The facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with pharmacy return/destruction guidelines, other applicable law and in accordance with facility policy. -Facility personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis.",2020-09-01
772,BANNER BOSWELL REHABILITATION CENTER,35121,10601 WEST SANTA FE DRIVE,SUN CITY,AZ,85351,2017-07-07,309,D,1,1,BCBE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, and review of policies and procedures, the facility failed to ensure physicians' orders were in place for the care and monitoring of one resident's (#15) [MEDICAL TREATMENT] central venous catheter. Findings include: Resident #15 was admitted on (MONTH) 29, (YEAR), with [DIAGNOSES REDACTED]. A physician's order dated (MONTH) 1, (YEAR) included for [MEDICAL TREATMENT] treatments on Tuesdays, Thursdays, and Saturdays. Review of the pre/post [MEDICAL TREATMENT] assessments completed by the off-site [MEDICAL TREATMENT] provider dated (MONTH) 4 and (MONTH) 6, (YEAR), revealed documentation that the resident had a CVC (central venous catheter) in the right femoral vein. However, there were no physician orders for the care or monitoring of the CVC site. In addition, there was no documentation that the resident's CVC site had been consistently monitored from (MONTH) 1 through 7, (YEAR). An interview was conducted on (MONTH) 7, (YEAR) at 1:15 p.m., with a RN (registered nurse/staff #137). Staff #137 stated that she was not aware of any monitoring of the resident's [MEDICAL TREATMENT], which was to be done. An interview was conducted with the DON (Director of Nursing/staff #72) and the corporate RN consultant (staff #146) on (MONTH) 7, (YEAR) at 1:30 p.m. Upon review of the resident's clinical record, staff #72 and staff #146 could not locate any consistent documentation regarding the monitoring of the resident's CVC [MEDICAL TREATMENT]. Staff #146 stated the expectation is that the CVC site would be monitored and documented in the clinical record, based on physician's orders and standard of practice. Review of a policy regarding physician's orders revealed that an order is required for all tests, services, therapies and treatments. A policy regarding Adult Patient Standards of Care included that upon admission, all patients have a baseline assessment of their problems/needs and receive an appropriate level of care. The completed patient assessment assists with the formulation of a plan of care and determines appropriate referrals and reassessments.",2020-09-01
773,BANNER BOSWELL REHABILITATION CENTER,35121,10601 WEST SANTA FE DRIVE,SUN CITY,AZ,85351,2017-07-07,314,D,1,1,BCBE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that thorough and timely assessments were completed for one resident (#156), with a pressure ulcer. Findings include: Resident #156 was admitted to the facility on (MONTH) 16, (YEAR), with [DIAGNOSES REDACTED]. Review of the 30-day MDS (Minimum Data Set) assessment dated (MONTH) 13, (YEAR) revealed the resident had a BIMS (brief interview for mental status) score of 15, which indicated no cognitive impairment. The MDS assessed the resident to require extensive assistance of one person with bed mobility and transfers. The MDS also identified that the resident had a risk of developing pressure ulcers and had an unstageable pressure ulcer that was not present on admission. The documentation included that the most severe type of tissue present was slough (yellow or white tissue). A wound ostomy consult note dated (MONTH) 15, (YEAR), documented the resident had a pressure ulcer on the left heel, which measured 2 x 3 x 0.3 centimeters (cm), with a small amount of serous drainage. The wound bed was pink/yellow in color, with 100% necrotic slough tissue and the surrounding skin was normal. The pressure ulcer was described as a full thickness injury, and that autolytic debridement was used. The note also included that the pressure ulcer was present on admission. Review of the resident's clinical record revealed there was no documentation that the left heel pressure ulcer had been thoroughly assessed at least weekly, (which included measurements, description of the wound bed and surrounding skin, if drainage was present, description of the wound edges, if any tunneling or undermining were present) from (MONTH) 16, (YEAR) through (MONTH) 14, (YEAR). The facility was unable to provide any clinical record documentation that thorough wound assessments of the resident's left heel had been completed from (MONTH) 16, (YEAR) through (MONTH) 14, (YEAR). Further review of the clinical record revealed the resident was admitted to the hospital on (MONTH) 15, (YEAR), and was readmitted to the facility on (MONTH) 1, (YEAR). Review of the admission physician's orders [REDACTED]. The orders also included for the resident to be on contact isolation precautions for a history [MEDICAL CONDITION] in the pressure ulcer. A physician's wound consult report dated (MONTH) 1, (YEAR) included the resident had a left heel stage III pressure ulcer, which measured 4 cm in diameter, with areas of yellowish tissue and no surrounding [MEDICAL CONDITION]. The documentation also included that the wound had been present for approximately 3-4 months. Review of a physician's progress note dated (MONTH) 7, (YEAR) revealed the resident had a heel ulcer. However, there were no measurements of the wound or any description of the wound. An interview was conducted with a licensed practical nurse (LPN/staff #27) on (MONTH) 7, (YEAR) at 12:31 p.m. She stated the resident was admitted to the facility with a pressure ulcer to the left heel. She stated wound assessments should always be documented in the wound notes section of the resident's chart. An interview was conducted with the Director of Nursing (DON/staff #72) on (MONTH) 7, (YEAR) at 12:44 p.m. She stated this resident's wound was present on admission. She stated staff does not measure the wound every time. She stated that any wounds beyond stage III pressure ulcers should be measured every week. She stated they do descriptions of the wounds with dressing changes and that they have a wound team that does the consultation notes. She stated staff probably should measure this wound, but they are not required too. She stated they do track the wound progression, as they have a vascular surgeon who comes weekly to see the wounds in the facility, and that he documents the wound and the descriptions. However, the facility was unable to provide any other wound specialist notes, or any additional wound assessment documentation regarding the left heel pressure ulcer. Review of the Skin, Wound and Pressure Ulcer Risk assessment, prevention, and management policy revealed that wound assessments should include location, wound bed, drainage, odor, color, periwound skin, as well as any erythemia, warmth, induration or damage. The policy further included that the patient's skin condition including any wounds is assessed and documented on admission, at the time of treatment, and that wound measurements are done on admission or when discovered and weekly.",2020-09-01
774,BANNER BOSWELL REHABILITATION CENTER,35121,10601 WEST SANTA FE DRIVE,SUN CITY,AZ,85351,2017-07-07,323,G,1,1,BCBE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, hospital and facility documentation, staff interviews, and review of policies and procedures, the facility failed to ensure that a gait belt was used when ambulating one resident (#386), who sustained a fall with injury. Findings include: Resident #386 was admitted to the facility on (MONTH) 2, (YEAR), with [DIAGNOSES REDACTED]. A Physical Therapy (PT) evaluation dated (MONTH) 3, (YEAR) indicated the resident had decreased balance, endurance, mobility and had a safety awareness deficit. Review of the PT plan of care dated (MONTH) 3, (YEAR) revealed a goal to provide supervision with ambulation, and to use a Front Wheeled Walker (FWW). The treatment plan included for balance training, gait training and safety training. An Occupational Therapy (OT) evaluation dated (MONTH) 3, (YEAR) included the resident had balance impairment, decreased coordination, decreased muscle strength, mobility impairment, and had a safety awareness deficit. The treatment plan was for balance training, coordination activities, safety training and functional transfer training. A nursing note dated (MONTH) 10, (YEAR) indicated the resident was being wheeled out of the bathroom in a wheelchair and started to slide down and was lowered to the floor. The resident sustained [REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 15, (YEAR) revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Per the MDS, the resident was assessed to be unsteady and was only able to stabilize, with human assistance when walking and required a one person assist with this task. A fall care plan identified that the resident was at risk for falls. Interventions included to implement environmental safety measures, provide ambulation assistance, and utilize walking aids when ambulating. The care plan did not include the extent of assistance that the resident required with ambulation. PT notes dated (MONTH) 23, (YEAR) indicated the resident required contact guard to limited assistance when ambulating. The notes included the resident ambulated 40 feet and that a gait belt was used. Review of a fall risk assessment dated (MONTH) 24, (YEAR) revealed the resident was at high risk for falls. The assessment noted the resident had a weak gait and was to call for assistance. The documentation also included the need for assistance and supervised transfers. Review of the nursing notes dated (MONTH) 25, (YEAR), revealed the resident turned on her call light to be assisted to the bathroom. A Certified Nursing Assistant (CNA/staff #2) answered the call light and while assisting the resident to the bathroom, the resident lost her balance, falling to the floor. Per the note, the resident hit the left side of her head on the corner of the bed, and landed on her left hip. The resident was bleeding from the left side of her head and complained of pain to her left hip, so the resident was transferred to the emergency room . According to the emergency room records, an x-ray of the left hip showed a fracture of the left femur. The resident required surgery for [REDACTED]. Review of the facility's investigation revealed a CNA (staff #2) was with the resident at the time of the fall. Staff #2 had taken the resident to the bathroom three times during the shift, twice before the fall. On the third time, staff #2 assisted the resident to the bathroom using her FWW. Staff #2 was opening the bathroom door and had one arm under the resident's arm, when the resident indicated that she was falling. Staff #2 was unable to stop the resident from falling. The report included that staff #2 had not used a gait belt. The investigation further included a written statement from staff #2. Staff #2 reported that with one arm he guided the resident's walker, and the other arm was under the resident's right armpit, as they walked to the bathroom. When they were at the bathroom door they stopped, so he could open the door, but as he was reaching for the door, the resident indicated that she was falling. He tried to grab under her arm to stabilize her, but the door and the walker were in his path and she slipped out of his grasp. The resident fell hitting the left side of her body, including her head and hip. The investigation further included that after the incident, staff #2 was counseled regarding not using a gait belt during a transfer. Review of facility employee documentation revealed that staff #2 had gotten the resident up two times earlier that night and had used a gait belt, however, the third time he did not use a gait belt, as the resident had done well so he felt that he did not need the gait belt. An interview was conducted with an OT (staff #139) at 8:25 a.m. on (MONTH) 6, (YEAR). She said the expectation regarding gait belts is that they should be used at all times, during ambulation and transfers. She stated that on occasion, there are residents who are at a very high level of functioning and are independent, so in those cases therapy may tell nursing that the resident does not need to wear a gait belt during transfers and ambulation. Staff #139 stated that this is very rare, and requires discussion between nursing and therapy. She stated the therapy department does provide education to staff regarding gait belts and that they had a skills fair about 6 months ago on how to correctly apply a gait belt. She also said that nurses are trained to know that a gait belt should be used each time a resident is ambulated. She stated that this resident needed staff assistance with ambulation and transfers, as she was unsteady and that the resident had fallen on more than one occasion, so a gait belt should have been used. She further stated that the resident may have fallen regardless of using a gait belt, but if staff would have used a gait belt, it would have been easier for the CNA to steady her, and this may have prevented the fall or lessened the impact. In an interview with a Licensed Practical Nurse (LPN/staff #73) at 8:30 a.m. on (MONTH) 6, (YEAR), staff #73 stated that CNAs and nurses are to use gait belts when ambulating or transferring a resident. He said this is always the case, especially if a resident has an unsteady gait. Staff #73 stated that therapy does provide gait belt training and that staff are told to use gait belts at all times. He said that all nursing staff receive a gait belt, which is part of their uniform. During an interview with a CNA (staff #118) at 8:45 a.m. on (MONTH) 6, (YEAR), she stated that in this facility, all residents are considered to be at risk for falls and that gait belts should be worn during all transfers and when ambulating a resident. She said that ambulating a resident with a gait belt is safer. The clinical rehabilitation services manager (staff #140) for the therapy department was interviewed at 10:40 a.m. on (MONTH) 6, (YEAR). She stated that all staff who assist a resident with ambulation or transfers should have a gait belt on at all times. She said the only exception is when a resident is very steady and therapy assesses them to be able to walk on their own, without a gait belt or assistance. She said this is rare, but when this does occur, the resident gets a walk badge that they wear so staff know this is okay. She stated that if a gait belt had been worn, the CNA would have been able to provide more stability for the safety of the resident. At this time, staff #140 reviewed the resident's therapy evaluations and notes and indicated that when the resident came in, she would have needed contact guard to minimum assistance with ambulation. She stated that the resident's status with ambulation did not change between the PT evaluation and the time of her discharge to the hospital, so a gait belt should have been used. After reviewing the residents who had walk badges, she stated this resident did not qualify and so a gait belt should have been used. An interview was conducted with staff #2 on (MONTH) 7, (YEAR) at 8:25 a.m. He stated that he had assisted the resident to the bathroom that night. He said her walker got caught on the door when they were going into the bathroom. He said he tried to grab her, but he was unable to steady her. He said that gait belts should be used at all times, but could not remember if he used a gait belt that night. He said that having a gait belt on stabilizes the resident. The Director of Nursing (DON/staff #72) was interviewed at 9:00 a.m. on (MONTH) 7, (YEAR). She stated that the CNA was not using a gait belt at the time of the incident but should have, because the resident had a weak gait. Staff #72 stated that if he had used a gait belt, the fall may still have occurred, but there is a good chance that the injury may not have been as bad. She said that after this incident they put an action plan in place regarding gait belt use to ensure staff use gait belts at all times. She said the facility does not have a specific gait belt policy, as gait belt use is standard CNA practice. Review of the facility's fall prevention policy and procedure revealed the purpose was to improve patient safety, by implementing interventions to decrease the risk of falling for high risk patients. Review of the Adult Standard of Care policy revealed that safety measures begin on admission and are addressed each shift. The policy included that staff incorporates the appropriate safety measures into the patient's plan of care, based on patient need.",2020-09-01
775,BANNER BOSWELL REHABILITATION CENTER,35121,10601 WEST SANTA FE DRIVE,SUN CITY,AZ,85351,2017-07-07,328,D,1,1,BCBE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review and staff interviews, the facility failed to ensure that a feeding tube formula was administered as ordered for one resident (#383). Findings include: Resident #383 was admitted to the facility on (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. The resident was discharged on (MONTH) 26, (YEAR). Review of the clinical record revealed the resident received nourishment via tube feeding. A physician's orders [REDACTED]. The times of administration were 6 a.m., 10 a.m., 2 p.m., 6 p.m. and 10 p.m. A nursing note dated (MONTH) 22, (YEAR) included that a Registered Nurse (RN/staff #91) understood the order to be 5 cans of [MEDICATION NAME] at 6 a.m., 5 cans at 10 a.m., 5 cans at 2 p.m., 5 cans at 6 p.m. and 5 cans at 10 p.m., instead of 5 cans divided among each scheduled time. Per the note, the resident received 5 cans of [MEDICATION NAME] at 2 p.m., resulting in the resident vomiting and having an episode of diarrhea. The Physician's Assistant (PA) was notified and ordered a chest x-ray. Review of a physicians progress note dated (MONTH) 22, (YEAR) revealed the resident was seen for vomiting after her tube feeding. The resident was given additional cans of food meant for later in the day. An x-ray was ordered to assess for possible aspiration. According to the x-ray report dated (MONTH) 22, (YEAR), there was no evidence of aspiration and no acute cardiopulmonary process. An interview was conducted with a RN (staff #58) on (MONTH) 6, (YEAR) at 1:45 p.m. She stated that staff #91 should not have administered 5 cans all at one time. She stated the resident did experience some nausea and diarrhea, after the incident and was monitored. She said that the PA was notified and a chest x-ray was ordered to rule out aspiration pneumonia and the x-ray was negative. An interview was conducted with the Director of Nursing (DON/staff #72) on (MONTH) 6, (YEAR) at 1:45 p.m. She stated staff #91 had administered the [MEDICATION NAME] in error on (MONTH) 22, (YEAR). An interview was conducted on (MONTH) 6, (YEAR) with the dietician (staff #138) who recommended the tube feeding orders. She stated the order was to administer one can of [MEDICATION NAME], five times daily. She stated there were family members in the resident's room when staff #91 administered the multiple cans of [MEDICATION NAME], and they became concerned when the amount seemed too large. The family then contacted staff #58 and the PA was immediately notified. She stated that one can of [MEDICATION NAME] is approximately 8 ounces and typical adverse reactions to the administration of a large amount would include nausea, vomiting and diarrhea. An interview was conducted with a Licensed Practical Nurse (staff #116) on (MONTH) 7, (YEAR) at 9:46 a.m. She stated that if she was unsure of a physician's orders [REDACTED]. An interview was conducted with staff #91 on (MONTH) 7, (YEAR) at 12:54 p.m. Staff #91 stated that she had received the order for the [MEDICATION NAME] 1.5, but understood the order to read 5 cans of [MEDICATION NAME], five times a day. She stated that in the afternoon of (MONTH) 22, (YEAR), she administered 4 cans of [MEDICATION NAME] per the feeding tube, and then the family in the room stopped her before she administered the fifth can.",2020-09-01
776,BANNER BOSWELL REHABILITATION CENTER,35121,10601 WEST SANTA FE DRIVE,SUN CITY,AZ,85351,2017-07-07,441,E,0,1,BCBE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, review of the Centers for Disease Control (CDC) 2007 guidelines and policy and procedures, the facility failed to ensure infection control procedures were followed, while providing care to four residents (#'s 156, 309, 364 and 392). Findings include: -Resident #156 was admitted to the facility on (MONTH) 1, (YEAR), with a [DIAGNOSES REDACTED]. An admission physician's orders [REDACTED]. Review of an infection care plan dated (MONTH) 1, (YEAR) revealed goals to achieve timely wound healing and to demonstrate appropriate precautions to prevent infection. An intervention included to implement isolation precautions. A medication pass observation was conducted on (MONTH) 6, (YEAR) at 8:30 a.m., with a licensed practical nurse (LPN/staff #27). Prior to entering resident #156's room, staff #27 was observed to don gloves, and a gown. Staff #27 then pulled a portable cart to the resident's doorway. The cart contained a computer, patient medications and a barcode scanner, which had a docking station on the cart. Staff #27 left the cart in the doorway and entered the resident's room, with the barcode scanner. Staff #27 then touched the resident's wrist with her gloved hand and scanned the barcode on the resident's wristband. She returned to the cart and used the barcode scanner to scan the resident's medications, which were on top of the cart, and put the medications into a cup. With the same gloves on, she returned the barcode scanner to the docking station, touched the mouse on the cart and then administered the medications to the resident. While inside of the room, the nurse removed her gown and gloves. Staff #27 then exited the room, pushing the medication cart out of the doorway into the hall. Staff #27 did not disinfect the barcode scanner or the computer and then placed the cart outside of resident #309's room. An interview was conducted with staff #27 on (MONTH) 7, (YEAR) at 12:41 p.m. She stated her process for the application of personal protective equipment (PPE) should be to apply gloves and then a gown. She stated that then when leaving an isolation room, she should remove the gown and gloves inside the room and then disinfect anything that had been brought into the room. She stated the scanner should be cleaned before using it for another resident. -Resident #309 was admitted to the facility on (MONTH) 4, (YEAR), with a [DIAGNOSES REDACTED]. An admission physician's orders [REDACTED]. During a medication pass observation conducted on (MONTH) 6, (YEAR) at 8:45 a.m., staff #27 was observed outside of the room of resident #309. Staff #27 applied gloves and then a gown, however, the gown was partially hanging off her hands. Staff #27 then pulled the same portable cart that she had used for resident #156, into the doorway of resident #309's room. Staff #27 was not observed to disinfect the computer or barcode scanner. Staff #27 then took the barcode scanner into the resident's room and scanned the resident's wristband. The resident refused the medications, so she returned the barcode scanner to the docking system on the cart. She then removed her gown and gloves inside of the resident's room and exited the room and pushed the cart out to the hallway. Staff #27 did not disinfect the computer or barcode scanner. Also during this same observation, the resident was observed working with physical therapy. The physical therapist (staff #145) was sitting on a chair in the resident's room and the back of her gown was open. Staff #145's clothing was exposed and was touching the chair. Staff #145 also had the sleeves of her gown rolled up to her shoulders, leaving both arms completely exposed. An interview was conducted with the Physical Therapist (staff #145) on (MONTH) 7, (YEAR) at 1:18 p.m. She stated that for the application of PPE, this includes applying gloves, a gown and tying the gown in the back. She also stated the gown should completely cover her arms. She stated she does remember that she had rolled the sleeves of her gown to her shoulders, but does not remember why she did so. Staff #145 stated she should have her arms covered. -Resident #364 was admitted to the facility on (MONTH) 22, (YEAR), with [DIAGNOSES REDACTED]. An admission physician's orders [REDACTED]. Review of the infection care plan dated (MONTH) 22, (YEAR) revealed a goal to demonstrate appropriate precautions to prevent infection. An intervention included implementing isolation precautions. Review of a physician's progress note dated (MONTH) 30, (YEAR) revealed the resident had a history of [REDACTED]. During a medication pass on (MONTH) 6, (YEAR) at 9 a.m., with a registered nurse (RN/staff #144), staff #144 was observed to donn gloves and a gown, then applied a second pair of gloves, while outside of the resident's room. Staff #144 then brought a portable cart into the resident's room, which contained a computer, barcode scanner and medications. Staff #144 scanned the resident's wristband with the barcode scanner and then scanned the medications and placed them into a cup. Staff #144 administered the resident's medications. With the same gloves on, staff #144 then touched the resident's arm, the bedside table, the resident's water bottle and the computer. Staff #144 then moved the portable cart to the doorway, and removed the top pair of her gloves, which still left one pair of gloves on. She then removed the medication wrappers from the top of the cart and removed her gown. She exited the resident's room with the portable cart, with the second pair of gloves still on. She then removed her gloves and placed them in a trash can in the hallway. Staff #144 did not disinfect the cart or any items on the cart. An interview was conducted with staff #144 on (MONTH) 7, (YEAR) at 1:14 p.m. She stated the general process for application of PPE is to apply gloves, a gown, tie the gown and then apply a second pair of gloves, over the top of the gown. She stated that after care is provided, the PPE should be removed inside the resident's room. She stated if an item is not disposable, it must be disinfected before leaving the room. She stated anything that goes into an isolation room should not come back out, but if it does, it should be disinfected, before using for another resident. An interview was conducted with the DON (Director of Nursing/staff #72) on (MONTH) 7, (YEAR) at 2:17 p.m. She stated the proper application of contact isolation PPE includes hand hygiene, followed by the application of the gown and then gloves. She stated staff should not bring portable computers into the room, but if they need to, they should clean it afterwards. She stated that staff should remove PPE before exiting the resident's room. She also stated that staff should not be rolling the sleeves of their gowns up, while in contact isolation rooms. Review of the Standard and Transmission based precautions policy revealed that contact isolation precautions should be used for MRSA patients. The policy included that equipment should be cleaned or disinfected immediately after use in an isolation room, and that gloves should be removed, prior to leaving the patient's environment. The policy also noted that staff should use appropriate approved disinfectant for the cleaning of equipment. -Resident #392 was admitted on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. An Internal Medicine Note dated (MONTH) 2, (YEAR), documented that resident #392 had recurrent[DIAGNOSES REDACTED] and was admitted for further physical therapy needs. The internal medicine note also documented that the resident had been admitted to the hospital prior to admission with diarrhea, and had been treated with intravenous antibiotics in the hospital. A physician's assistant note dated (MONTH) 5, (YEAR), documented the resident continued to have loose stools, and to continue with contact precautions. An observation was conducted on (MONTH) 7, (YEAR) at 9:56 a.m., of resident #392 in her room, which was designated as an isolation room. At this time, a physical therapist (staff #145) was observed inside of the room, and was assisting the resident with dressing and getting out of bed. Staff #145 then assisted the resident with ambulating to the bathroom and then to the sink. Staff #145 then assisted the resident with sitting in a chair. Staff #145 was wearing a disposable gown, which was tied around the waist, however, it was open in the back, exposing the back of her clothing. After assisting resident #392 to sit in a chair, staff #145 then sat down on a chair next to the resident and began providing therapy. The back of staff #145's clothing was observed to be in contact with the chair. During an interview conducted on (MONTH) 7, (YEAR) at 10:24 a.m., the DON stated that resident #392 has had a[DIAGNOSES REDACTED] infection with diarrhea symptoms since admission, and that she continued to have diarrhea. During an interview with staff #145 on (MONTH) 7, (YEAR) at 1:00 p.m., she stated that she was supposed to wrap the disposable gown completely around her clothing, prior to entering an isolation room. She stated that she was not aware that the gown was open in the back, or that her clothing had come in contact with the chair in the isolation room. Review of the Infection Control policies revealed that staff are to wrap a (disposable) gown around the back, prior to entering a contact isolation room, and that staff are not to directly touch any contaminated surfaces in the room. Review of the Donning and Doffing of PPE policy revealed the gown should fully cover the torso from the neck to the knees, should cover the arms to the end of the wrists, and should wrap around the back and fastened in the back of the neck and waist. The procedure also revealed that gloves should extend to cover the wrist of the isolation gown. Review of the CDC Isolation precautions 2007 guidelines revealed to remove gloves and gown before leaving the patient room. The guidelines included that if common use of equipment is unavoidable with multiple patients, clean and disinfect the equipment before using on another patient.",2020-09-01
777,BANNER BOSWELL REHABILITATION CENTER,35121,10601 WEST SANTA FE DRIVE,SUN CITY,AZ,85351,2018-09-28,578,D,0,1,U1X411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, and policies and procedures, the facility failed to ensure that advance directives were complete and/or accurate for three residents (#74, #77 and #168). Findings include: -Resident #74 was admitted to the facility on (MONTH) 22, (YEAR), with a [DIAGNOSES REDACTED]. Review of the clinical record revealed a prehospital medical care directive which included the resident was a Do Not Resuscitate (DNR) status. The medical care directive was signed by the resident on (MONTH) 18, (YEAR). However, review of the physician orders [REDACTED].>An interview was conducted with a Registered Nurse (staff #102) on (MONTH) 28, (YEAR) at 9:56 a.m. She stated the orders needed to be corrected because they were not consistent. -Resident #77 was admitted to the facility on (MONTH) 20, (YEAR), with a [DIAGNOSES REDACTED]. Review of the clinical record revealed a prehospital medical care directive which documented that the resident was a DNR status. The medical care directive was dated (MONTH) 20, (YEAR) and was signed by a staff member. However, it was not signed by the resident/representative. An interview was conducted with the Director of Nursing (staff #56) on (MONTH) 28, (YEAR) at 10:00 a.m. She stated advance directives should be completed and then scanned into the electronic system. She stated the staff person scanning the papers into the electronic system would not be aware if the advance directive forms were fully completed and/or accurate. She further stated it would be important for advance directives to be completed and be accurate. -Resident #168 was admitted to the facility on (MONTH) 15, (YEAR), with [DIAGNOSES REDACTED]. Review of the resident's electronic clinical record revealed an entry for Advanced Directives. The entry was dated (MONTH) 17, (YEAR), however; this document was unable to be opened and viewed. A physician's orders [REDACTED]. On (MONTH) 25, (YEAR), a copy of the resident's Advanced Directives were requested. However, the facility personnel were unable to open the file or provide a copy of the resident's Advanced Directives. During an interview conducted on (MONTH) 26, (YEAR) at 2:24 p.m. with the Admissions Coordinator (staff #5), she stated that the nurses on the unit or the case manager completes the Advance Directive paperwork upon admission. An interview was conducted on (MONTH) 26, (YEAR) at 2:28 p.m. with the Unit Secretary (staff #51), who stated that the Advance Directives are completed by the nurse, and then the nurse scans it into their computer system. She stated that after it is scanned into the computer, the paper documents are moved to the Health Information Management office and that a copy is not kept in the resident's folder. During an interview conducted on (MONTH) 26, (YEAR) at 2:47 p.m. with the Director of Nursing (staff #56), she stated that the expectation is that the Advance Directive paperwork is scanned into the electronic medical record and should be available for reviewing. She stated that the electronic medical record shows that the document was scanned in, but they were unable to open the document. She further stated that the Health Information Management office was unable to locate the document in their files. Staff #56 said the document was re-completed with the resident on (MONTH) 25, (YEAR). Review of a policy titled, Arizona Advanced Health Care Directives revealed that each patient is provided written information at the time of admission describing the person's rights to make decisions concerning his or her health care, including the right to accept or refuse medical or surgical treatment and the right to formulate or revise Advanced Directives. The policy also included that a copy is to be placed in the designated area in the medical record or scan the document into the medical record.",2020-09-01
778,BANNER BOSWELL REHABILITATION CENTER,35121,10601 WEST SANTA FE DRIVE,SUN CITY,AZ,85351,2018-09-28,655,E,0,1,U1X411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews and staff interviews, the facility failed to develop baseline care plans for five residents (#'s 5, 11, 77, 78 and 267). Findings include: -Resident #11 was admitted to the facility on (MONTH) 8, (YEAR), with [DIAGNOSES REDACTED]. and diabetes mellitus type II. Review of a 5-day Minimum Data Set (MDS) assessment dated (MONTH) 15, (YEAR) revealed the resident was cognitively intact, with a BIMS (Brief Interview for Mental Status) score of 15. Review of the (MONTH) (YEAR) physician orders [REDACTED]. The (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of the resident's baseline care plans including the Interdisciplinary Plan of Care revealed that no care plans had been developed to address the following areas: depression and the use of psychoactive medications, the use of insulin/diabetes and diuretic therapy. During an interview conducted on (MONTH) 26, (YEAR) at 10:46 a.m. with a registered nurse (RN/staff #93), she stated that care plans are started on admission for issues which include areas such as oxygen, glucose monitoring for diabetes and the use of [MEDICAL CONDITION] medications. During an interview conducted on (MONTH) 26, (YEAR) at 12:25 p.m. with a licensed practical nurse (LPN/staff #28), she stated that care plans are initially done by the RN's, then she adds or subtracts information from the care plan as needed. During an interview conducted on (MONTH) 26, (YEAR) at 12:48 p.m. with the Director of Nursing (DON/staff #56), she stated that initial care plans are completed by the RN's and should include diabetes. Staff #56 said that the care plans should include functional goals and customized care. She further stated that psychiatric issues are not always on the 48 hour care plan, but should be generated on the Interdisciplinary Plan of Care. -Resident #5 was admitted to the facility on (MONTH) 2, (YEAR), with [DIAGNOSES REDACTED]. Physician admission orders [REDACTED]. A review of the baseline care plans revealed there were no care plans that had been developed to address the resident's [MEDICAL CONDITION] disorder, anxiety, depression or the use of psychoactive medications. An interview was conducted on (MONTH) 20, (YEAR) at 1:30 p.m., with a LPN (MDS nurse/staff #16). He stated that he could not locate the baseline care plans for this resident regarding mental/behavioral disorders. He stated that if a resident was admitted with these problems and was receiving psychoactive medications, a baseline care plan should have been developed. An interview was conducted with a RN (staff #102) on (MONTH) 20, (YEAR) at 1: 32 p.m. She stated the admission nurse is responsible for the completion of the baseline care plans, however the mental/emotional problems are not care planned upon admission, because staff need time to assess the mental/emotional needs of the resident even though all other major medical issues or conditions are included on the care plan. She further stated that it made sense that all major areas both medical and mental, would be included on the baseline care plans, so staff would have the information which was needed. -Resident #77 was admitted on (MONTH) 20, (YEAR), with [DIAGNOSES REDACTED]. Review of the admission physician orders [REDACTED]. A review of the MAR for (MONTH) (YEAR) revealed the resident was administered the [MEDICATION NAME]/[MEDICATION NAME] on multiple occasions. Review of the resident's baseline care plans revealed there was no care plan developed to address the resident's pain. A policy was requested on (MONTH) 21, (YEAR) at 11:30 a.m. related to the development of baseline care plans, and the Administrator stated that the facility did not have a policy. An interview was conducted with a LPN (staff #16) on (MONTH) 27, (YEAR) at 1:25 p.m. He stated the resident was being treated with as needed pain medication and that there was no baseline care plan developed. Staff #16 also said that the resident's admitting [DIAGNOSES REDACTED]. An interview was conducted with a RN (staff #102) on (MONTH) 27, (YEAR) at 1:48 p.m. She stated this resident had pain issues, which needed to be included in the baseline care plans. -Resident #78 was admitted to the facility on (MONTH) 23, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident was receiving [MEDICAL TREATMENT] three times a week and had an arteriovenous (AV) fistula on the left arm. Review of the resident's baseline care plans revealed there was no care plan developed that addressed [MEDICAL TREATMENT] and the AV fistula site. An interview was conducted on (MONTH) 27, (YEAR) at 9:41 a.m., with a RN (staff #94). She stated that resident #78 goes to [MEDICAL TREATMENT] treatments every Tuesday, Thursday and Saturday. She stated the resident has an AV fistula on her left arm and that [MEDICAL TREATMENT] should be care planned with interventions. An interview was conducted on (MONTH) 28, (YEAR) at 9:16 a.m. with a LPN (staff #16). He stated that care plans are initiated by the RN's. He stated on admission the baseline care plan should include [MEDICAL TREATMENT] treatments. At this time, he reviewed the resident's clinical record and stated there was not a [MEDICAL TREATMENT] care plan, however, there should be one. An interview was conducted on (MONTH) 28, (YEAR) at 12:34 p.m., with the DON (staff #56). She stated that care plans are developed based on the resident's diagnoses, central lines, pain, and psychiatric needs. -Resident #267 was admitted on (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. Review of the admission physician's orders [REDACTED]. A review of the baseline care plans revealed they did not address the resident's needs related to a delusional disorder and the use of an antipsychotic medication. An interview with staff #56 was conducted on (MONTH) 28, (YEAR) at 10:18 a.m. Staff #56 stated that the Health Unit Coordinator coordinates the baseline care plans and that all team members contribute to the baseline care plan. Staff #56 said that she expects the baseline care plan to include any medical conditions, therapy goals, and discharge plans of the resident. She stated that they were not addressing psychosocial concerns or mental health concerns on the baseline care plans.",2020-09-01
779,BANNER BOSWELL REHABILITATION CENTER,35121,10601 WEST SANTA FE DRIVE,SUN CITY,AZ,85351,2018-09-28,658,D,1,1,U1X411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews and policy review, the facility failed to ensure one resident (#66) was provided adequate care and services related to a peripherally inserted central catheter (PICC) line. Findings include: Resident #66 was admitted to the facility on (MONTH) 23, (YEAR), with [DIAGNOSES REDACTED]. A physician's order dated (MONTH) 23, (YEAR) included the resident had a PICC (peripherally inserted central catheter) line to the right antecubital on admission. Review of the Lines tubes and drains assessment dated (MONTH) 23, (YEAR) revealed the resident was admitted with a PICC line to the right antecubital, and that the dressing was dry and intact and there were no complications. The documentation also noted that the date of the last dressing change was (MONTH) 22, (YEAR). A physician's order dated (MONTH) 25, (YEAR) included for [MEDICATION NAME] (antibiotic) 1000 milligrams to be administered via the PICC to the right arm. Further review of the admission orders [REDACTED]. Continued review of the Lines tubes and drains assessment revealed the PICC line dressing was changed 10 days later on (MONTH) 2, (YEAR). According to the admission Minimum Data Set (MDS) assessment dated (MONTH) 5, (YEAR), the resident scored a 3 on the Brief Interview for Mental Status (BIMS), indicating the resident had severe cognitive impairment. Per the MDS, the resident required extensive assistance for most activities of daily living. The MDS also included the resident received intravenous medications. Further review of the clinical record revealed there was no documentation of any further PICC line site care or dressing changes which were done after (MONTH) 2. In addition, the clinical record documentation showed that the resident was discharged on (MONTH) 14, (YEAR). There were no physician orders which included that the PICC line was to be removed prior to discharge or that the PICC line was to remain in place when discharged , with specific instructions for care and treatment. A social services note dated (MONTH) 21, (YEAR) revealed the social worker (staff #110) spoke with the resident's family regarding the resident's PICC line and reported that the resident was taken to urgent care to have the PICC line removed. An interview was conducted on (MONTH) 26, (YEAR) at 12:02 p.m. with the social worker (staff #110). She stated the nurse forgot to remove the PICC line before the resident was discharged . An interview was conducted on (MONTH) 27, (YEAR) at 10:35 a.m. with a registered nurse (RN/staff #112). She stated that per the nursing report provided to her from the previous nurse, she was not informed that the resident had a PICC line. She stated on the resident care information sheet (Kardex), there was no information regarding the resident having a PICC line. She stated there were no orders to discontinue or leave the PICC line in place, and no orders for line maintenance. She stated that as she was preparing the resident for discharge, the resident was completely dressed and had a [NAME]et on, when she completed the nursing assessment. She further stated the resident was discharged with a PICC line in place. An interview was conducted on (MONTH) 27, (YEAR) at 2:38 p.m., with the former Director of Nursing (staff #113). He stated that the resident was sent home with a PICC line. He stated it was against professional standards of practice not to discontinue the PICC line or obtain an order to remove the line. An interview was conducted on (MONTH) 27, (YEAR) at 9:12 a.m. with a RN (staff #93). She stated if a resident is admitted with a PICC line, an assessment is completed. Staff #93 stated that orders are obtained for flushing the lines, monitoring the site, and changing the dressing every 7 days. She stated the dressings for central lines are changed every 7 days from the date that is on the dressing. She stated if the resident is not going home with a central line, an order for [REDACTED].>An interview was conducted on (MONTH) 27, (YEAR) at 1:57 p.m. with a RN (staff #102). She stated if a resident is admitted with a PICC line the nurses are to document the location, and a PICC line assessment is completed including the date of the last dressing change. She stated dressing changes are completed every 7 days. She further stated that orders should be obtained for changing the dressing, maintaining the line for patency, and an order to use the line for medications or labs. She stated that PICC lines are assessed and documented on per shift. She also said an order is needed to remove a PICC line. At this time, she reviewed the clinical record and stated there were incomplete PICC line assessments. An interview was conducted on (MONTH) 27, (YEAR) at 8:13 a.m., with the Director of Nursing (staff #56/DON). She stated that she was not employed by the facility during the resident's stay. She said the current practice for a resident who is admitted with a PICC line is to review the date on the dressing and change the dressing every 7 days. She stated that central lines are routinely flushed and an order is in place. She stated before a line can be removed, the physician will review the line and notify staff if the line can be removed in the facility or will need to be removed in the hospital. She stated there needs to be a physician's order before a central line can be removed. Review of a policy titled Central Venous Access Devices revealed this is all-inclusive regarding central venous access devices and encompasses centrally and peripherally inserted central catheters (PICC). Per the policy, site care and dressing changes are completed by the registered nurses and are to be changed every 7 days. The policy included that a physician's order is required for maintaining line patency. The policy also included that line necessity is documented every shift, with a site assessment, unexpected outcomes and interventions, presence of blood return, which lumen is being used and medications/flushing. The policy further noted that a PICC line may be removed by a validated clinician, per scope of practice.",2020-09-01
780,BANNER BOSWELL REHABILITATION CENTER,35121,10601 WEST SANTA FE DRIVE,SUN CITY,AZ,85351,2019-12-06,607,D,1,1,U51711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to implement their abuse policy regarding reporting and protection for an allegation of abuse involving one of two sampled residents (#72). The deficient practice could result in the potential for abuse to be unreported and ongoing. Findings include: Resident #72 was admitted to the facility on (MONTH) 21, (YEAR) with [DIAGNOSES REDACTED]. Review of a facility report dated (MONTH) 27, (YEAR) revealed that on (MONTH) 23, (YEAR) at approximately 7:30 a.m., the resident's Certified Nursing Assistant (CNA/staff #42) reported to the nurse the resident had a skin tear on the hand that was bleeding. The nurse assessed the injury and noted the resident was bleeding from a foam dressing that was already in place. As the nurse was leaving the room to get supplies, a family member was entering the room. When the nurse returned to the resident's room, she observed the family member screaming at the CNA and taking pictures. The unit manager Registered Nurse (RN/staff #114) was notified and took over the care of the resident. The report included the resident had multiple skin tears and that the family member accused the CNA of abusing the resident. An investigation was initiated. The report did not include measures were implemented to prevent further potential abuse while the investigation was in progress. Further review of the report revealed no evidence the allegation of abuse was reported immediately, but not later than 2 hours after the allegation was made to the administrator, State Survey Agency and adult protective services (APS). The report included the State agency was notified via the after-hours number on (MONTH) 23, (YEAR) at 9:09 p.m. and APS was notified on (MONTH) 27, (YEAR). An interview was conducted with staff #114 on (MONTH) 4, 2019 at 1:57 p.m. Staff #114 stated that regarding the incident that occurred on (MONTH) 23, (YEAR), she thought the family member had retracted the abuse allegation so she did not immediately inform the Director of Nursing (DON/staff #115) and did not notify the administrator (staff #70) and did not suspend staff #42. Staff #114 stated staff #42 continued to provide care to residents and that the residents were not protected from the potential for further abuse. An interview was conducted with the DON (staff #115) on (MONTH) 6, 2019 at 11:15 a.m. Staff #105 stated the administrator, who is the designated facility abuse officer, is to be immediately notified when there is an allegation of abuse. Staff #115 stated the administrator was eventually notified of this incident; however it was much later that day (December 23, (YEAR)). Staff #115 also stated the State Survey Agency and APS were not notified within the required two hour time frame. Staff #115 stated that when there is an allegation of abuse and the perpetrator is staff, the staff is suspended until the investigation is completed for the protection of the residents. Staff #115 further stated staff #42 was not suspended, per policy, and continued to provide resident care. An interview was conducted with the administrator (staff #70) on (MONTH) 6, 2019 at 12:15 p.m. Staff #70 stated staff are to immediately notify her when there is an allegation of abuse. Staff #70 stated that she has to report the abuse allegation to the State Survey Agency and APS within two hours. Regarding the incident that occurred on (MONTH) 23, (YEAR), staff #70 stated staff #114 did not immediately report the abuse allegation and therefore the allegation was not reported to the State Survey Agency and APS within the required time frame. Staff #70 also stated staff #42 was not suspended and was allowed to continue to provide care to residents which was not in compliance with their policy. The facility's policy regarding abuse revised (MONTH) 16, (YEAR), revealed abuse allegations are reported per Federal and State Law. Staff must always report any abuse or suspicion of abuse immediately to the administrator. The policy also revealed the facility will ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made to the State Survey Agency and APS. The policy also included it is their policy that the resident(s) will be protected from the alleged offender(s). Staff accused of alleged abuse will be placed on administrative leave pending the results of a thorough investigation.",2020-09-01
781,BANNER BOSWELL REHABILITATION CENTER,35121,10601 WEST SANTA FE DRIVE,SUN CITY,AZ,85351,2019-12-06,609,D,1,1,U51711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure an allegation of abuse involving one of two sampled residents (#72) was reported to the administrator, State Survey Agency, and adult protective services (APS) within the required timeframe. The deficient practice could result in abuse allegations not being report as required. Findings include: Resident #72 was admitted to the facility on (MONTH) 21, (YEAR) with [DIAGNOSES REDACTED]. Review of a facility report dated (MONTH) 27, (YEAR) revealed that on (MONTH) 23, (YEAR) at approximately 7:30 a.m., the resident's Certified Nursing Assistant (CNA/staff #42) reported to the nurse the resident had a skin tear on the hand that was bleeding. The nurse assessed the injury and noted the resident was bleeding from a foam dressing that was already in place. As the nurse was leaving the room to get supplies, a family member was entering the room. When the nurse returned to the resident's room, she observed the family member screaming at the CNA and taking pictures. The unit manager Registered Nurse (RN/staff #114) was notified and took over the care of the resident. The report included the resident had multiple skin tears and that the family member accused the CNA of abusing the resident. Further review of the report revealed no evidence the allegation of abuse was reported immediately, but not later than 2 hours after the allegation was made to the administrator, State Survey Agency and APS. The report included the State agency was notified via the after-hours number on (MONTH) 23, (YEAR) at 9:09 p.m. and APS was notified on (MONTH) 27, (YEAR). An interview was conducted with staff #114 on (MONTH) 4, 2019 at 1:57 p.m. Staff #114 stated that regarding the incident that occurred on (MONTH) 23, (YEAR), she thought the family member had retracted the abuse allegation so she did not immediately inform the Director of Nursing (DON/staff #115) and did not notify the administrator (staff #70). An interview was conducted with DON (staff #115) on (MONTH) 6, 2019 at 11:15 a.m. Staff #115 stated the administrator, who is the designated facility abuse officer, is to be immediately notified when there is an allegation of abuse. Staff #115 stated the administrator was eventually notified of this incident; however it was much later that day (December 23, (YEAR)). Staff #115 also stated the State Survey Agency and APS were not notified within the required two hour time frame. An interview was conducted with the administrator (staff #70) on (MONTH) 6, 2019 at 12:15 p.m. Staff #70 stated staff are to immediately notify her when there is an allegation of abuse. Staff #70 stated that she has to report the abuse allegation to the State Survey Agency and APS within two hours. Regarding the incident that occurred on (MONTH) 23, (YEAR), staff #70 stated staff #114 did not immediately report the abuse allegation and therefore the allegation was not reported to the State Survey Agency and APS within the required time frame. The facility's policy regarding abuse revised (MONTH) 16, (YEAR), revealed abuse allegations are reported per Federal and State Law. Staff must always report any abuse or suspicion of abuse immediately to the administrator. The policy also revealed the facility will ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made to the State Survey Agency and APS.",2020-09-01
782,BANNER BOSWELL REHABILITATION CENTER,35121,10601 WEST SANTA FE DRIVE,SUN CITY,AZ,85351,2019-12-06,610,D,1,1,U51711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure action was taken to prevent further abuse from occurring while the investigation was in progress for an allegation of abuse involving one of two sampled residents (#72). The deficient practice could result in residents not being protected from the potential for further abuse. Findings include: Resident #72 was admitted to the facility on (MONTH) 21, (YEAR) with [DIAGNOSES REDACTED]. Review of a facility report dated (MONTH) 27, (YEAR) revealed that on (MONTH) 23, (YEAR) at approximately 7:30 a.m., the resident's Certified Nursing Assistant (CNA/staff #42) reported to the nurse the resident had a skin tear on the hand that was bleeding. The nurse assessed the injury and noted the resident was bleeding from a foam dressing that was already in place. As the nurse was leaving the room to get supplies, a family member was entering the room. When the nurse returned to the resident's room, she observed the family member screaming at the CNA and taking pictures. The unit manager Registered Nurse (RN/staff #114) was notified and took over the care of the resident. The report included the resident had multiple skin tears and that the family member accused the CNA of abusing the resident. An investigation was initiated. However, the report did not include measures were implemented to prevent further potential abuse while the investigation was in progress. An interview was conducted with staff #114 on (MONTH) 4, 2019 at 1:57 p.m. Staff #114 stated that she did not suspend staff #42 and that staff #42 continued to provide care to residents. She stated staff #42 was not suspended until the Director of Nursing (DON) was aware staff #42 was still providing care to resident. Staff #114 stated the residents were not protected from the potential for further abuse. An interview was conducted with the DON (staff #115) on (MONTH) 6, 2019 at 11:15 a.m. Staff #115 stated that when there is an allegation of abuse and the perpetrator is staff, the staff is suspended until the investigation is completed for the protection of the residents. Staff #115 further stated staff #42 was not suspended, per policy, and continued to provide resident care. An interview was conducted with the administrator (staff #70) on (MONTH) 6, 2019 at 12:15 p.m. Staff #70 stated staff #42 was not suspended and was allowed to continue to provide care to residents which was not in compliance with their policy. The facility's policy regarding abuse revised (MONTH) 16, (YEAR), revealed it is their policy that the resident(s) will be protected from the alleged offender(s). Staff accused of alleged abuse will be placed on administrative leave pending the results of a thorough investigation.",2020-09-01
783,BANNER BOSWELL REHABILITATION CENTER,35121,10601 WEST SANTA FE DRIVE,SUN CITY,AZ,85351,2019-12-06,686,G,0,1,U51711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, interviews and policy review, the facility failed to ensure that one resident (#222) with a pressure ulcer received the necessary treatment and services to promote healing. The deficient practice resulted in a delay in wound treatment being initiated, a lack of thorough assessments being completed and consistent monitoring of the pressure ulcer at least weekly, and the wound was discovered to have deteriorated. Findings include: Resident #222 was admitted to the facility on (MONTH) 21, 2019, with [DIAGNOSES REDACTED]. A Braden Scale dated (MONTH) 21, 2019 revealed a score of 14, which indicated the resident was at moderate risk for the development of a pressure ulcer. A care plan dated (MONTH) 21, 2019 for impaired skin integrity included the following goals: demonstrate behaviors or techniques to prevent skin breakdown or facilitate healing, maintain optimal nutrition and physical well being, and verbalize understanding of condition and causative factors. Interventions were to consider nutrition services, consider use of specialty bed, inspect skin every shift, maintain clean, dry skin at all times, reposition frequently while mobility impaired, teach behaviors or techniques to prevent skin breakdown or promote healing and teach proper nutrition and hydration for prevention maintenance and repair. Review of an incision/wound/skin assessment dated (MONTH) 21, 2019 performed by a floor nurse revealed the resident had a flat, localized maroon [DIAGNOSES REDACTED] (redness) area on the medial sacrum, with surrounding tissue intact and normal in color. This assessment showed that this was over a bony prominence. The assessment did not include any measurements of the area or the type of wound. A physician's orders [REDACTED]. However, these orders did not include any wound treatment to the [DIAGNOSES REDACTED] area on the medial sacrum. A functional abilities assessment dated (MONTH) 22, 2019 revealed the resident was at substantial/maximal assistance for rolling left and right and was dependent with toileting, hygiene, wheelchair mobility and chair to bed transfers. A cognitive-linguistic evaluation dated (MONTH) 22, 2019 revealed a brief interview for mental status score a 4 out of 15, indicating severe cognitive impairment. Review of an incision/wound/skin assessment dated (MONTH) 22, 2019 performed by a floor nurse revealed the resident had a flat, non-blanchable pink-red localized [DIAGNOSES REDACTED] area on the medial sacrum, with surrounding tissue intact and normal in color. There were no measurements of the area and the type of wound was not defined. Review of an incision/wound/skin assessment dated (MONTH) 23, 2019 performed by a floor nurse revealed the resident had a localized purple pressure ulcer on the medial sacrum, with attached edges and surrounding tissue showing [DIAGNOSES REDACTED] on intact skin. The pressure ulcer measured 2.5 cm in length by 3 cm width. The documentation included the wound had deteriorated, and described it as denuded and darker red, with no signs or symptoms of infection. Per the assessment, the wound was cleaned with a commercial cleansing solution and a foam dressing was applied. However, further review of the clinical record revealed there was no documentation that the physician/nurse practitioner was notified of the pressure ulcer to the medial sacrum, and there was no treatment order for the sacrum on (MONTH) 21, 22 or 23, 2019. In addition, there was no clinical record documentation of the use of a specialty bed or mattress, which was in place from (MONTH) 21 through (MONTH) 23, 2019, as mentioned in the care plan. An incision/wound/skin assessment dated (MONTH) 24, 2019 performed by a floor nurse included the resident had a localized purple pressure ulcer on the medial sacrum, with wound edges unattached to wound bed, with surrounding tissue showing [DIAGNOSES REDACTED] on intact skin. Documentation included the wound had deteriorated and was described as denuded and darker red, with no signs or symptoms of infection. The wound was cleaned with a commercial cleansing solution and a foam dressing was applied. There were no measurements of the pressure ulcer in this assessment. A physician's orders [REDACTED]. Review of an OMBRA admission Minimum Data Set (MDS) assessment dated (MONTH) 27, 2019, revealed the resident had a BIMS score of 4, which indicated severe cognitive impairment. Per the MDS, the resident required the assistance of two staff with bed mobility, transfers and hygiene. The MDS further included that the resident had a suspected deep tissue injury. A Braden score dated (MONTH) 1, 2019 revealed a score of 13, which indicated the resident was at moderate risk for development of a pressure ulcer. A physician's orders [REDACTED]. The order also included for a consult with the wound/ostomy nurse. An observation was conducted on (MONTH) 2, 2019 at 12:26 p.m., of the resident in bed with a pressure reducing mattress in place. At this time, an interview with a family member was conducted, who stated that the resident has a bedsore near his anus and thinks that it happened here. The next pressure ulcer assessment was completed 10 days after the last assessment (November 24). According to the incision/wound/skin assessment dated (MONTH) 3, (YEAR) performed by a floor nurse, the medial sacrum pressure ulcer was now described as maroon, red and yellow in color, had 90% granulated tissue and 10% slough, with a small amount of serous exudate, and the surrounding tissue had maceration and moisture. The wound measured 3.2 cm x 3.0 cm x 0.1 cm. The first assessment performed by the wound consultant was dated (MONTH) 4, 2019. Per the wound ostomy inpatient consult form dated (MONTH) 4, 2019, the sacrum had an open wound which measured 3.1 cm x 3.3 cm x 0.1 cm, with purple discoloration to the periwound. Per this document, nursing reports that slough has been present initially and is not resolving (however, there is no documentation of any slough to the wound until the (MONTH) 3 assessment), and that the wound appears consistent with a stage 3 pressure ulcer. The documentation also stated that charting indicates this wound may have initially presented as a deep tissue injury, which progressed into an open wound. Per the note, this wound nurse consultant spoke with a family member who stated that the resident did not have open wounds to the sacrum in the past. A wound observation was conducted on (MONTH) 5, 2019 at 10:00 a.m., with a RN (staff #12) and a LPN (staff #157 ). Staff #12 provided wound care as ordered. The wound was observed to have a pink wound bed with a flaky, macerated appearance and the wound measured 3.1 cm x 3.3 cm x 0.1 cm. During the observation, staff #12 stated that wounds are measured once a week by the charge nurse. An interview was conducted on (MONTH) 6, 2019 at 9:11 a.m., with a licensed practical nurse (LPN/staff #157), who stated that if we find a wound, then we do a wound consult. She said that she obtained a wound consult because the wound was deteriorating. She said that she doesn't see any wound consult before the one that she asked for on (MONTH) 2. She also pulled up the physician orders [REDACTED]. An interview was conducted on (MONTH) 6, 2019 at 9:30 a.m. with the Director of Nursing (DON/staff #115), who stated that her expectations for wounds was for the nurses to assess the wound, notify the physician, and obtain new orders. While reviewing the clinical record for this resident, she stated that she did not see where the nurses notified the doctor before (MONTH) 24, and that the wound consult was not requested until (MONTH) 2. She said the pressure ulcer was getting worse, but they were following it and putting interventions in place, however, she did not have any documentation of this. A follow up interview was conducted on (MONTH) 6, 2019 at 11:55 a.m., with staff #157. She stated if there is no order for wound treatment, she would immediately notify the provider and would also obtain an order for [REDACTED].>An interview was conducted on (MONTH) 6, 2019 at 12:36 p.m., with a RN (staff #37). She stated that all wounds should have a treatment order and an order for [REDACTED].#37 stated that on admission the nurse should have called the physician for a wound consultant, as it could develop into a deeper wound and get worse. She said that you don't know how deep it is when it's a deep tissue injury. She stated that they did not do a good wound assessment with measurements, until (MONTH) 23. She said the size of the wound should be included on the assessments. She stated that it might take until the next day for a wound consultant, but the nurse can put interventions in place, such as she would talk with the manager and order a special mattress, turn the resident every two hours and refer the resident to the dietician for wound healing. A copy of a text conversation dated (MONTH) 6, 2019 at 2:04 p.m. was provided by the DON. The text was between the DON and and a RN (staff #150). Per the text, staff #150 reported that she was there when the resident was admitted and that a waffle mattress was put on that night. The DON also provided a handwritten note dated (MONTH) 6, 2019 from a RN (staff #204). Per the note, staff #204 stated that she removed the waffle mattress from the bed and replaced it with an APP overlay mattress on (MONTH) 24. However, there was no documentation in the clinical record that a waffle mattress had been utilized. Review of a policy regarding Skin, Wound, and Pressure Ulcer Risk Assessment, Prevention, and Management revealed the purpose was to prevent skin injury and promote healing of wounds associated with pressure friction, shear, immobility and moisture through the use of evidence based guidelines, ongoing assessment, and coordinated treatment, so that residents may enjoy optimal health and comfort and participate to their fullest potential in daily living. The policy included that an unavoidable skin injury occurs even when a facility evaluates a resident's clinical condition and risk factors, defines and implements interventions consistent with the resident's needs/goals/recognized standards of practice, monitors and evaluates the impact of interventions, and revises the interventions as appropriate. The policy included that an avoidable skin injury occurs when the facility does not perform one or more of the above functions. The policy stated that a pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or pressure in combination with shear and/or friction. Under the section for wound assessment, it included the following should be documented: location; wound bed; drainage; odor; color and periwound skin for [DIAGNOSES REDACTED], warmth, induration or damage. Resident's skin condition including any wounds is assessed and documented on admission and at time of treatment. Wound measurements are done on admission or wound discovery, weekly and at regular intervals. Residents identified at risk for skin breakdown will have preventative measures implemented and appropriately documented. Per the policy, pressure ulcers are staged by Wound Ostomy Continence Nurses, wound care specialists or designee, nurse practitioners and physicians.",2020-09-01
784,BANNER BOSWELL REHABILITATION CENTER,35121,10601 WEST SANTA FE DRIVE,SUN CITY,AZ,85351,2019-12-06,689,D,1,1,U51711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on closed clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#73) was provided adequate supervision to prevent an elopement. The deficient practice has the potential for residents to be at risk for elopement. Findings include: Resident #73 was admitted to the facility on (MONTH) 25, (YEAR) with [DIAGNOSES REDACTED]. Review of an elopement risk assessment dated (MONTH) 25, (YEAR) revealed a score of 7, which indicated the resident was at risk for elopement. A score of 5 or greater meant the resident was at risk for elopement. The assessment revealed the resident had a [DIAGNOSES REDACTED]. The assessment included addressing elopement precaution on the care plan and did not include an elopement device was in place. The admission baseline care plan dated (MONTH) 25, (YEAR) revealed the resident had no safety care problems regarding elopement wandering and to monitor the resident for adjustment to being placed in the facility. The care plan included the resident could be up with assistance and that the resident used a manual/electric wheelchair for mobility. The care plan did not include the resident was assessed to be at risk for elopement or interventions for elopement precaution. Review of the facility's mobility assessment tool dated (MONTH) 26, (YEAR) revealed the resident did not display safety awareness/alert. The admission Minimum Data Set (MDS) assessment dated (MONTH) 5, (YEAR) revealed a score of 12 on the Brief Interview for Mental Status, which indicated the resident had moderate cognition impairment. The assessment included the resident had not exhibited wandering behavior and was self-sufficient once in the wheelchair for locomotion on and off the unit. The assessment also included cane/crutch was checked for mobility devices that were normally used; wheelchair was not checked. The facility's mobility assessment tool dated (MONTH) 8, (YEAR) at 10:45 a.m. revealed the resident did not display safety awareness/alert. Review of a psychologist progress note dated (MONTH) 8, (YEAR) revealed the resident presented with cognitive dysfunction with a severity rating of at least a moderate level. A physician progress notes [REDACTED]. The resident thought she was going out to dinner with her husband and that her husband was going to put her away. The resident denied fever, chills, or urinary symptoms. The note included the resident's intermittent confusion was worse today and that the urine would be checked as this was a recent change. Review of the clinical record revealed no evidence the nursing staff had observed and assessed a change in the resident's cognition/confusion on (MONTH) 8, (YEAR). Review of a nursing note dated (MONTH) 8, (YEAR) at 8:18 p.m. revealed visitors reported that upon entering the facility, they saw a woman in a wheelchair just outside the front door. The visitors stated the woman was talking and not making any sense. The note included the writer went to the front entrance and saw resident #73 in a wheelchair approximately 30 feet from the entrance with a staff member beside her. The resident appeared confused and believed there was danger inside of the facility. Another nursing note dated (MONTH) 8, (YEAR) at 8:28 p.m. revealed this writer heard staff talking about a resident being outside. The writer went outside and found the resident in front at the parking area with one of the staff. The resident was confused, thinking that someone was trying to blow up the place. The writer was able to convince the resident to go inside. Notifications were made to the physician and family. The note included staff were given instructions to keep a close eye on the resident and that a wander guard would be put on. Review of a physician progress notes [REDACTED]. The noted included the resident was started on an antibiotic and would follow cultures. An interview was conducted with the front lobby receptionist (staff #90) on (MONTH) 4, 2019 at 10:46 a.m. She stated her work hours are from 8:00 a.m. until 5:00 p.m. with a 30 minute lunch break. Staff #90 stated that when she is having lunch and when she leaves for the day at 5:00 p.m., there is no staff at the front lobby desk. She stated a sign is placed on the counter when she not there. Staff #90 stated the sign instructs to proceed down the hall to the nurse's station for assistance. She stated that if a resident is confused and does not have a wander guard, the resident would be able to leave the facility through the front doors when no staff is present. Staff #90 stated that if a resident has a wander guard and tries to leave through the front doors; an alarm would sound to alert the staff. During an interview conducted with a Certified Nursing Assistant (staff #97) on (MONTH) 4, 2019 at 1:25 p.m., staff #97 stated that if a resident has a change in their usual condition and becomes confused she must immediately report this change to a nurse. An interview was conducted with a Registered Nurse (staff #114) on (MONTH) 6, 2019 at 9:35 a.m. She stated that for an elopement risk assessment with a score of 7, a wander guard should be placed on the resident. Staff #114 stated she was unsure why resident #73 did not have a wander guard. Staff #114 stated the admission elopement risk assessment for resident #73 was incorrect because the resident had the ability to be independently mobile (which would have increased the score to 10). Staff #114 further stated the provider is usually very good about alerting the nursing staff when a resident has a change. The Registered Nurse stated that on (MONTH) 8, (YEAR), the provider should have told the staff about the change in the resident's cognition/confusion. Staff #114 stated that if the provider had notified them, maybe they would have kept a closer eye on the resident. An interview was conducted with the Director of Nursing (staff #115) on (MONTH) 6, 2019 at 10:44 a.m. Staff #115 stated an elopement risk assessment is completed for a resident on admission and that if the resident is assessed to be a high risk, a wander guard would be placed on for safety. She stated the expectation is that the elopement risk assessment be accurate. She stated the front lobby area is unsecured after 5:00 p.m. and a resident who is confused and without a wander guard, could exit the facility without staff knowing. The Director of Nursing stated that the provider did not notify the staff of the change in resident #73 on (MONTH) 8, (YEAR) so the staff were not aware of the resident's change in cognition/confusion. The facility's policy regarding elopement revised (MONTH) 16, (YEAR) revealed elopement is the ability of a resident who is not capable of protecting themselves from harm to successfully leave the facility unsupervised and unnoticed and who may enter into harm's way. The purpose included implementing prevention strategies for those residents identified as an elopement risk. A facility provided risk assessment tool or scoring system is utilized. The risk score includes a defined parameter which, when reached, indicates an increase risk and prompts prevention strategies. Interventions that may be used for residents identified as high risk for elopement included frequent monitoring of the resident's whereabouts to assure the resident remains in the facility (e.g., every one-half hour check) and implementation of alert device or other electronic alert systems. The policy also included if a resident is identified as moderate to high risk for elopement, establish an interim plan of care.",2020-09-01
785,RIDGECREST HEALTHCARE,35125,16640 NORTH 38TH STREET,PHOENIX,AZ,85032,2018-03-14,584,E,0,1,7ZN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, resident and staff interviews, facility documentation and policy review, the facility failed to provide maintenance services, by failing to repair the ceiling in one resident's (#101) room, by failing to repair damaged walls in one resident's room, and by failing to repair a section of baseboard trim in a common area on the Renaissance Road unit. Findings include: Resident #101 was admitted on (MONTH) 3, (YEAR). A nurses note dated (MONTH) 18, (YEAR), included that the resident's ceiling had dripped water onto the resident's bed, and that she had been moved to a different room. An interview was conducted on (MONTH) 5, (YEAR) at 2:40 p.m., with resident #101. The resident was angry and stated that she was unable to return to her room, due to the leaky ceiling. The resident stated that they had not repaired the ceiling yet and staff were aware that she wanted to move back to her room. At this time, an observation of the ceiling in the resident's room was conducted and the ceiling had a large brown stained area over the bed. An interview was conducted on (MONTH) 9, (YEAR) at 9:30 a.m., with a licensed vocational nurse (staff #18). Staff #18 stated that when maintenance is needed on the unit, a staff member writes the issue on the Maintenance Request Log located at the nurses station. Staff #18 stated that if it is an emergency such as a leaky ceiling, staff also call the maintenance supervisor. Staff #18 stated that the ceiling leak in the resident's room had occurred more than two weeks ago, and the maintenance department had been notified on the Maintenance Request Log and by phone, but had not repaired the ceiling. Review of the Maintenance Request Log on the unit revealed there were no requests for the ceiling leak in the resident's log to be repaired. -Random observations were conducted during the survey and in room [ROOM NUMBER], sections of the wall located behind the headboards of beds A and B were gouged and scraped. Dried spackle was also observed on the scraped areas and was rough to the touch. On the Renaissance Road unit in the resident common area, a section of baseboard trim was missing. An environmental tour of the facility was conducted on (MONTH) 9, (YEAR) at 1:30 p.m., with the Maintenance Director (staff #166). The Maintenance Director stated that he does maintenance rounds weekly, but not room inspections. Staff #166 stated that if a maintenance repair is needed, staff notify the maintenance department by filling out a request on the Maintenance Request Log, which is located on each unit. He stated that maintenance staff check the Maintenance Request Log daily and make an entry in the log, when the repair is completed. Staff #166 stated that he was unaware of the ceiling leak in the resident's room and that the ceiling needed to be repaired. He also stated that the walls in room [ROOM NUMBER] needed to be repaired, and that the baseboard trim needed to be repaired in the common area on the Renaissance Unit. An interview was conducted on (MONTH) 13, (YEAR) at 3:00 p.m. with the Administrator (staff #400). The Administrator stated that when larger maintenance repairs are needed (such as a leaky ceiling), the maintenance staff should inform her and then the repair services are arranged. Staff #400 stated that repair services had been initiated for the leaky ceiling shortly after the leak had occurred, but the facility was still working on fixing the leak. Review of a policy and procedure titled, Repair/Maintenance Request Log revealed that it is the responsibility of all staff to report and document any repair or maintenance related issues on the Repair/Maintenance log. Any emergencies or safety issues shall be reported immediately to the maintenance department. It is the responsibility of the maintenance department to ensure that all requests for repairs or maintenance are performed in a timely manner and all emergencies along with safety issues are immediately responded to and completed.",2020-09-01
786,RIDGECREST HEALTHCARE,35125,16640 NORTH 38TH STREET,PHOENIX,AZ,85032,2018-03-14,600,E,1,1,7ZN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, facility documentation and policies and procedures, the facility failed to ensure female residents were free from sexual abuse by one resident (#26). Findings include: Resident #26 was admitted to the facility on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. Review of the Behavioral Care Plan initiated on (MONTH) 21, (YEAR) revealed the resident was wandering into peers space with attempts to touch them, and had socially inappropriate behaviors which included taking clothes off and urinating, and defecating and masturbating. The care plan also included that the resident had a history of [REDACTED]. Interventions included to administer medications, coordinate care with the psychiatrist, provide privacy for the resident to masturbate, report behavior changes to the physician, psychiatrist or clinical behavior director for recommendations, and redirect resident to his room if he walks out naked. According to a Psychiatric Mental Health Nurse Practitioner (PMHNP) progress note dated (MONTH) 4, (YEAR), the resident has been exposing himself to other residents, which occurred more in the evening. Recommendations included for a one piece jumpsuit that fastens in the back to increase staff management of his ability to undress and expose himself to other residents. A Health Status note dated (MONTH) 5, (YEAR) at 5:30 p.m. revealed the resident came out of his room with only a T-shirt on, and was holding his penis, which was stiff. The resident then walked up to a female resident who was sitting at the dining room table. The resident was escorted to his room and dressed. Will monitor behavior. A Behavior note dated (MONTH) 5, (YEAR) at 8:33 p.m. revealed the resident was found in a female resident's room with no clothes on, and loose stool was running down his leg. The female resident was screaming and a Certified Nursing Assistant (CNA) redirected the resident and cleaned and dressed him. A Health Status note dated (MONTH) 5, (YEAR) at 8:35 p.m. documented the resident continues to come out of his room in various stages of undress and although he is redirected, he continues the same behavior of exposure. The physician and psychiatrist were notified. A physician's progress note dated (MONTH) 6, (YEAR) at 9:33 p.m. included that staff reported the resident was sexually inappropriate toward female residents, and that the resident had similar episodes at another facility. The note included the psychiatrist was notified. Review of a quarterly Minimum Data Set (MDS) assessment dated (MONTH) 7, (YEAR) revealed the resident had a Brief Interview for Mental Status score of 9, which indicated the resident had moderate cognitive impairment. The MDS included the resident could walk in the corridor, with the supervision of one person. The Behavior Care Plan was revised on (MONTH) 7, (YEAR) to reflect provide resident with one-piece jumpsuit that fastens in the back to decrease self exposure of genitalia to others. A Health Status note dated (MONTH) 9, (YEAR) at 9:08 p.m. documented the resident continued to have intrusive behaviors toward female residents and will stand inches away from female residents and stare. Resident #26 had to be redirected multiple times throughout the day and evening shift, as he continued to come out of his room disrobed from the waist down. A Health Status note dated (MONTH) 10, (YEAR) at 9:50 p.m. included the resident continued to be intrusive of female residents and will stand inches away from them staring and holding their hand. Resident #26 had to be redirected multiple times throughout the day. A Health Status note dated (MONTH) 16, (YEAR) at 10:05 p.m. revealed the resident continued to intrude on personal space with fell ow peers, and has to be continually reminded to leave female residents alone. The resident repeatedly comes out of his room disrobed from the waist down. Review of the Behavioral Rounds documentation dated (MONTH) 19, (YEAR) by the Unit Manager (staff #123) and the Clinical Director/Licensed Clinical Social Worker (staff #395), revealed that resident #26 had jumpsuit's on order. A Health Status note dated (MONTH) 23, (YEAR) at 9:11 p.m. included the resident appeared hypersexual throughout the day and has intrusive behaviors toward female residents. The resident comes out of his room undressed from the waist down. A Health Status note dated (MONTH) 24, (YEAR) at 9:22 p.m. included the resident continued to come out of his room disrobed from the waist down and continued to go into female resident rooms and was intrusive to female residents. The resident is constantly being redirected, but shortly goes back to the same behavior. A Behavior note dated (MONTH) 25, (YEAR) at 8:41 p.m. included the resident was found in a female resident's bed. The female resident was moving around the bed pulling back the covers, as if she was going to lay down. Resident #26 was redirected. A Health Status note dated (MONTH) 26, (YEAR) at 9:48 p.m. revealed the resident was found naked in a female resident's bed, but the female resident was not in the room. The resident was redirected to his own room and was assisted with getting dressed. The resident attempted two more times to go back to the same female residents room. A Behavior note dated (MONTH) 28, (YEAR) at 9:22 p.m. included that resident #26 has been coming out in the hall with his pants down around his ankles, wearing a brief and a T-shirt. The note further included the resident was in the dining room and placed his hands on a female resident's breasts. A CNA separated the residents and resident #26 left the dining room smiling. The note also stated that when the nurse went to a female resident's room to provide a treatment, resident #26 was in the room wearing only a gown and the female resident had on pajamas consisting of a top and bottom. A Behavior note dated (MONTH) 29, (YEAR) at 4:28 p.m. included the resident walked over to a female resident and put his hand on her breasts. A CNA was by the female resident and immediately redirected the resident. A Behavior note dated (MONTH) 29, (YEAR) at 8:29 p.m. included the resident was redirected away from a female resident's room eight times this evening since 7:30 p.m. According to an e-mail dated (MONTH) 30, (YEAR) at 1:32 p.m. from the Director of Nursing (staff #401) to the Clinical Director/Licensed Clinical Social Worker (staff #395), staff #401 wrote that resident #26 who resides on the Sunset Unit has been very hypersexual for the last two days. Trying to grab peers and staff, attempting to climb into female peers beds. The e-mail included that the nurse has a call out to the PMHNP and that they have placed him on 1-1 as he is wild. I'm not sure of his history but I'm concerned if he (is) appropriate for the unit. The 1-1 is until further notice to protect the female residents on this unit. In an e-mail response from staff #395 to staff #401 dated (MONTH) 30, (YEAR) at 2:26 p.m., staff #395 wrote I believe (PMHNP) wrote orders to get him jumpsuit's 2-3 weeks ago and I was under the impression that 7 were on order. The 1:1 is a good plan for the interim. He has been getting more hypersexual and needing more supervision. I know he has a TBI ([MEDICAL CONDITION]) and has a history of sexual behaviors. He frequently has an erection when walking around the unit. I would recommend the nurse check the recent psych notes from the (PMHNP's) last visit. I don't believe that the use of PRN (as needed) meds have been all that effective with him. Could someone please look into the jumpsuit's? He may need a higher level of care if the current interventions are not working. A Behavior note dated (MONTH) 30, (YEAR) at 4:22 p.m. included that this morning the resident has been very sexually inappropriate and intrusive toward female residents. The resident would not follow redirection and would continually go into female residents rooms and stand over the females inches away, attempting to touch them. The Director of Nursing (DON) was notified and orders were given to place the resident on 1:1 observation until further notice. The PMHNP was notified. A Health Status note dated (MONTH) 30, (YEAR) at 9:19 p.m. revealed the resident is on 1:1 observation, but continues to attempt to get near female residents. The resident told staff with a smile on his face, that he wanted to go into another female's room and lay some pipe. The behavior care plan was revised on (MONTH) 30, (YEAR) to reflect that the resident had increased sexual behaviors, which may lead to increased conflict with other residents, as the resident is entering female resident rooms, disrobing, and exhibiting sexually intrusive behaviors. The only interventions which were added included to monitor behaviors daily and review increasing behaviors requiring re-evaluation. Review of the Behavioral Rounds documentation dated (MONTH) 3, (YEAR) by the Unit Manager (staff #123) and the Clinical Director/Licensed Clinical Social Worker (staff #395), revealed resident #26 has been exposing himself and going into female resident's beds, is grabbing at residents and refusing medications. Further review of the resident's clinical record revealed that the physician and PMHNP had made multiple changes to the resident's medication regimen from (MONTH) 4 through (MONTH) 29, (YEAR) and utilized jumpsuit's for the resident. However, there were no other interventions put into place to ensure multiple female residents were protected from resident #26 until (MONTH) 30, when he was placed on 1:1 supervision. Review of the Behavioral Rounds documentation dated (MONTH) 10, (YEAR) by the Unit Manager (staff #123) and the Clinical Director/Licensed Clinical Social Worker (staff #395), revealed that resident #26 was on 1:1 with a CN[NAME] The note further included that the resident was attempting to go into a female resident's room and that he was targeting her. A PMHNP progress note dated (MONTH) 12, (YEAR) revealed the resident had stated I think I screwed someone. The Behavior section of the notes documented the PMHNP had a teleconference last weekend, due to the resident's increased sexualized behavior and that the resident was on 1:1 assignment for his safety, and the safety of other residents on the unit. Continued review of the clinical record revealed that resident #26 was moved to the high acuity behavior unit within the facility on (MONTH) 13, (YEAR). An interview was conducted with the Registered Nurse/Unit Manager (staff #124) on (MONTH) 14, (YEAR) at 9:22 a.m. Staff #124 stated the unit serves residents that have dementia with behaviors, such as residents with sexualized behaviors, but usually it is directed toward staff, so we provide redirection and alternate activities. Staff #124 stated if a resident's sexualized behaviors are directed toward peers and it gets too bad, we have to keep them away from other peers and may have to place them on 1:1 monitoring. Staff #124 stated if a resident with behaviors is not easily redirectable, we can also contact the clinical behavior director. Staff #124 stated there are three CNAs here during the day and there are currently 20 residents. She said that resident #26 was very sexual and would come out of his room disrobed, masturbate and would try to go into female resident rooms. She stated that resident #26 would also come out of his room and urinate on the floor. Staff #124 stated that if a resident made sexual contact with another resident, they would immediately report it and protect the other residents by separating them. She stated that resident #26 was put on 1:1 observation and they sought a higher level of care for him. Staff #124 stated when resident #26 first got here he did not exhibit those behaviors. In an interview conducted with a LPN (licensed practical nurse/staff #36) on (MONTH) 14, (YEAR) at 10:45 a.m., staff #36 stated that if she witnessed a resident grab the breasts of another resident, she would ensure the residents were separated and she would notify the supervisor, because that falls under resident abuse and has to be reported immediately. Staff #36 further stated she recalled resident #26 and that he was sexually intrusive, wandering into female resident rooms and walking around disrobed. Staff #36 stated that on the morning of (MONTH) 30, (YEAR), during shift report a nurse (staff #402) advised her that resident #26 had grabbed the breasts of two female residents and that he was found in the bed with a female resident, but a blanket separated them. Staff #36 stated she also notified the DON again, when she called to get 1:1 permission. In an interview conducted with the Regional Clinical Director (acting Director of Nursing/DON/staff #401) on (MONTH) 14, (YEAR) at 11:12 a.m., staff #401 stated she was serving as the interim DON at the facility in (MONTH) of (YEAR). Staff #401 stated if any issues arose with residents, staff notified the unit manager, and the unit manager would notify her. Staff #401 stated that she did receive a call on (MONTH) 30, (YEAR) about the resident's intrusive behaviors, and she made the decision to place the resident on 1:1 supervision around the clock. In an interview conducted with a LPN (staff #402) on (MONTH) 15, (YEAR) at 1:15 p.m. via telephone, staff #402 stated that resident #26 was sexually inappropriate and touched two different resident's breasts on two different days. Staff #402 stated he walked up to an elderly female resident and put his hands on her breasts in the dining room, but she didn't recall the resident's name. Staff #402 said that the next day he followed another female resident and walked up to her and touched her breasts. She said that she had identified one of the female residents and told the Unit Manager (staff #124). Staff #402 stated she called the physician, who stated he would be in to make some changes in the resident's medications. Review of the facility's investigative report received on (MONTH) 16, (YEAR), revealed that on two occasions resident #26 had placed his hands on female resident's breasts in (MONTH) (YEAR). The report did not identify the female residents. The investigation included interviews with CNA staff who recalled the sexual behavior of resident #26, but not the touching. The report further included that the facility did not substantiate any resident to resident altercations. Also, the report did not include that they had substantiated any abuse. Per the report, resident #26 remains at the facility on the high acuity on the Behavioral Unit, with a 2 to 1 ratio for close supervision. Review of a policy titled, Abuse Prevention and Prohibition Program revealed To ensure that residents' rights are protected by providing a method for the prevention of any type of resident abuse. The policy included that abuse will not be tolerated in this facility at any time. The policy stated that It is the policy of this facility to take proactive measures to prevent the occurrence of alleged abuse to any resident. Each resident has the right to be free from verbal, sexual, physical, and mental abuse .Resident must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents . The policy defined sexual abuse as non-consensual contact of any type with a resident. The policy further included that Supervisors shall immediately intervene, correct, and report identified situations where abuse is at risk for occurring.",2020-09-01
787,RIDGECREST HEALTHCARE,35125,16640 NORTH 38TH STREET,PHOENIX,AZ,85032,2018-03-14,604,D,0,1,7ZN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and policies and procedures, the facility failed to ensure that one resident (#90) was free of physical restraints. Findings include: Resident #90 was admitted on (MONTH) 24, (YEAR), with [DIAGNOSES REDACTED]. Review of a care plan revised on (MONTH) 10, (YEAR), revealed the resident was at risk for injury related to a history of falls, dementia and poor safety awareness. The care plan included that the resident attempted to ambulate by herself frequently and stands up from her chair impulsively. Interventions were to assist with all transfers and provide assistance to maintain safety and encourage independence. A quarterly MDS (Minimum Data Set) assessment dated (MONTH) 1, (YEAR) included a BIMS (Brief Interview for Mental Status) score of 3, which indicated the resident had severe cognitive impairment. The MDS identified that the resident required extensive assistance of one person with walking and with transfers to and from the wheelchair. The MDS further included the resident was not steady when standing up or walking, and was able to stabilize her balance with staff assistance. The assessment did not include documentation that any restraints were in use. Review of a monthly maintenance note by the nurse practitioner dated (MONTH) 12, (YEAR), revealed that the resident had fallen on (MONTH) 2, (YEAR). The note included that the resident gets up from the wheelchair by herself and thinks that she can walk safely. Per the note, the resident needed close monitoring and would benefit from 1:1 care, due to a history of falling. During an observation conducted on (MONTH) 5, (YEAR) at 9:15 a.m., resident #90 was seated in a wheelchair in the common area in the Sunset Boulevard unit, with the back of her wheelchair situated directly in front of a wall. There was also a large table which been placed directly in front of the resident's chair. At this time, the resident was observed to make repetitive attempts to stand and attempted to push the table away, however, she was unable to move the table. The placement of the resident's chair against the wall and a table placed in front of the resident, prevented the resident from standing. Three staff members were in the common area and did not intervene when the resident attempted to stand up or when trying to push the table away from her. Another observation was conducted on (MONTH) 7, (YEAR) at 8:40 a.m. of the resident seated in her wheelchair in the common area. The wheels on the resident's wheelchair were locked. In front of the resident was a table, which had been pushed up against the wheelchair. At this time, a CNA (Certified Nursing Assistant) was seated next to the resident. The resident made multiple attempts to stand and push away the table. Each time she succeeded in standing, the CNA would gently push the resident back down into the wheelchair, and reposition the chair back up against the table, telling the resident to sit back down. Further review of the clinical record revealed there was no documentation that the resident had been assessed for the safe use of a table as a restraint device, nor was there documentation of any medical symptoms that warranted the use of restraints. An interview was conducted on (MONTH) 7, (YEAR) at 8:50 a.m. with the CNA (staff #17), who had been seated next to the resident. The CNA stated that resident #90 had a history of [REDACTED]. She stated she was not familiar with the resident's care plan for fall prevention. Staff #17 stated that the resident was able to stand, but the table was preventing the resident from falling. An interview was conducted on (MONTH) 7, (YEAR) at 9:01 a.m., with a nurse manager (staff #124). Staff #124 stated that staff should not have positioned the resident between a wall and a table, or position the resident in a manner that prevented her from standing up. Staff #124 stated that staff were not supposed to place a table in front of the resident to prevent her from falling. Staff #124 stated that the table was not part of the resident's care plan to prevent falls. An interview was conducted on (MONTH) 8, (YEAR) at 1:50 p.m., with the Director of Nursing (staff #391). Staff #391 stated that a restraint is Anything the prevents a resident's movement and that the facility did not approve the use of non-traditional restraints. Staff #391 stated that staff should not have used the table or any other device to prevent the resident's movement. Review of a policy and procedure regarding Restraints included that residents are to be assessed prior to the application of restrictive devices to determine medical symptoms that may require the use of the restraint, to determine how the use of the restraint would treat the medical symptom, protect the resident's safety, and assist the resident in attaining or maintaining their highest practicable level of physical and psychosocial well-being. The policy also included that if considering initiating a restraint, attempt alternative methods prior to restraining devices and document effectiveness.",2020-09-01
788,RIDGECREST HEALTHCARE,35125,16640 NORTH 38TH STREET,PHOENIX,AZ,85032,2018-03-14,607,E,1,1,7ZN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews, facility documentation and policies and procedures, the facility failed to implement their abuse policies, by failing to thoroughly investigate an allegation of sexual abuse for one resident (#360), and by failing to investigate alleged sexual abuse involving female residents by resident (#26). Findings include: -Resident #360 was admitted on (MONTH) 23, (YEAR) with a re-admission on (MONTH) 1, (YEAR). [DIAGNOSES REDACTED]. An admission MDS (Minimum Data Set) assessment dated (MONTH) 20, (YEAR) included the resident had a BIMS (Brief Interview for Mental Status) score of 12, which indicated the resident had moderate cognitive impairment. Review of the facility's investigative report revealed that on (MONTH) 19, (YEAR), the resident told a staff member that two male visitors had come into her room and threatened her and had touched her inappropriately. The documentation included that the resident could not remember the exact day. Further review of the investigative report revealed that it was not thorough, as the facility failed to conducted interviews with other resident's at the time of the allegation. An interview was conducted with the Administrator (staff #400) on (MONTH) 8, (YEAR) at 12:12 p.m. Staff #400 stated that there had been no interviews with other residents on the unit where resident #360 resided. Staff #400 stated that resident interviews would be an important part of the investigation, in order to determine if any other residents had seen any unknown male visitors in the vicinity of resident #360's room. Staff #400 stated that resident #360 was in a private room so there was no roommate to interview. Staff #400 further stated that the facility policy only addresses interviewing other residents regarding alleged abuse by staff. Staff #400 said no one thought about the possibility that other residents may have seen someone near resident #360's room. -Resident #26 was admitted to the facility on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed there were multiple entries which included that from (MONTH) 5, (YEAR) through (MONTH) 10, (YEAR), the resident exhibited increased sexual behaviors as follows: disrobing and walking around naked with an erection exposing himself to other residents, entered female resident's rooms and got into female resident's beds with and without the female resident present, grabbed the breasts of two female residents, had to be continually reminded to leave female residents alone, and made multiple attempts to try and touch female residents. The facility was unable to provide any documentation that the incidents of abuse were investigated at the time of the incidents, per their policy. An interview was conducted on (MONTH) 3, (YEAR) at 11:12 a.m., with the Regional Clinical Director (acting Director of Nursing/staff #401). Staff #401 stated that she was serving as the interim DON in the facility in (MONTH) of (YEAR). Staff #401 stated that she did receive a call on (MONTH) 30, (YEAR) about how intrusive the resident was and she made the decision to place the resident on 1:1 supervision. Staff #401 stated that she had spoken with the nurse who wrote the two notes about resident #26 touching the female resident's breasts, but the nurse did not give any information about who the residents were, so they could not investigate it. An interview with the Administrator (staff #400) was conducted on (MONTH) 12, (YEAR) at 3:30 p.m. Staff #400 stated the facility did not have an investigative report, because there was no victim identified. The Administrator stated she would now initiate an investigation. Review of a policy titled, Abuse Prevention and Prohibition Program revealed To ensure that residents' rights are protected by providing a method for the prevention of any type of resident abuse. The policy included that abuse will not be tolerated in this facility at any time. The policy stated that It is the policy of this facility to take proactive measures to prevent the occurrence of alleged abuse to any resident. Each resident has the right to be free from verbal, sexual, physical, and mental abuse .Resident must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents . The policy defined sexual abuse as non-consensual contact of any type with a resident. The policy further included that Supervisors shall immediately intervene, correct, and report identified situations where abuse is at risk for occurring. Further review of the policy revealed under the Identification of Abuse section, that all incidents of suspected or alleged abuse will be promptly investigated by the assigned staff. The investigation and report shall include the following: -Review all relevant documentation; -Review the resident's medical record to determine events preceding the alleged incident -Interview the person(s) making the incident report -Interview any witnesses to the alleged incident and include witness written reports which are signed and dated -Interview the resident (as medically appropriate) -Interview facility staff members who have had contact with the resident during the period of the alleged incident -Interview the resident's roommate, family members, and visitors -Review all events leading up to the alleged incident -Communicate with the Administrator/designee who is the Facility Abuse Prevention Coordinator on a daily basis regarding the progress of the investigation and -Prepare an investigation report documenting findings of the investigation.",2020-09-01
789,RIDGECREST HEALTHCARE,35125,16640 NORTH 38TH STREET,PHOENIX,AZ,85032,2018-03-14,608,E,1,1,7ZN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, facility documentation and policies and procedures, the facility failed to report a reasonable suspicion of a crime of sexual abuse of female residents by resident (#26) to law enforcement. Findings include: Resident #26 was admitted to the facility on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. Review of the Behavioral Care Plan initiated on (MONTH) 21, (YEAR) revealed the resident had the following behaviors: was wandering into peers space with attempts to touch them, had socially inappropriate behaviors which included taking clothes off and urinating, and defecating and masturbating. The care plan also included that the resident had a history of [REDACTED]. Interventions included to administer medications, coordinate care with the psychiatrist, provide privacy for the resident to masturbate, report behavior changes to the physician, psychiatrist or clinical behavior director for recommendations, and redirect resident to his room if he walks out naked. According to a Psychiatric Mental Health Nurse Practitioner (PMHNP) progress note dated (MONTH) 4, (YEAR), the resident exposed himself to other residents, which occurred more in the evening. Recommendations included for a one piece jumpsuit that fastens in the back to increase staff management of his ability to undress and expose himself to other residents. A Health Status note dated (MONTH) 5, (YEAR) at 5:30 p.m. revealed the resident came out of his room with only a T-shirt on, and was holding his penis, which was stiff. The resident then walked up to a female resident who was sitting at the dining room table. The resident was escorted to his room and was dressed. Will monitor behavior. A Behavior note dated (MONTH) 5, (YEAR) at 8:33 p.m. revealed the resident was found in a female residents room with no clothes on, and loose stool was running down his leg. The female resident was screaming and a Certified Nursing Assistant (CNA) redirected the resident and cleaned and dressed him. A Health Status note dated (MONTH) 5, (YEAR) at 8:35 p.m. documented the resident continues to come out of his room in various stages of undress and though he is redirected, he continues the same behavior of exposure. The physician and psychiatrist were notified. A physician's progress note dated (MONTH) 6, (YEAR) at 9:33 p.m. included that staff reported the resident was sexually inappropriate toward female residents, and the resident had similar episodes at another facility. The note included the psychiatrist was notified. Review of a quarterly Minimum Data Set (MDS) assessment dated (MONTH) 7, (YEAR) revealed the resident had a Brief Interview for Mental Status score of 9, which indicated the resident had moderate cognitive impairment. The MDS included the resident could walk in the corridor, with the supervision of one person. The Behavior Care Plan was revised on (MONTH) 7, (YEAR) to reflect provide resident with one-piece jumpsuit that fastens in the back to decrease self exposure of genitalia to others. A Health Status note dated (MONTH) 9, (YEAR) at 9:08 p.m. documented the resident continued to have intrusive behaviors toward female residents and will stand inches away from female residents and stare. The resident had to be redirected multiple times throughout the day and evening shift, as he continued to come out of his room disrobed from the waist down. A Health Status note dated (MONTH) 10, (YEAR) at 9:50 p.m. included the resident continued to be intrusive of female residents and will stand inches away from them staring and holding their hand. Resident #26 had to be redirected multiple times throughout the day. A Health Status note dated (MONTH) 16, (YEAR) at 10:05 p.m. revealed the resident continued to intrude on personal space with fell ow peers, and has to be continually reminded to leave female residents alone. The resident repeatedly comes out of his room disrobed from the waist down. Review of the Behavioral Rounds documentation dated (MONTH) 19, (YEAR) by the Unit Manager (staff #123) and the Clinical Director/Licensed Clinical Social Worker (staff #395), revealed resident #26 had jumpsuit's on order. A Health Status note dated (MONTH) 23, (YEAR) at 9:11 p.m. included the resident appeared hypersexual throughout the day and has intrusive behaviors toward female residents. The resident comes out of his room undressed from the waist down. A Health Status note dated (MONTH) 24, (YEAR) at 9:22 p.m. included the resident continued to come out of his room disrobed from the waist down and continued to go into female resident rooms and was intrusive to female residents. The resident is constantly being redirected, but shortly goes back to the same behavior. A Behavior note dated (MONTH) 25, (YEAR) at 8:41 p.m. included the resident was found in a female resident's bed. The female resident was moving around the bed pulling back the covers, as if she was going to lay down. Resident #26 was redirected. A Health Status note dated (MONTH) 26, (YEAR) at 9:48 p.m. revealed the resident was found naked in a female resident's bed, but the female resident was not in the room. The resident was redirected to his own room and was assisted with getting dressed. The resident attempted two more times to go back to the same female residents room. A Behavior note dated (MONTH) 28, (YEAR) at 9:22 p.m. included that resident #26 has been coming out in the hall with his pants down around his ankles, wearing a brief and a T-shirt. The note further included the resident was in the dining room and placed his hands on a female resident's breasts. A CNA separated the residents and resident #26 left the dining room smiling. The note also stated that when the nurse went to a female resident's room to provide a treatment, resident #26 was in the room wearing only a gown and the female resident had on pajamas consisting of a top and bottom. A Behavior note dated (MONTH) 29, (YEAR) at 4:28 p.m. included the resident walked over to a female resident and put his hand on her breasts. A CNA was by the female resident and immediately redirected the resident. A Behavior note dated (MONTH) 29, (YEAR) at 8:29 p.m. included the resident was redirected away from a female resident's room eight times this evening since 7:30 p.m. According to an e-mail dated (MONTH) 30, (YEAR) at 1:32 p.m. from the Director of Nursing (staff #401) to the Clinical Director/Licensed Clinical Social Worker (staff #395), staff #401 wrote that resident #26 who resides on the Sunset Unit has been very hypersexual for the last two days. Trying to grab peers and staff, attempting to climb into female peers beds. The e-mail included that the nurse has a call out to the PMHNP and that they have placed him on 1-1 as he is wild. I'm not sure of his history but I'm concerned if he (is) appropriate for the unit. The 1-1 is until further notice to protect the female residents on this unit. In an e-mail response from staff #395 to staff #401 dated (MONTH) 30, (YEAR) at 2:26 p.m., staff #395 wrote I believe (PMHNP) wrote orders to get him jumpsuit's 2-3 weeks ago and I was under the impression that 7 were on order. The 1:1 is a good plan for the interim. He has been getting more hypersexual and needing more supervision. I know he has a TBI ([MEDICAL CONDITION]) and has a history of sexual behaviors. He frequently has an erection when walking around the unit. I would recommend the nurse check the recent psych notes from the (PMHNP's) last visit. I don't believe that the use of PRN (as needed) meds have been all that effective with him. Could someone please look into the jumpsuit's? He may need a higher level of care if the current interventions are not working. A Behavior note dated (MONTH) 30, (YEAR) at 4:22 p.m. documented that this morning the resident has been very sexually inappropriate and intrusive toward female residents. The resident would not follow redirection and would continually go into female residents rooms and stand over the females inches away, attempting to touch them. The Director of Nursing (DON) was notified and orders were given to place the resident on 1:1 observation until further notice. The PMHNP was notified. A Health Status note dated (MONTH) 30, (YEAR) at 9:19 p.m. revealed the resident is on 1:1 observation, but continues to attempt to get near female residents. The resident told staff with a smile on his face, that he wanted to go into another female's room and lay some pipe. The behavior care plan was revised on (MONTH) 30, (YEAR) to reflect that the resident had increased sexual behaviors, which may lead to increased conflict with other residents, as the resident is entering female resident rooms, disrobing, and exhibiting sexually intrusive behaviors. The only interventions which were added included to monitor behaviors daily and review increasing behaviors requiring re-evaluation. Review of the Behavioral Rounds documentation dated (MONTH) 3, (YEAR) by the Unit Manager (staff #123) and the Clinical Director/Licensed Clinical Social Worker (staff #395), revealed resident #26 has been exposing himself and going into female resident's beds, is grabbing at residents and refusing medications. Review of the resident's clinical record revealed that the physician and PMHNP had made multiple changes to the resident's medication regimen from (MONTH) 4 to (MONTH) 29, (YEAR) and utilized jumpsuit's for the resident. However, there were no other interventions put into place to ensure multiple female residents were protected from resident #26, until (MONTH) 30, when he was placed on 1:1 supervision. Review of the Behavioral Rounds documentation dated (MONTH) 10, (YEAR) by the Unit Manager (staff #123) and the Clinical Director/Licensed Clinical Social Worker (staff #395), revealed that resident #26 was on 1:1 with a CN[NAME] The note further included that the resident was attempting to go into a female resident's room and that he was targeting her. A PMHNP progress note dated (MONTH) 12, (YEAR) revealed the resident had stated I think I screwed someone. The Behavior section of the notes documented the PMHNP had a teleconference last weekend, due to the resident's increased sexualized behavior and that the resident was on 1:1 assignment for his safety, and the safety of other residents on the unit. Further review of the clinical record revealed that resident #26 was moved to the high acuity behavior unit within the facility on (MONTH) 13, (YEAR). The facility was unable to provide any documentation that the incidents of sexual abuse were reported to law enforcement. An interview was conducted with a Registered Nurse/Unit Manager (staff #124) on (MONTH) 14, (YEAR) at 9:22 a.m. Staff #124 stated if a resident sexually contacts another resident we would immediately report it and protect the resident by removing them. Staff #26 stated that the resident was in female resident's beds and he touched female resident's breasts, and it should have been reported and action taken much sooner. In an interview conducted with a LPN (staff #36) on (MONTH) 14, (YEAR) at 10:45 a.m., staff #36 stated that if she witnessed a resident grab the breasts of another resident she would ensure the residents were separated and she would notify the supervisor and tell them what happened, because that falls under resident abuse and has to be reported immediately. Staff #36 stated that resident #26 was sexually intrusive, wandered into female resident rooms, and walked around disrobed. Staff #36 stated when she got report from staff #402 on the the morning of (MONTH) 30, (YEAR), staff #402 advised her that resident #26 had grabbed the breasts of two female residents and that he was found in bed with a female resident, but a blanket separated them. She said that she told her supervisor and notified the DON, when she called to get the 1:1 permission. An interview was conducted on (MONTH) 3, (YEAR) at 11:12 a.m., with the Regional Clinical Director (acting Director of Nursing/staff #401). Staff #401 stated that she had spoken with the nurse who wrote the two notes about resident #26 touching the female resident's breasts and that outside agencies were not notified. An interview was conducted with a LPN (staff #402) on (MONTH) 15, (YEAR) at 1:15 p.m. via telephone. Staff #402 stated that resident #26 was sexually inappropriate and touched two different female resident's breasts on two different days. Staff #402 stated he walked up to an elderly female resident and put his hands on her breasts in the dining room, and then the next day he followed another female resident and walked up to her and touched her breasts. Staff #402 stated that she did let the Unit Manager (staff #124) know. Review of a policy titled, Abuse Prevention and Prohibition Program revealed To ensure that residents' rights are protected by providing a method for the prevention of any type of resident abuse. The policy included that abuse will not be tolerated in this facility at any time. The policy stated that It is the policy of this facility to take proactive measures to prevent the occurrence of alleged abuse to any resident. Each resident has the right to be free from verbal, sexual, physical, and mental abuse .Resident must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents . The policy defined sexual abuse as non-consensual contact of any type with a resident. The policy also included that Supervisors shall immediately intervene, correct, and report identified situations where abuse is at risk for occurring. The policy further included that facility staff are mandated reporters and are obligated by the Elder Justice Act to report known or suspected instances of abuse. Reporting requirements included that the facility will report known or suspected instances of abuse immediately via telephone to the proper local authorities.",2020-09-01
790,RIDGECREST HEALTHCARE,35125,16640 NORTH 38TH STREET,PHOENIX,AZ,85032,2018-03-14,609,E,1,1,7ZN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, facility documentation and policies and procedures, the facility failed to report incidents of sexual abuse of female residents by one resident (#26) to the State agency within two hours, as required. Findings include: Resident #26 was admitted to the facility on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed that in (MONTH) and (MONTH) (YEAR), there were multiple progress notes from nursing, a nurse practitioner, physician and social worker which documented the following incidents involving resident #26: -September 4: The resident exposed himself to other residents. -September 5: The resident came out of his room with only a T-shirt on. The resident had a stiff penis which he was holding in his hand and walked up to a female resident who was sitting at the dining room table. The resident was also found in a female resident's room with no clothes on and had loose stool which was running down his leg. The female resident was screaming. The physician and psychiatrist were notified. -September 6: Staff reported that the resident was sexually inappropriate toward female residents and has had similar episodes at another facility. -September 9, 10 and 16: The resident continues to intrude on personal space with fell ow residents. He stands inches away from female residents and stares and holds their hand. He has to be continually reminded to leave female residents alone. The resident repeatedly came out of his room disrobed from the waist down. -September 23: The resident appeared hypersexual throughout the day and has intrusive behaviors toward female residents. -September 25: The resident was found in a female resident's bed. The female was moving around the bed pulling back the covers, as if she was going to lay down. -September 26: The resident was found naked in a female resident's bed, but the female resident was not in the room. The resident was redirected to his own room, but attempted two more times to go back to the same female's room. -September 28: The resident has been coming out in the hall with his pants down around his ankles and only wearing a brief and a T-shirt. The resident was also in the dining room and placed his hands on a female resident's breasts. -September 29: The resident walked over to a female resident and put his hand on her breasts. The resident was redirected away from the female resident's room eight times this evening since 7:30 p.m. -September 30: This morning the resident has been very sexually inappropriate and intrusive toward female residents. He continually goes into female resident's rooms and stands over them inches away, attempting to touch them. The Director of Nursing was notified and the resident was placed on 1:1. In an e-mail communication from the DON (staff #401) and the Clinical Director/Licensed Clinical Social Worker (LCSW/staff #395) on (MONTH) 30, (YEAR) at 1:32 p.m., staff #401 wrote that resident #26 has been very hypersexual for the last two days. Trying to grab peers and staff, attempting to climb into female peers beds. We have placed him on 1:1 as he is wild. The 1:1 is until further notice to protect the female residents on this unit. In an e-mail response from staff #395 to staff #401 on (MONTH) 30, (YEAR) at 2:26 p.m., staff #395 wrote that the 1:1 is a good plan for the interim. He has been getting more hyper sexual and needing more supervision. He has a TBI ([MEDICAL CONDITION]) and a history of sexual behaviors. He frequently has an erection when walking around the unit. Review of the Behavioral Rounds documentation dated (MONTH) 10, (YEAR) by the Unit Manager (staff #123) and the Clinical Director/Licensed Clinical Social Worker (staff #395), revealed that resident #26 was on 1:1 with a CN[NAME] The note further included that the resident was attempting to go into a female resident's room and that he was targeting her. The facility was unable to provide any documentation that the above incidents were reported to the State agency, within two hours. In an interview conducted on (MONTH) 3, (YEAR) at 11:12 a.m. with the Regional Clinical Director (acting Director of Nursing/staff #401), staff #401 stated she was serving as the interim DON in the facility in (MONTH) of (YEAR). Staff #401 stated she did receive a call on (MONTH) 30, (YEAR) about how intrusive the resident was and she made the decision to place the resident on 1:1 supervision. Staff #401 stated that she had spoken with the nurse who wrote the two notes about resident #26 touching the female resident's breasts, but the nurse did not give any information about who the residents were, so they could not investigate it. Staff #401 stated that outside agencies were not notified, because they did not have the name of any victims to say they were abused. In an interview conducted with a LPN (staff #36) on (MONTH) 14, (YEAR) at 10:45 a.m., staff #36 stated that she witnessed the resident grab the breasts of a female resident. She said that she notified the supervisor, because it falls under resident abuse and has to be reported immediately. An interview was conducted with a LPN (staff #402) on (MONTH) 15, (YEAR) at 1:15 p.m. via telephone. Staff #402 stated that resident #26 was sexually inappropriate and touched two different resident's breasts on different days. Staff #402 stated the resident walked up to an elderly female resident and put his hands on her breasts in the dining room, but she did not recall the resident's name. She said the next day he followed another female resident and walked up to her and touched her breasts. Staff #402 stated that she was able to identify one of the female residents and told the Unit Manager (staff #124). Staff #402 further stated that the Director of Nursing and the Administrator did not ask her any questions about the incidents. Review of the Abuse Prevention and Prohibition Program policy revealed that abuse will not be tolerated at any time. Each resident has the right to be free from verbal, sexual, physical, and mental abuse. The policy included that all incidents of suspected or alleged abuse will be promptly investigated by the assigned staff and to communicate daily with the Administrator, who is the Facility Abuse Prevention Coordinator regarding the progress of the investigation. Under the Reporting section, the policy included that facility staff are mandated reporters and are obligated by the Elder Justice Act to report known or suspected instances of abuse. The policy further stated that the facility will report known or suspected instances of abuse immediately via telephone to the State agency, and follow up with a written report within five days. The abuse policy did not include that allegations/alleged abuse need to be reported to the State agency no later than two hours after the allegation is made.",2020-09-01
791,RIDGECREST HEALTHCARE,35125,16640 NORTH 38TH STREET,PHOENIX,AZ,85032,2018-03-14,610,E,1,1,7ZN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews, facility documentation and policies and procedures, the facility failed to conduct abuse investigations involving one resident (#26) who displayed sexual behaviors toward female residents, and failed to conduct a thorough investigation regarding an allegation of abuse for one resident (#360). Findings include: -Resident #360 was admitted on (MONTH) 23, (YEAR) with a re-admission on (MONTH) 1, (YEAR). [DIAGNOSES REDACTED]. An admission MDS (Minimum Data Set) assessment dated (MONTH) 20, (YEAR) included the resident had a BIMS (Brief Interview for Mental Status) score of 12, which indicated the resident had moderate cognitive impairment. Review of the facility's investigative report revealed that on (MONTH) 19, (YEAR), the resident told a staff member that two male visitors had come into her room and threatened her and had touched her inappropriately. The documentation included that the resident could not remember the exact day. Further review of the investigative report revealed that it was not thorough, as the facility failed to conducted interviews with other resident's at the time of the allegation. An interview was conducted with the Administrator (staff #400) on (MONTH) 8, (YEAR) at 12:12 p.m. Staff #400 stated that there had been no interviews with other residents on the unit where resident #360 resided. Staff #400 stated that resident interviews would be an important part of the investigation, in order to determine if any other residents had seen any unknown male visitors in the vicinity of resident #360's room. Staff #400 stated that resident #360 was in a private room so there was no roommate to interview. Staff #400 further stated that the facility policy only addresses interviewing other residents regarding alleged abuse by staff. Staff #400 said no one thought about the possibility that other residents may have seen someone near resident #360's room. -Resident #26 was admitted to the facility on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed there were multiple entries which included that from (MONTH) 5, (YEAR) through (MONTH) 10, (YEAR), the resident exhibited increased sexual behaviors as follows: disrobing and walking around naked with an erection exposing himself to other residents, entered female resident's rooms and got into female resident's beds with and without the female resident present, grabbed the breasts of two female residents, had to be continually reminded to leave female residents alone, and made multiple attempts to try and touch female residents. The facility was unable to provide any documentation that the above incidents were investigated at the time they occurred. An interview was conducted on (MONTH) 3, (YEAR) at 11:12 a.m., with the Regional Clinical Director (acting Director of Nursing/staff #401). Staff #401 stated that she was serving as the interim DON in the facility in (MONTH) of (YEAR). Staff #401 stated that she did receive a call on (MONTH) 30, (YEAR) about how intrusive the resident was and she made the decision to place the resident on 1:1 supervision. Staff #401 stated that she had spoken with the nurse who wrote the two notes about resident #26 touching the female resident's breasts, but the nurse did not give any information about who the residents were, so they could not investigate it. An interview with the Administrator (staff #400) was conducted on (MONTH) 12, (YEAR) at 3:30 p.m. Staff #400 stated the facility did not have an investigative report, because there was no victim identified. The Administrator stated she would now initiate an investigation. Review of a policy titled, Abuse Prevention and Prohibition Program revealed To ensure that residents' rights are protected by providing a method for the prevention of any type of resident abuse. The policy included that abuse will not be tolerated in this facility at any time. The policy stated that It is the policy of this facility to take proactive measures to prevent the occurrence of alleged abuse to any resident. Each resident has the right to be free from verbal, sexual, physical, and mental abuse .Resident must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents . The policy defined sexual abuse as non-consensual contact of any type with a resident. The policy further included that Supervisors shall immediately intervene, correct, and report identified situations where abuse is at risk for occurring. Further review of the policy revealed under the Identification of Abuse section, that all incidents of suspected or alleged abuse will be promptly investigated by the assigned staff. The investigation and report shall include the following: -Review all relevant documentation; -Review the resident's medical record to determine events preceding the alleged incident -Interview the person(s) making the incident report -Interview any witnesses to the alleged incident and include witness written reports which are signed and dated -Interview the resident (as medically appropriate) -Interview facility staff members who have had contact with the resident during the period of the alleged incident -Interview the resident's roommate, family members, and visitors -Review all events leading up to the alleged incident -Communicate with the Administrator/designee who is the Facility Abuse Prevention Coordinator on a daily basis regarding the progress of the investigation and -Prepare an investigation report documenting findings of the investigation.",2020-09-01
792,RIDGECREST HEALTHCARE,35125,16640 NORTH 38TH STREET,PHOENIX,AZ,85032,2018-03-14,689,D,0,1,7ZN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, staff interviews, facility documentation and policy and procedures, the facility failed to ensure that the resident environment remains free of accident hazards, by failing to ensure that bed loops were applied safely on two residents (#99 and # 47) beds. Findings include: -Resident #99 was admitted on (MONTH) 8, (YEAR), with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of a care plan revealed the resident was at risk for injury from falls related to impaired mobility and balance deficits, had difficulty with transfers when moving from a seated position to a standing position, used high risk medications, had a history of [REDACTED]. The care plan included that the resident has poor safety awareness related to dementia, and has a habit of putting self on the floor. An intervention included that a bed loop had been added to the resident's bed on (MONTH) 27, (YEAR). Review of the most recent bed safety assessment dated (MONTH) 5, (YEAR) revealed the resident had a history of [REDACTED]. The assessment also included a recommendation not to use side rails. A MDS (Minimum Data Set) assessment dated (MONTH) 6, (YEAR), included a BIMS (Brief Interview for Mental Status) score of 9, which indicated the resident had moderate cognitive impairment. The MDS also included the resident required one person limited assistance for bed mobility and transferring, and was not steady. Review of a Maintenance Request Log form included an entry dated (MONTH) 5, (YEAR) which read, Bed loop needs to be attached to bed. Another entry on the log included that the repair had been completed on (MONTH) 6. There were no additional requests in the maintenance log after (MONTH) 5, (YEAR), for repair of the bed loop on the resident's bed. An observation of the resident's bed was conducted on (MONTH) 9, (YEAR) at 10:45 a.m. At this time, the resident was not in his bed. The bed loop was observed to be attached to the frame of the bed, however, the bed loop was very loose and wobbled several inches away from the side of the bed, when gently gripped. An observation was conducted on (MONTH) 12, (YEAR) at 8:45 a.m. of the resident lying in bed. The bed loop was observed to be attached to the bed frame. At this time, the resident was observed to use the bed loop to sit up, and then maneuvered from the bed to his wheelchair. When the resident gripped the bed loop, it wobbled several inches and was loosely attached to the bed. An interview was conducted on (MONTH) 9, (YEAR) at 10:00 a.m., with the Admissions Director (staff #128). Staff #128 stated that she did room rounds every Tuesday and Thursday. Staff #128 stated that these rounds include checking the bed loops to ensure that they are not loose and will not come undone. An interview was conducted on (MONTH) 9, (YEAR) at 10:30 a.m. with a CNA (Certified Nursing Assistant/staff #107) . Staff #107 stated that the bed loop on the resident's bed becomes loose at times and maintenance staff have to come once a week and tighten it to the bed. An interview was conducted on (MONTH) 9, (YEAR) at 1:30 p.m., with the Maintenance Director (staff #166). Staff #166 stated that he conducts maintenance rounds of the building weekly, but does not inspect individual rooms. Staff #166 stated that if a repair is needed, staff fills out the Maintenance Request Log located at each nurses station, and that the logs are checked daily by maintenance staff. An interview was conducted on (MONTH) 12, (YEAR) at 8:45 a.m. with a nurse (staff #115). The nurse stated that although the bed loop on the resident's bed was loose, it had not caused the resident to fall. -Resident #47 was admitted to the facility on (MONTH) 29, 2014, with [DIAGNOSES REDACTED]. Review of the Bed Safety Awareness assessment dated (MONTH) 29, (YEAR) revealed the resident had poor bed mobility and had difficulty with balance or poor trunk control. The assessment included the resident did not desire a rail for positioning or support, and was not using one. No recommendations were made for any type of assistive device on the bed. Review of the quarterly MDS assessment dated (MONTH) 26, (YEAR) revealed the resident had a BIMS score of 5, which indicated the resident had severe cognitive impairment. The MDS also included the resident required two-person extensive assistance for bed mobility and transfers. An observation of resident #47's bed was conducted on (MONTH) 6, (YEAR). The bed was observed to have a bed loop positioning bar attached to the left side of the bed toward the top. The frame of the bed loop was clamped and screwed to a wood plank but was loose, and the wood plank extended approximately 8-10 inches out from the bed. A second observation of the resident's bed was conducted on (MONTH) 7, (YEAR) at 1:17 p.m. The bed loop remained extended away from the bed and the wood plank used to clamp the bed loop was extending approximately 2 inches beyond the top of the resident's mattress. A third observation of the resident's bed was conducted on (MONTH) 9, (YEAR) at 9:35 a.m., with Central Supply staff (staff #45). The bed loop remained extended away from the bed and the wood plank used to clamp the bed loop was extending approximately 2 inches beyond the top of the resident's mattress. At this time, an interview was conducted with staff #45, who stated that he assists with the application of the bed loops. He said the bar and wood plank on the resident's bed is not applied correctly and that it was a problem. Staff #45 stated the bar has to come off or be fixed right now. Staff #45 stated that they do not have enough supplies or pieces to correctly apply the bed loops, because they are expensive. He said that they have been using zip ties to secure them to the bed, but lately the have had to screw them into the beds to make sure they do not come off. In an interview conducted with the Director of Maintenance (staff #166) on (MONTH) 9, (YEAR) at 9:40 a.m., staff #166 stated that he was not aware there were guidelines on how to safely apply the bed loops to a resident's bed. Staff #166 stated that maintenance staff do not do rounds of resident rooms to check for maintenance concerns or safety issues with bed rails or bed loops. He said instead the administration team performs Ambassador rounds and looks at the room for any concerns. In an interview conducted with the Admissions Director (staff #128) on (MONTH) 9, (YEAR) at 10:00 a.m., staff #128 stated she is assigned to do ambassador rounds for resident #47's room. Staff #128 stated she rounds on Tuesday and Thursday and uses a form to document if things are working such the call light and TV. Staff #128 further stated if there are bed loops on a bed she would check to see if they are loose. Review of a policy and procedure titled, Side Rail Safety included a statement that bed rails should only be used in a safe manner which prevents injury, when any type of rail is required to assist with bed mobility. Review of a policy and procedure titled, Repair/Maintenance Request Log revealed that it is the responsibility of all staff to report and document any repair or maintenance related issues on the Repair/Maintenance log. Any emergencies or safety issues shall be reported immediately to the maintenance department. It is the responsibility of the maintenance department to ensure that all requests for repairs or maintenance are performed in a timely manner and that all emergencies along with safety issues are immediately responded to and completed.",2020-09-01
793,RIDGECREST HEALTHCARE,35125,16640 NORTH 38TH STREET,PHOENIX,AZ,85032,2018-03-14,700,E,0,1,7ZN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, resident and staff interviews and policy and procedures, the facility failed to ensure that two residents (#47 and #100) were assessed for the safe use of bed loops prior to installation, failed to ensure that one resident (#75) was assessed for the safe use of bed bolsters, and failed to ensure one resident's (#99) safety assessment recommendations were followed regarding the use of side rails. Findings include: -Resident #99 was admitted on (MONTH) 8, (YEAR), with [DIAGNOSES REDACTED]. A physician's order dated (MONTH) 27, (YEAR) included for the resident to have a bed loop (grab bar/curved support bed rail) applied to the bed to promote safe transfers. Review of a form titled, Release for Use of Restraints and Restraint Alternatives revealed an entry dated (MONTH) 27, (YEAR) that a verbal consent had been obtained for the use of the bed loop. Review of a care plan revealed the resident was at risk for injury from falls related to impaired mobility and balance deficits, had difficulty with transfers when moving from a seated position to a standing position, used high risk medications, had a history of [REDACTED]. The care plan included that the resident has poor safety awareness related to dementia, and has a habit of putting self on the floor. An intervention included that a bed loop had been added to the resident's bed on (MONTH) 27, (YEAR). Review of the most recent bed safety assessment dated (MONTH) 5, (YEAR) revealed the resident had a history of [REDACTED]. The assessment also included a recommendation to not use side rails. A MDS (Minimum Data Set) assessment dated (MONTH) 6, (YEAR), included a BIMS (Brief Interview for Mental Status) score of 9, which indicated the resident had moderate cognitive impairment. The MDS also included the resident required one person limited assistance for bed mobility and transferring, and was not steady. An observation of the resident's bed was conducted on (MONTH) 9, (YEAR) at 10:45 a.m. At this time, the resident was not occupying his bed and a bed loop was attached to the frame of the bed. An observation was conducted on (MONTH) 12, (YEAR) at 8:45 a.m. of the resident lying in bed and the bed loop was attached to the bed frame. An interview was conducted on (MONTH) 12, (YEAR) at 10:30 a.m., with the Unit Manager (staff #124). Staff #124 stated that bed safety assessments are completed quarterly by the night nurse. An interview was conducted on (MONTH) 12, (YEAR) at 11:20 a.m., with the Director of Nursing (DON/staff #391). Staff #391 stated that the bed loop was a type of bed rail. The DON reviewed the bed safety assessment for resident #99 and stated that the assessment included a recommendation not to use bed rails. Staff #391 stated that the bed safety assessment should have been updated when the bed loop was applied to the bed to include a recommendation to use the bed loop. -Resident #47 was admitted to the facility on (MONTH) 29, 2014, with [DIAGNOSES REDACTED]. Review of the Bed Safety Awareness assessment dated (MONTH) 29, (YEAR) revealed the resident had poor bed mobility and had difficulty with balance or poor trunk control. The assessment included the resident did not desire a rail for positioning or support, and was not using one. No recommendations were made for any type of assistive device on the bed. According to a quarterly MDS assessment dated (MONTH) 26, (YEAR), the resident had a BIMS score of 5, which indicated severe cognitive impairment. The MDS also assessed the resident as having poor bed mobility. The MDS did not include that the resident had a rail in place for positioning. Review of the Activities of Daily Living/Mobility Care Plan revised on (MONTH) 8, (YEAR) revealed the following interventions: two person Hoyer lift used for transfers, extensive assistance of two persons for bed mobility and toileting and remind resident to make body changes while in bed and wheelchair. An observation of resident #47's bed was conducted on (MONTH) 6, (YEAR). There was one positioning bar (bed loop) on the left side of the bed, toward the top. Additional observations of the resident's bed were conducted on (MONTH) 7, (YEAR) at 1:17 p.m. and on (MONTH) 9, (YEAR) at 9: 35 a.m. During both observations, there was a bed loop attached to the resident's bed. Review of the clinical record revealed there was no documentation that resident #47 was assessed for the safe use of the bed loop, nor were there any recommendations for a bed loop. There was also no physician's order for its use. In an interview conducted on (MONTH) 12, (YEAR) at 9:21 a.m. with the Director of Rehabilitation (staff #386), staff #386 stated the rehabilitation staff will assess a new resident or an existing resident following a fall, which may include an assessment of the room and recommendations for a bed loop. Staff #386 stated the long term residents are re-evaluated by therapy on a quarterly basis and if side rails or positioning bars are on the bed at the time of the assessment, the therapist would assess for resident safety with the positioning bar. -Resident #100 was admitted to the facility on (MONTH) 29, 2014 and readmitted on (MONTH) 22, (YEAR), with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated (MONTH) 7, (YEAR) revealed the resident had a BIMS score of 13, which indicated the resident was cognitively intact. The assessment also documented the resident required extensive assistance of two persons for bed mobility, toilet use, and personal hygiene and required total dependence of two persons for transfers. Review of the clinical record revealed that Bed Safety Assessments were completed on (MONTH) 28, (YEAR), (MONTH) 1, (YEAR), (MONTH) 8, (YEAR) and (MONTH) 4, (YEAR). All of the assessments indicated the resident had no device or bed loop in place and none were recommended. An observation of resident #100's bed was conducted on (MONTH) 6, (YEAR) at 9:23 a.m. The resident's bed had a bed loop attached to the right, top side of the bed. Further review of the clinical record revealed there was no documentation that the resident had been assessed for the safe use of the bed loop. There was also no recommendations for a bed loop or a physician's order for its use. In an interview with the Director of Nursing (DON/staff #391) conducted on (MONTH) 12, (YEAR) at 9:49 a.m., the DON stated that the bed safety assessments are completed at least annually and when there is a change. Staff #391 stated that a bed safety assessment should be completed before a bed is altered, such as if side rails or positioning bars were added. -Resident #75 was readmitted to the facility on (MONTH) 20, (YEAR), with [DIAGNOSES REDACTED]. Review of a release form titled, Use of Restraints and Restraint Alternative dated (MONTH) 21, (YEAR), revealed that bed bolsters were in use. The form indicated the responsible party was to sign the release form for their use. The form also included that restraints could only be used with a physician's order. Further review of the form revealed there was no resident/responsible party signature for the bed bolsters. A physician's order dated (MONTH) 22, (YEAR) included for bed bolsters to be on when resident is in bed every shift for safety. A bed safety assessment was completed on (MONTH) 23, (YEAR). Under the section for bed safety measures, it stated that based on the information from the evaluation, select all appropriate alternative bed safety equipment measures which are in place. Some of the devices listed included a trapeze, tab alarm, low bed, floor mat, and bed bolsters. However, bed bolsters were not checked as being utilized. A physician's order dated (MONTH) 24, (YEAR) at 7:32 p.m. revealed an order to discontinue the bed bolsters. The reason was not included. Review of the admission MDS assessment dated (MONTH) 26, (YEAR), revealed a BIMS score of 12, which indicated the resident had moderate cognitive impairment. The MDS also included the resident required extensive assistance with bed mobility, transfers and toilet use. The MDS indicated that no restraints were in use. On (MONTH) 7, (YEAR) at 11:00 a.m., the resident was observed in bed with 1/4 size bed bolsters in place to the middle portion of the bed on each side. Further review of the clinical record revealed there was no evidence that the facility conducted an assessment for the safe use of the bolsters, nor provided the resident with the risks and benefits of utilizing bed bolsters. There was also no current order for the use of [REDACTED] An interview was conducted with a Registered Nurse (staff #134) on (MONTH) 8, (YEAR) at 10:32 a.m. Staff #134 stated that she believed the bed bolsters were ordered by the physician and that the resident had signed a consent form, before the bolsters were placed on the bed. Staff #134 stated that she assumed the resident was assessed for their use. On (MONTH) 8, (YEAR) at 11:10 a.m., an interview was conducted with resident #75. Resident #75 stated that he had been shown how to put the bed bolsters down, but his right hand was weak and he could not use his left hand to raise or lower the bed bolsters. He stated that he has to call staff to put the bolsters up or down. The resident stated that if they take to long to respond when he has to use the bathroom, then he crawls around the bed bolsters to get out of bed. On (MONTH) 8, (YEAR) at 1:15 p.m., another interview was conducted with staff #134, who stated that when bolsters are used, a consent form should be completed and signed by the resident/responsible party before putting the bolsters on the bed. Staff #134 also stated that the nurse should call the physician and obtain orders for the use of bed bolsters. Staff #134 stated that if the resident was unable to take the bolsters off the bed, an assessment should be done to determine if the bolsters were a restraint or not. Another interview was conducted with staff #134 on (MONTH) 8, (YEAR) at 1:49 p.m. Staff #134 stated the resident was unable to put the bed bolsters up or down on his own and that resident #75 had to call staff for assistance when he wanted the bed bolsters to be lowered. An interview was conducted with the Director of Nursing (DON/staff #391) on (MONTH) 8, (YEAR) at 1:58 p.m. She stated that the resident/family are to be informed of the risks of using restraints. The DON stated that she expected nursing staff to obtain physician orders, assess the resident for safety, and obtain a signed consent, prior to placing bolsters on a resident's bed. Review of a policy and procedure titled, Bed Safety Assessment revealed that residents will be assessed for bed safety and the use of side rails and adaptive equipment while in bed. The policy included the nurse was to review the risks and benefits of the side rails with the resident or resident's representative and any need for changes. The use of bed/side rails or other adaptive equipment is to be included in the resident's Plan of Care. The policy also included to obtain a physician's order for the type of device and rationale for use.",2020-09-01
794,RIDGECREST HEALTHCARE,35125,16640 NORTH 38TH STREET,PHOENIX,AZ,85032,2018-03-14,732,E,0,1,7ZN311,"Based on observations, staff interviews, and facility documentation,the facility failed to ensure that the nurse staffing data information was posted on a daily basis. Findings include: An observation was conducted on (MONTH) 5, (YEAR) at 8:15 a.m. of the Daily Staff Posting information, which was located in the main hallway off of the lobby. The Daily Staff Posting information was dated March, 2, (YEAR). Additional observations were conducted of the Daily Staff Posting information on (MONTH) 5, (YEAR) and the same posting information remained in place until 3:30 p.m. A review of the facility's Daily Staff Posting documentation for January, (MONTH) and (MONTH) (YEAR) revealed the following: -There were no posting records for (MONTH) 3, 12, 17, 18, 20, 21, 22, 23, 24, 26, 27, 28, 29, 30 or 31; -There were no posting records for (MONTH) 1 or 19 -There were no posting records for (MONTH) 1, 3, 4, An interview was conducted with the staffing coordinator (staff #62) on (MONTH) 13, (YEAR) at 9:55 a.m. The staffing coordinator stated she was responsible for completing the Daily Staff Posting, but no one is assigned to do it on the weekends or if she is not at work. She also said that she may have forgotten to do it. Staff #62 was unable to provide any additional staff posting documentation for the above dates. In an interview conducted with the Director of Nursing (DON/staff #391) on (MONTH) 13, (YEAR) at 10:54 a.m., the DON stated the staffing coordinator is the person that completes the Daily Staff Posting information and that they do not have a process in place to ensure the posting information is done on the weekends or when the staffing coordinator is not here. The DON stated the facility does not have a policy regarding the Daily Staff Posting.",2020-09-01
795,RIDGECREST HEALTHCARE,35125,16640 NORTH 38TH STREET,PHOENIX,AZ,85032,2018-03-14,773,D,1,1,7ZN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to promptly notify the physician of critical laboratory results for one resident (#15). Findings include: Resident #15 was admitted to the facility on (MONTH) 3, (YEAR) and discharged to the hospital on (MONTH) 2, (YEAR). [DIAGNOSES REDACTED]. Review of a Significant Change in Status Minimum Data Set (MDS) assessment dated (MONTH) 15, (YEAR), revealed the resident had a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. The MDS also included the resident had a catheter in place. A progress note dated (MONTH) 31, (YEAR) revealed resident #15 was sent to the emergency department (ED) for chest pain and burning in her head. Review of the hospital laboratory results revealed the following: CBC (complete blood count): WBC = 6.8 (normal) Hemoglobin = 10.8 (low) Hematocrit = 32.9 (low) Red blood cell count (RBC) = 3.74 (low) CMP (complete metabolic panel): Blood glucose = 213 (high) Sodium - 139 (normal) Chloride - 108 (high) Creatinine -0.74 (normal) Blood Urea Nitrogen - 32 (high) urinalysis: urine was cloudy with 3+ leukocytes, white blood cells (WBC) and bacteria present Review of the ED Summary note concluded that the resident had acute [MEDICATION NAME] and atypical chest pain. The resident was discharged from the ED back to the facility at 7:39 p.m. on (MONTH) 31. A physician's orders [REDACTED]. A nursing progress note dated (MONTH) 1, (YEAR) at 3:30 p.m. documented the resident was slightly confused after returning from the ED last night and the physician was notified and new orders for labs were received. Review of the laboratory results revealed that the CBC and CMP were collected on (MONTH) 1, (YEAR) at 8:20 p.m. and completed at 10:00 p.m. (9:00 p.m. Pacific Time per lab report). The report revealed the following results: CBC: WBC = 13.0 (high) reference range = 4.0 - 10.0 RBC = 3.24 of (low) reference range = 3.93 - 5.22 Hemoglobin = 9.6 (low) reference range = 11.2 - 15.7 Hematocrit = 28.7 (low) reference range = 34.1 - 44.9 CMP: Blood glucose of 523 (high/identified as critical) reference range = 70 - 99 and documented as verified by repeat analysis Blood Urea Nitrogen = 70 (high - identified as critical) reference range = 7 - 25 Creatinine = 2.1 (high) reference range = .6 -1.3 Sodium = 131 (low) reference range = 136 - 145 Chloride = 95 (low) reference range = 98 - 107 A nursing progress note dated (MONTH) 1, (YEAR) at 9:52 p.m. documented the nurse was waiting for lab results, and the physician was aware that the results were pending. Further review of the clinical record and facility documentation revealed that the physician was notified multiple times on (MONTH) 1, (YEAR) between 7:45 p.m. and midnight regarding the resident's high blood sugar levels. The documentation included that the physician responded with insulin orders. However, there was no further documentation that the physician was notified of the critical lab results from (MONTH) 1 at 10 p.m. through the night shift on (MONTH) 2, nor was there any documentation that the lab had called the facility with the critical lab results during this timeframe. A late entry note by the day shift nurse dated (MONTH) 2, (YEAR) at 8:04 a.m. included that the resident was sent to the ED for BUN labs per MD and left the facility via stretcher. Review of the hospital records revealed the resident was transferred to the ED at 8:35 a.m. on (MONTH) 2, (YEAR), due to altered mental status. Review of the ED physician's note dated (MONTH) 2, (YEAR) at 8:41 a.m., included the resident was making repetitive statements and was only oriented to self, not time or place, and was not able to answer simple current event questions. Per the note, the resident presented with signs of dehydration with dry cracked lips, dry tongue and dry mucous membranes. The hospital records described the resident as appearing very dehydrated and was prescribed intravenous fluids, and labs were ordered. Additional [DIAGNOSES REDACTED]. The ED lab results for (MONTH) 2, (YEAR) were received at 9:30 a.m. with the following results: WBC = 12.2 (H) RBC = 3.97 (L) Glucose = 403 (H) Sodium = 130 (L) Chloride = 94 (L) Calcium = 11.3 (H) BUN = 67 (H) Creatinine = 1.93 (H) Urine appearance = cloudy Urine Leukocytes = 3+ Urine Blood = 1+ Urine [NAME] Blood Cells = 6 Urine Bacteria = 4+ Further review of the hospital records revealed the resident was admitted to the Intensive Care Unit. An interview was conducted on (MONTH) 7, (YEAR) at 10:26 a.m., with a Licensed practical Nurse (LPN/staff #85), who was the resident's day shift nurse on (MONTH) 2, (YEAR). Staff #85 stated that during the morning report (on (MONTH) 2), she was told that the evening and night shift nurses had sent a message to the physician about the lab results, but there were no orders so she contacted the physician, because the resident's BUN was 70, which is almost three times the normal range and she was concerned about her kidneys not working. Staff #85 stated the nurses on the previous shifts should have called the physician. An interview was conducted with a LPN (staff #341) on (MONTH) 7, (YEAR) at 12:38 p.m., who was the night shift nurse on duty caring for resident #15 (on the 10 p.m. - 6 a.m. shift on (MONTH) 1-2). Staff #341 stated if she calls the physician she always put a note in the chart. Staff #341 stated she did not remember this resident having critical lab results and calling the physician, but if there were she would have put a note in the clinical record. An interview was conducted with the resident's physician (staff #398) on (MONTH) 8, (YEAR) at 11:13 a.m. The physician stated that she ordered labs on (MONTH) 1, (YEAR) and when she received the results, the resident was sent back to the ED. The physician stated that these type of lab results should be pursued to ensure physician notification and that a response is received. An interview was conducted with the Director of Nursing (DON/staff #391) on (MONTH) 9, (YEAR) at 8:29 a.m. Staff #391 stated that lab results are returned via FAX and if the result is critical, the lab usually calls the nurse to advise them of the results. Staff #391 stated when the results are returned, the nurse should call the physician and obtain any new orders, write a progress note that the call has been made and if orders were received, then carry out the orders. Staff #391 stated if the lab results are critical, the nurse should call immediately and keep trying until the physician is reached. Staff #391 stated if the physician is not reached after 30 minutes and there have been repeated attempts, the nurse should contact the medical director. The DON stated the Fax log revealed that the lab results came across the FAX machine at 1:07 a.m. on (MONTH) 2, (YEAR), and that the lab did not have a log of when the lab results were called to the facility, but there was still a delay. A staff communication tool posted in the Station 2 nurses station included that when calling the doctor have all information ready. The 5th bullet point on the list documented, If the doctor doesn't call back within 15 minutes, Call Again! A facility policy titled Lab Work, Ordering and Reporting revealed to obtain lab work and report lab results in a manner to ensure resident health care needs are met and addressed timely. The policy also included the following: -A licensed nurse may take phone reports of lab results and record it on a preliminary phone report form and/or record the results in the nurses notes, pending the printed final lab report. The licensed nurse may use the lab computer to access the results. -If critical or stat labs have not been received in a timely manner, the nurse should call for them. -Upon being notified of a critically abnormal lab result, the licensed nurse will phone the results immediately to the physician and obtain and implement physician's orders [REDACTED].",2020-09-01
796,RIDGECREST HEALTHCARE,35125,16640 NORTH 38TH STREET,PHOENIX,AZ,85032,2018-03-14,825,D,1,1,7ZN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on closed clinical record review, staff interviews and policy review, the facility failed to ensure that a therapy recommendation for restorative services was provided for one resident (#361). Findings include: Resident #361 was admitted on (MONTH) 17, 2011, with [DIAGNOSES REDACTED]. A MDS (Minimum Data Set) assessment dated (MONTH) 31, (YEAR), included a BIMS (Brief Interview for Mental Status) score of 3, which indicated the resident had severe cognitive impairment. The MDS did not included that the resident had any functional limitation in range of motion to the upper extremities (including wrists or hands). Review of the closed record revealed a nurse health status note dated (MONTH) 10, (YEAR), which included that the resident had complained of pain in her right wrist and that an x-ray of the wrist had been ordered. A radiology report dated (MONTH) 10, (YEAR) included that there was no fracture or dislocation of the right wrist and that it was normal. The physician was notified. A physician's orders [REDACTED]. Review of an occupational therapy (OT) evaluation dated (MONTH) 15, (YEAR), revealed the range of motion for the resident's right upper extremity was within functional limits. The evaluation included that skilled occupational therapy was not warranted at that time, due to a change in the resident's alertness level, and her inability to comprehend and follow through with instructions. Another physician's orders [REDACTED]. An OT evaluation dated (MONTH) 1, (YEAR) included that nursing had reported a drop in the resident's right wrist. The evaluation included that skilled OT services were necessary to develop a restorative program/home exercise program, in order to maximize the resident's bilateral upper extremity range of motion. The evaluation also included under discharge plan that the resident was to remain in the facility, with Restorative Nursing Program. Further review of the closed clinical record revealed there was no documented evidence that resident #361 received restorative services or that an exercise program had been developed to treat the resident's right wrist, as recommended by OT. Continued review of the closed clinical record revealed that resident #361 expired on (MONTH) 27, (YEAR). An interview was conducted on (MONTH) 7, (YEAR) at 9:50 a.m., with OT staff (staff #386) and a therapy tech (staff #382). Staff #386 reviewed the therapy evaluation dated (MONTH) 1, (YEAR), and stated that the evaluation included to develop a restorative program to treat the resident's bilateral upper extremity range of motion problem and right wrist drop. Staff #382 stated there was no restorative program for the resident and thought the resident had declined restorative therapy services. An interview was conducted on (MONTH) 7, (YEAR) at 10:00 a.m. with a restorative nursing assistant (staff #34). Staff #34 stated that the resident did not have a documented restorative program and had never received restorative services. Interviews were conducted on (MONTH) 7, (YEAR) at 10:20 a.m. and 12:20 p.m. with the Director of Nursing (DON/staff #391). During the interviews, the DON stated that when the occupational therapist recommends restorative therapy for a resident, the therapist creates a restorative program and forwards the program to the restorative therapy department. The DON stated that the restorative therapy department never received a restorative program for resident #361, and that the recommended restorative services were not provided. The facility was unable to provide any documented evidence that a restorative program had been developed for this resident, or that she had refused restorative therapy. A policy and procedure titled, Evaluation/Therapy Treatment Plan included that rehabilitation therapy services are designed to address recovery or improvement in function and when possible, restoration to a previous level of well-being. The policy also included Follow the components of the evaluation/therapy plan for completion requirements. A policy and procedure titled, Medical Necessity included that rehabilitative therapy includes services designed to address recovery or improvement in function and restoration to a previous level of functioning and well-being. Components of the rehab record should include design of a therapy treatment plan that addresses the resident's disorder.",2020-09-01
797,RIDGECREST HEALTHCARE,35125,16640 NORTH 38TH STREET,PHOENIX,AZ,85032,2018-03-14,880,D,0,1,7ZN311,"Based on observations, staff interviews and policy and procedures, the facility failed to ensure infection control procedures were followed. Findings include: -During a dining observation conducted on (MONTH) 5, (YEAR) at 11:34 a.m. on the Renaissance Unit, a Certified Nursing Assistant (staff #26) was observed assisting a resident to don his shoes. Staff #26 then sat in a chair next to the resident and assisted the resident with eating his lunch. Staff #26 did not wash or sanitize his hands, after assisting the resident with putting on his shoes. In an interview conducted with staff #26 on (MONTH) 5, (YEAR) at 1:17 p.m., he stated that he had put the resident's shoes on and then assisted the resident with eating. Staff #26 stated that he was in a hurry and forgot to wash or sanitize his hands. Review of a policy titled, Hand Hygiene revealed that employees are required to wash their hands thoroughly before meals and after touching objects that may be soiled. -An observation was conducted on (MONTH) 5, (YEAR) at 8:40 a.m. on the 200 hallway. At this time, there were three mechanical lifts in the hallway in the following condition: -The Reliant 600 hoyer lift had blackish gray dirt on the base and metal bars, had loose debris on the base and the blue foam handles had a dried white substance on them. -The Reliant 450 hoyer lift had blackish gray dirt on the base and metal bars, had loose debris on the base and the blue canvas handle grip was grayish in color. -The Reliant 350 Sara lift had blackish gray dirt on the base and metal bars and had loose debris on the base. A follow up observation was conducted on (MONTH) 6, (YEAR) at 10 a.m. and at 1:24 p.m. All three lifts were in the same condition. The Reliant 600 hoyer lift was being brought out of a resident's room during the afternoon observation. Another follow up observation was conducted on (MONTH) 7, (YEAR) at 12:09 p.m., with a licensed practical nurse (LPN/staff #19). The lifts were in the same condition as above. During the observation, the Reliant 450 lift was observed in a resident's room. At this time, an interview was conducted with staff #19. She stated that other equipment is wiped down with bleach wipes, but was not sure who is supposed to clean the hoyer lifts and how frequently there were to be cleaned. Staff #19 stated that the lifts are very dirty and thought that maintenance was responsible for cleaning them. In an interview with the Director of Nursing (DON/staff #391) on (MONTH) 9, (YEAR) at 8:23 a.m., the DON stated the hoyer lifts should have a thorough deep cleaning once each week and the night shift should wipe them down on a daily basis as well. The DON stated that maintenance is responsible for making sure that occurs, but she has never seen a cleaning schedule or log documenting that it happens. Staff #391 stated that there has been a change in maintenance staff, so they may not be aware that they are supposed to do that. An interview was conducted with the Director of Maintenance (staff #166) on (MONTH) 9, (YEAR) at 9 a.m. Staff #166 stated that he was just made aware on (MONTH) 7, that maintenance is responsible for cleaning the hoyer lifts. He said that he has checked all of the department logs and there is no log for the cleaning of the lifts. In an interview conducted with the Manager of Housekeeping (staff #187) on (MONTH) 9, (YEAR) at 9:03 a.m., staff #187 stated that usually the Certified Nursing Assistants on the weekend do the cleaning of the equipment. Review of a policy titled, General Infection Prevention and Control Equipment Cleaning and Disinfecting revealed that shared patient care equipment will be cleaned and disinfected according to current infection prevention guidelines. The policy included that, The Infection Control Committee members will share responsibility during environmental rounds for inspecting equipment to see that it is clean and that disinfecting policies are being followed.",2020-09-01
798,RIDGECREST HEALTHCARE,35125,16640 NORTH 38TH STREET,PHOENIX,AZ,85032,2018-03-14,921,D,0,1,7ZN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, facility documentation, and policy review, the facility failed to ensure that handrails in one resident corridor were free of rough splintery surfaces. Findings include: During observations on the Ocean Drive unit conducted on (MONTH) 7, (YEAR) at 1:00 p.m., the following were observed: -A section of the wooden handrail which was attached to the wall adjacent to room [ROOM NUMBER] had rough splintery surfaces. -A section of the wooden handrail which was attached to the wall between room [ROOM NUMBER] and #207 had rough splintery surfaces, with splinters which were visibly sticking out of the wood. An interview was conducted on (MONTH) 9, (YEAR) at 1:30 p.m., with the Maintenance Director (staff #166). The Maintenance Director stated that the wooden handrails had splinters and that a section of the handrail next to room [ROOM NUMBER] also had a nail-head protruding from it. Staff #166 stated that he conducts maintenance rounds of the building weekly and if repairs are needed, staff fill out the Maintenance Request Log located at each nurses station. He said the logs are checked daily by maintenance staff. Another interview was conducted on (MONTH) 12, (YEAR) at 9:49 a.m. with the Maintenance Director, who stated that he had reviewed the Maintenance Request Log for the Ocean Drive unit and there were no work orders regarding handrails with splinters. Review of a policy and procedure titled, Repair/Maintenance Request Log revealed that it is the responsibility of all staff to report and document any repair or maintenance related issues on the repair/maintenance log. Any emergencies or safety issues shall be reported immediately to the maintenance department. It is the responsibility of the maintenance department to ensure that all requests for repairs or maintenance are performed in a timely manner and all emergencies along with safety issues are immediately responded to and completed.",2020-09-01
799,RIDGECREST HEALTHCARE,35125,16640 NORTH 38TH STREET,PHOENIX,AZ,85032,2019-05-02,600,G,1,0,I6RS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, hospital records, facility documentation, resident and staff interviews, review of the State Agency Complaint/Incident Tracking System, and review of policies and procedures, the facility failed to ensure that multiple residents on the Sedona Unit were protected from mental, verbal, and sexual abuse by one resident (#1), and that one resident (#2) was free from mental and sexual abuse from resident #1 which resulted in psychosocial harm. The sample size was two residents. Findings include: -Resident #2 was admitted to the facility on (MONTH) 25, 2019 and readmitted on (MONTH) 22, 2019. [DIAGNOSES REDACTED]. A written care plan initiated on (MONTH) 29, 2019 included that resident #2 had behaviors including paranoid statements, territorial behaviors and that she was afraid of men. Also, she had hallucinations that men come into her room at night. The care plan included a goal that the resident would have fewer than daily episodes of behaviors. The care plan interventions included to intervene as necessary to protect the rights and safety of others, to monitor behavior episodes and attempt to determine underlying causes, and to consider the location, time of day, persons involved, and situations. An Admission MDS (Minimum Data Set) assessment dated (MONTH) 31, 2019 included that resident #2 had a BIMS (Brief Interview for Mental Status) score of 3 which indicated that the resident had severely impaired cognition. The MDS assessment included that the resident had symptoms of [MEDICAL CONDITION] that included hallucinations and delusions. Behavioral symptoms included verbal behaviors directed at others which put the resident at risk for significant injury, interfered with care, and interfered with participation in social interactions. Review of a hospital psychosocial assessment dated (MONTH) 4, 2019 included that the resident had a lifelong history of mental illness, including multiple past suicide attempts. The assessment included that resident #2 had made references to having been sexually assaulted at age 16, stating I was raped as a [AGE] year old and that the sexual assault had affected her life ever since. A behavioral plan updated on (MONTH) 17, 2019 included that resident #2 may be at risk for being traumatized due to poor orientation to place and situation, and that her history was significant for kidnapping and rape by several men which had a profound effect on her psychological well being. The plan included that resident #2 had difficulty interacting with most male staff and residents. A health status note dated (MONTH) 23, 2019 included that at 3:00 p.m. resident #2 had gone to the nurses station screaming and hollering that the crazy guy showed her his penis. Resident #2 identified resident #1 as the resident who had showed his penis to her. The note included that resident #1 was immediately placed on 1:1 (one to one) observation with staff, and that resident #2 had been walking up and down the hallway screaming for the entire shift. -Resident #1 was admitted on (MONTH) 7, 2019 with [DIAGNOSES REDACTED]. Review of the clinical record revealed a psychiatric evaluation completed prior to the resident's admission, dated (MONTH) 2, 2019. The evaluation included that resident #1 had been hypersexual, and had engaged in sexual activities at another other nursing facility. Review of a form titled Placement Referral Form completed prior to the resident's admission, dated (MONTH) 3, 2019, revealed that resident #1 constantly asks for sex and sexual acts from others and that he had masturbated in front of peers. The form included that resident #1 had a sexual encounter with a peer, and that police and APS (Adult Protective Services) had been notified. An admission MDS dated (MONTH) 14, 2019 included that resident #1 had a BIMS score of 3 which indicated that the resident had severely impaired cognition. The assessment included that resident #1 was ambulatory with supervision and had delusions that put him at risk for illness or injury and interfered with his care and participation in social interactions. The assessment included that the resident was intrusive to others and that his behavior significantly disrupted the living environment. Review of the behavior care plan, revised on (MONTH) 14, 2019, revealed the resident had behaviors including sexual requests, disrobing in public areas, inappropriate antisocial and sexual behaviors, and intrusive wandering. The care plan included a goal that resident #1 will have episodes of behaviors less than daily. Interventions included the following: -Administer medications as ordered. -Alarm placed above the resident's door to alert staff when the resident is exiting his room. -Assist the resident to develop more appropriate methods of coping and interacting with peers. Encourage him to express feelings appropriately. -Attempt to redirect sexual stimulation within the privacy of his room. -Caregivers to provide opportunity for positive interaction and attention. Stop and talk with him as passing by. -If reasonable, discuss his behavior. Explain/reinforce why (his) behavior is inappropriate and/or unacceptable to him. -Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to an alternative location as needed. -Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. -Staff to redirect as needed. An annual history and physical note dated (MONTH) 25, 2019 included that staff reported ongoing sexual behaviors towards self, staff and peers and the resident was receiving 1:1 monitoring. The note also included a plan that the resident would continue to receive close supervision and 1:1 monitoring until the behavior resolved. Review of the clinical record did not reveal additional documentation the the resident was provided close, or 1:1 supervision for sexual behaviors. A psychiatric progress note dated (MONTH) 26, 2019 included that staff reported resident #1 had been hypersexual. The note included that resident #1 had been pulling out his penis in public, urinating outside in front of others, propositioning female staff and residents to engage in sexual activity with him, and going into female resident's rooms and staring at them while they sleep. The note included that the resident continued to exhibit these behaviors despite repeated redirection from staff members, and that his [MEDICAL CONDITION] have been more frequent and severe. The note included that medications had been reviewed and changes made to the resident's psychoactive medications. A behavioral care progress note dated (MONTH) 8, 2019 for the p.m. shift included that resident #1 was very sexual acting, he had been observed in the courtyard and hallway taking out his penis and had tried to go into other resident rooms. A behavioral progress note dated (MONTH) 12, 2019 for the p.m. shift included that resident #1 had been pacing in the hallway with his hands in his pants, and had asked a female resident for some pussy. Review of the clinical record did not reveal any additional information regarding the female peer, or if staff had intervened. A behavioral progress note dated (MONTH) 16, 2019 at 11:00 a.m. included that resident #1 was harassing all of the residents, walked up to a resident and pulled down his pants and exposed himself right next to a resident. The note included that resident #1 pulled his pants down a total of 3 times, stole food from another resident, and that he was getting uncomfortably close to many residents. The note also included he did not listen to any of us which included CNA's (Certified Nursing Assistants) and a nurse. Review of the clinical record, facility documentation, and the State Agency Complaint/Incident Tracking System data revealed that the incidents on (MONTH) 8, 12, and 16, 2019 regarding the resident exposing himself to other residents and using sexual language to residents were not reported to the State Agency and there was no evidence that resident #1 was provided increased monitoring and supervision, including 1:1 close observation, or that the resident's care plan had been updated to include any additional interventions to prevent additional [MEDICAL CONDITION] towards peers. A health status note dated (MONTH) 21, 2019 at 9:01 p.m. included that resident #1 had made several sexual attempts towards other female residents, and that the resident had exposed his private parts five times to other residents and staff. The note included that the resident needed close monitoring around other residents. Continued review of the clinical record did not reveal any additional documented information regarding increased supervision or monitoring that had been provided to resident #1, including 1:1 or close observation for the resident's sexual behavior towards peers, or that the resident's care plan was updated at that time to include any additional interventions to prevent further sexual behavior towards peers. A health status note dated (MONTH) 23, 2019 at 9:49 p.m. included that at approximately 3:00 p.m. a resident (#2) had approached the nurses station and stated that another resident (#1) had exposed his penis to her. Resident #1 was immediately placed on 1:1 supervision and facility management was notified. Resident #1 was then transferred to another unit. Review of two investigative reports dated (MONTH) 25, 2019 included the following information: -During a clinical review on (MONTH) 22, 2019 a nurses progress note was found dated (MONTH) 21, 2019 at 9:00 p.m. that resident #1 had made sexual acts towards peers and flashed his private parts five times to staff and peers. An investigation was conducted, and the facility concluded that resident #1 had not acted sexually towards other residents, and that no other residents were involved in the incidents. -On (MONTH) 23, 2019 at 3:30 p.m. resident #1 and #2 were outside on the patio area. A CNA was monitoring the patio entrance to the hallway, and the CNA was watching resident #2 when she started screaming. The CNA entered the patio and saw resident #1 with his pants open. Resident #2 entered the hallway and reported that she had seen the private areas of resident #1 to the nurse. Resident #1 was placed on 1:1 supervision and moved to another unit. Education was provided to staff regarding the protocol for 1:1 supervision with residents. The report included that there was no intent to harm resident #2 when resident #1 exposed himself to her. However, the report stated that staff monitoring and redirection were unsuccessful with preventing resident #1 from disrobing. Review of the clinical record revealed a Discharge MDS dated (MONTH) 26, 2019 that included resident #1 had been discharged to a psychiatric hospital. An interview was conducted on (MONTH) 1, 2019 at 12:25 p.m. with a CNA/staff #48. Staff #48 stated that resident #2 was very afraid of men, and that resident #1 was known to take his pants down when he was outside on the patio. She stated that the residents on the Sedona Unit were confused and that two of them were able to answer questions. She stated resident #2 was one of the residents who was able to answer questions. An interview was conducted on (MONTH) 1, 2019 at 12:30 p.m. with resident #2. During the interview, staff #48 (who was female) remained in the room, standing next to the State Agency interviewer (who was male) due to the resident's fear of men. The resident stated she remembered two incidents that involved resident #1. She stated that one day when she was outside on the patio, resident #1 came outside and pulled his pants down in front of her and she became scared. She stated she shouted at him and a staff person who was at the door to the patio came and took resident #1 away. She stated repeatedly during the interview that resident #1 took down his pants in front of her and showed his thing to her and that she was scared. During the interview, she became increasingly fearful and anxious, and then stated I can't talk about this anymore. An interview was conducted on (MONTH) 1, 2019 at 2:14 p.m. with an RN (Registered Nurse/staff #93). He stated that he was the nurse on the afternoon shift on (MONTH) 21, 2019 and that resident #1 pulled his pants down and exposed himself to a male peer in a wheelchair, and the male resident did not react. He stated resident #1 had also walked around the dining room, repeatedly exposing himself to peers making statements the he wanted someone to lick or suck on his penis, and that he pulled his penis out of his pants and showed it to other residents. He stated that staff had redirected resident #1 repeatedly that afternoon, and that the resident continued to expose himself to residents and staff. He also stated the residents who he had exposed himself to did not react to his behavior and did not say anything as they were confused. The RN stated that it was his first day on the job, and although he had been provided abuse prevention training during orientation prior to his first day, he did not know what he was supposed to do. During an interview with the administrator/staff #185 conducted on (MONTH) 1, 2019 at 2:45 p.m. she stated that the note describing the behavior of resident #1 on (MONTH) 21, 2019 was discovered the next day during the morning meeting, and that it was investigated. She stated that none of the residents who were interviewed expressed that they had been abused. However, despite a witness statement that resident #1 had purposely targeted multiple residents when he exposed himself and made sexual comments, the administrator stated that through the facility investigation it was determined that resident #1 had not targeted other residents when he exposed himself. The administrator further stated that resident #1 was not placed on 1:1 supervision at that time, because when he had exposed himself multiple times on (MONTH) 21, 2019, his behavior was directed at staff and not other residents. She stated that resident #1 was placed on 1:1 supervision with staff after he had exposed himself to resident #2 on (MONTH) 23, 2019. An interview was conducted on (MONTH) 1, 2019 at 3:00 p.m. with an LPN (Licensed Practical Nurse/staff #117). She stated that on (MONTH) 23, 2019 when she was at the nurses station on the Sedona Unit resident #2 came running up to the nurses station screaming in the hallway he pulled it out. She described that resident #2 was very agitated and that a CNA (staff #85) had witnessed resident #1 pull his penis out and show it to resident #2. She stated that resident #1 was placed on 1:1 supervision, escorted to his room and remained in his room until he was moved to another unit. She stated that resident #2 remained anxious and upset for the remainder of the afternoon shift. She stated that when the incident occurred resident #1 was not being provided increased supervision or monitoring due to his known recent history of sexual behavior directed towards other residents. An interview was conducted on (MONTH) 1, 2019 at 3:30 p.m. with CNA/staff #85. She stated that on (MONTH) 23, 2019 resident #2 was on the patio and resident #1 also wanted to go onto the patio, she tried to discourage him from going on to the patio because resident #2 was there. She stated she was unable to prevent resident #1 from entering the patio because he became aggressive and she was the only staff at the end of the hallway. She stated she remained in the doorway of the patio, where she could monitor the patio and the hallway on the Sedona Unit. She stated resident #1 went behind the patio door and she could not see what he was doing. Resident #2 began screaming, and when she looked behind the door she saw resident #1 staring at resident #2, and he had his pants down as though he was showing his penis to resident #2. She stated that resident #1 was definitely hiding behind the door, and that he was purposefully showing his penis to resident #2. She immediately told resident #2 to leave the courtyard and to tell the nurse what had happened, and when she tried to assist resident #1 to pull his pants up he began to fight her. She stated resident #1 would not leave the courtyard until staff assistance arrived and he was escorted to his room. An interview was conducted on (MONTH) 2, 2019 at 8:50 a.m. with the ADON (Assistant Director of Nursing/staff #98) she stated that the reason resident #1 had not been placed on 1:1 supervision on (MONTH) 21, (YEAR) after he had exposed himself multiple times to other residents was that it sounded like the resident's behavior was directed at staff and not at other residents. She stated it was possible that resident #1 may have been placed on increased supervision at that time, she was not sure. She stated that if resident #1 had been placed on increased supervision on (MONTH) 21, 2019 the care plan for resident #1 would have been updated, and the increased level of supervision would have been communicated directly to the staff. She stated that resident #2 had a history of [REDACTED].#2 had [MEDICAL CONDITION] and was afraid of men. Review of a policy and procedure titled Abuse Prohibition and Prevention included a policy statement that the facility prevents abuse and exploitation of residents, each resident has the right to be free from mental/emotional, verbal, and sexual abuse, and residents must not be subjected to abuse by anyone including other residents. The policy noted that the supervisor shall immediately intervene, correct, and report identified situations where abuse may occur, conduct ongoing resident assessments and care planning for appropriate interventions to monitor resident needs, and address behaviors such as verbally aggressive behavior, intimidating sexually aggressive behavior including saying sexual things and inappropriate touching. The policy noted that facility staff will be able to identify the different types of abuse including mental/verbal and sexual abuse. The policy noted that occurrences, patterns, and trends will be assessed by administrative staff, licensed staff, and the interdisciplinary team to determine the corrective action based on the results of the investigation.",2020-09-01
800,RIDGECREST HEALTHCARE,35125,16640 NORTH 38TH STREET,PHOENIX,AZ,85032,2019-05-02,607,E,1,0,I6RS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, resident and staff interviews, facility documentation, and review of the State Agency data base the facility failed to implement policies and procedures that prohibited, prevented, investigated and reported multiple allegations of mental, verbal and sexual abuse of multiple residents on the Sedona Unit by one resident (#1). The sample size was one resident. Findings include: -Resident #2 was admitted to the facility on (MONTH) 25, 2019 and readmitted on (MONTH) 22, 2019. [DIAGNOSES REDACTED]. An Admission MDS (Minimum Data Set) assessment dated (MONTH) 31, 2019 included that resident #2 had a BIMS (Brief Interview for Mental Status) score of 3 which indicated that the resident had severely impaired cognition. The MDS assessment included that the resident had symptoms of [MEDICAL CONDITION] that included hallucinations and delusions. Behavioral symptoms included verbal behaviors directed at others which put the resident at risk for significant injury, interfered with care and interfered with participation in social interactions. A health status note dated (MONTH) 23, 2019 at 9:39 p.m. included that at 3:00 p.m. resident #2 had gone to the nurses station screaming and hollering that the crazy guy showed her his penis. Resident #2 identified resident #1 as the resident who had showed his penis to her. The note included that resident #1 was immediately placed on one to one observation with staff, and that resident #2 had been walked up and down the hallway screaming for the entire shift. -Resident #1 was admitted on (MONTH) 7, 2019 with [DIAGNOSES REDACTED]. An admission MDS (Minimum Data Set Assessment) dated (MONTH) 14, 2019 included that resident #1 had a BIMS (Brief Interview for Mental Status) score of 3 which indicated that the resident had severely impaired cognition. The assessment included that resident #1 was ambulatory with supervision, had delusions that put him at risk for illness or injury and interfered with his care and participation in social interactions. The assessment included that the resident was intrusive to others and that his behavior significantly disrupts the living environment. A psychiatric progress note dated (MONTH) 26, 2019 included that staff reported resident #1 had been hypersexual. The note included that resident #1 had been pulling out his penis in public, urinating outside in front of others, propositioning female staff and residents to engage in sexual activity with him, and going into female resident's rooms and staring at them while they sleep. The note included that the resident continued to exhibit these behaviors despite repeated redirection from staff members, and that his [MEDICAL CONDITION] have been more frequent and severe. The note included that medications had been reviewed and changes made to the resident's psychoactive medications. Review of records did not reveal any documented evidence that staff reports that the resident had had been pulling out his penis in public, and propositioning female residents to engage in sexual activity with him had been reported by staff or investigated by the facility. A behavioral progress note dated (MONTH) 12, 2019 for the P.M. shift included that resident #1 had been pacing in the hallway with his hands in his pants, and had asked a female resident for some pussy. Review of records did not reveal any additional information that the incident on (MONTH) 12, 2019 had been reported by staff or investigated by the facility. A behavioral progress note dated (MONTH) 16, 2019 at 11:00 a.m. included that resident #1 was harassing all of the residents, walked up to a resident and pulled down his pants and exposed himself right next to a resident. The note included that resident #1 pulled his pants down a total of 3 times, stole food from another resident, and that he was getting uncomfortably close to many residents. The note also included he did not listen to any of us which included CNA's (Certified Nursing Assistants) and a nurse. Continued review of records (including the State Agency base) did not reveal any documented evidence that the sexual abuse of multiple residents described in the behavioral note was reported immediately or within 2 hours to the DON (Director of Nursing), or the Administrator, to the State Agency, to law enforcement or to any required agency, and there was no evidence that the sexual abuse abuse of multiple residents on (MONTH) 16, 2019 was investigated by the facility. A health status note dated (MONTH) 21, 2019 at 9:01 p.m. included that resident #1 had made several sexual attempts towards other female residents, and that the resident had exposed his private parts five times to other residents and staff. The note included that the resident needed close monitoring around other resident's. Continued review of the records did not reveal any additional documented evidence that the sexual abuse of multiple residents described in the behavioral note was reported immediately or within 2 hours to the DON (Director of Nursing), or the Administrator, to the State Agency, to law enforcement or to any required agency. A health status note dated (MONTH) 23, 2019 at 9:49 p.m. included that at approximately 3:00 p.m. a resident (#2) had approached the nurses station and stated that another resident had exposed his penis to her. Resident #2 identified as the resident #1 who had exposed himself to her. Resident #1 was immediately placed on 1:1 supervision, and facility management was notified. Review of two investigative reports dated (MONTH) 25, 2019 included the following information: -During a clinical review on (MONTH) 22, 2019 a nurses progress note was found dated (MONTH) 21, 2019 at 9:00 p.m. that resident #1 had made sexual acts towards peers and flashed his private parts five times to staff and peers. An investigation was conducted, and the State Agency, Law enforcement and other entities were notified on (MONTH) 22, 2019. Education was provided to staff regarding the protocols for types of abuse, and responsibilities of timely reporting of abuse incidents. -On (MONTH) 23, 2019 at 3:30 p.m. resident #1 and #2 were outside on the patio area. A CNA was monitoring the patio entrance to the hallway, and the CNA was watching resident #2 when she started screaming. The CNA entered the patio and saw resident #1 with his pants open. Resident #2 entered the hallway and reported that she had seen the private areas of resident #1 to the nurse. An interview was conducted on (MONTH) 1, 2019 at 2:14 p.m. with an RN (Registered Nurse/staff #93). He stated that he was the nurse on the afternoon shift on (MONTH) 21, 2019 and that resident #1 pulled his pants down and exposed himself to a male peer in a wheelchair, and walked around the dining room repeatedly exposing himself to peers making statements the he wanted someone to lick or suck on his penis, and that he pulled his penis out of his pants and showed it to other residents. The RN stated that it was his first day on the job, and although he had been provided abuse prevention training during orientation prior to his first day, he did not know what he was supposed to do, and he did not notify anyone. During an interview with the Administrator/staff #185 conducted on (MONTH) 1, 2019 at 2:45 p.m. she stated that the note describing the behavior of resident #1 on (MONTH) 21, 2019 was discovered the next day during the morning meeting, and that it was investigated and reported on (MONTH) 22, 2019. An interview was conducted on (MONTH) 1, 2019 at 3:00 p.m. with an LPN (Licensed Practical Nurse/staff #117). She stated that on (MONTH) 23, 2019 she was at the nurses station on the Sedona Unit and resident #2 came running up to the nurses station screaming in the hallway he pulled it out. She described that resident #2 was very agitated and that a CNA (staff #85) had witnessed resident #1 pull his penis out and show it to resident #2. She stated that resident #2 remained upset for the remainder of the afternoon shift. An interview was conducted on (MONTH) 1, 2019 at 3:30 with CNA/staff #85. She described that on (MONTH) 23, 2019 resident #2 was on the patio and began screaming. She stated that when she looked behind the door of the patio, resident #1 was definitely hiding behind the door, and that he was purposefully showing his penis to resident #2. An interview was conducted on (MONTH) 2, 2019 at 8:50 a.m. with the ADON (Assistant Director of Nursing/staff #98) she stated that the RN/staff #93 should have reported that resident #1 had pulled his pants down and exposed himself repeatedly to multiple peers and made sexual statements to them on (MONTH) 21, 2019 immediately to the DON (Director of Nursing) or the Administrator. She stated that staff are supposed to report any allegations abuse including sexual abuse immediately to the DON (Director of Nursing) or the Administrator and that all of the staff have been educated on the reporting requirements. She stated that if staff cannot reach the DON or the Administrator by phone, they must make the notifications themselves (including to law enforcement). Review of a policy and procedure titled Abuse Prohibition and Prevention included a policy statement that the facility prevents abuse and exploitation of residents, each resident has the right to be free from mental/emotional, verbal, and sexual (abuse), and residents must not be subjected to abuse by anyone including other residents. The policy also included the following: -The supervisor shall immediately intervene, correct and report identified situations where abuse is at risk for occurring, and ongoing resident assessments and care planning for appropriate interventions are performed to monitor resident needs and address behaviors such as verbally aggressive behavior such as intimidating, sexually aggressive behavior such as saying sexual things, and inappropriate touching. -Facility staff are able to identify the different types of abuse (including) mental/verbal, and sexual abuse. Occurrences, patterns and trends will be assessed by Administrative staff, licensed staff, interdisciplinary team to determine the corrective action based on the results of the investigation. -All employees will be oriented to their role in abuse prevention as mandated reporters and that abuse will not be tolerated in this facility. Facility staff are Mandatory Reporters and all mandated reporters will report reasonable suspicion of a crime against a resident when it is objectively reasonable for a person to entertain a suspicion of conduct that appears to be treatment resulting in mental suffering. -Examples of crimes that would be reported include but are not limited to assault, and sexual abuse. The facility will report allegations of abuse even if there is no reasonable suspicion immediately-no later than 2 hours-for all abuse (actual, alleged or potential) to law enforcement, the State Survey Agency, the Ombudsman, and APS. -All incidents of suspected abuse or alleged abuse will be promptly investigated by the assigned staff, who will be informed of the nature of the incident and continue the investigation process. Occurrences, patterns and trends will be assessed by Administrative staff, licensed staff, Interdisciplinary Team to determine the corrective action based on the results of the investigation",2020-09-01
801,RIDGECREST HEALTHCARE,35125,16640 NORTH 38TH STREET,PHOENIX,AZ,85032,2019-05-02,608,E,1,0,I6RS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, facility documentation, and review of policies and procedures, the facility failed to report a reasonable suspicion of a crime on multiple occasions to law enforcement regarding verbal, mental and sexual abuse abuse of residents on the Sedona Unit by one resident (#1). The sample size was one resident. Findings include: Resident #1 was admitted on (MONTH) 7, 2019 with [DIAGNOSES REDACTED]. An admission MDS (Minimum Data Set Assessment) dated (MONTH) 14, 2019 included that resident #1 had a BIMS (Brief Interview for Mental Status) score of 3 which indicated that the resident had severely impaired cognition. The assessment included that resident #1 was ambulatory with supervision, had delusions that put him at risk for illness or injury and interfered with his care and participation in social interactions. The assessment included that the resident was intrusive to others and that his behavior significantly disrupts the living environment. A psychiatric progress note dated (MONTH) 26, 2019 included that staff reported resident #1 had been hypersexual. The note included that resident #1 had been pulling out his penis in public, urinating outside in front of others, propositioning female staff and residents to engage in sexual activity with him, and going into female resident's rooms and staring at them while they sleep. The note included that the resident continued to exhibit these behaviors despite repeated redirection from staff members, and that his [MEDICAL CONDITION] have been more frequent and severe. The note included that medications had been reviewed and changes made to the resident's psychoactive medications. Review of records did not reveal any documented evidence that staff reports that the resident had had been pulling out his penis in public, and propositioning female residents to engage in sexual activity with him had been reported to law enforcement. A behavioral progress note dated (MONTH) 12, 2019 for the P.M. shift included that resident #1 had been pacing in the hallway with his hands in his pants, and had asked a female resident for some pussy. Review of the clinical record did not reveal any additional information regarding the female peer, or if staff had intervened or reported the incident to law enforcement. A behavioral progress note dated (MONTH) 16, 2019 at 11:00 a.m. included that resident #1 was harassing all of the residents, walked up to a resident and pulled down his pants and exposed himself right next to a resident. The note included that resident #1 pulled his pants down a total of 3 times, stole food from another resident, and that he was getting uncomfortably close to many residents. The note also included he did not listen to any of us which included CNA's (Certified Nursing Assistants) and a nurse. Continued review of records (including the State Agency data base) did not reveal any documented evidence that the sexual abuse of multiple residents described in the behavioral note on (MONTH) 16, 2019 was reported to law enforcement . A health status note dated (MONTH) 21, 2019 at 9:01 p.m. included that resident #1 had made several sexual attempts towards other female residents, and that the resident had exposed his private parts five times to other residents and staff. The note included that the resident needed close monitoring around other resident's. Continued review of the clinical record did not reveal any additional documented information that that the sexual abuse of multiple residents described in the behavioral note on (MONTH) 21, 2019 was reported to law enforcement. Review of two investigative reports dated (MONTH) 25, 2019 included that during a clinical review on (MONTH) 22, 2019 a nurses progress note was found dated (MONTH) 21, 2019 at 9:00 p.m. that resident #1 had made sexual acts towards peers and flashed his private parts five times to staff and peers. The investigation was started and the Phoenix Police were notified on (MONTH) 22, 2019 of that incident. An interview was conducted on (MONTH) 1, 2019 at 2;14 p.m. with an RN (Registered Nurse/staff #93). He stated that he was the nurse on the afternoon shift on (MONTH) 21, 2019 and that resident #1 pulled his pants down and exposed himself to a male peer in a wheelchair, and walked around the dining room repeatedly exposing himself to peers making statements the he wanted someone to lick or suck on his penis, and that he pulled his penis out of his pants and showed it to other residents. The RN stated that it was his first day on the job, and although he had been provided abuse prevention training during orientation prior to his first day, he did not know what he was supposed to do, and he did not notify anyone. During an interview with the Administrator/staff #185 conducted on (MONTH) 1, 2019 at 2:45 p.m. she stated that the note describing the behavior of resident #1 on (MONTH) 21, 2019 was discovered the next day during the morning meeting, and that it was investigated and the police were notified at that time. During an interview conducted on (MONTH) 1, 2019 at 3:10 p.m. with the DSD (Director of Staff Development/staff #66) she stated that new hire staff are provided orientation prior to their first day working with residents that includes definitions of abuse, and to report all abuse allegations within 2 hours to the state Agency, Ombudsman, APS and the Administrator. She stated that is the facility policy. An interview was conducted on (MONTH) 2, 2019 at 8:50 a.m. with the ADON (Assistant Director of Nursing/staff #98) she stated that staff are to immediately report any allegations of abuse including sexual abuse immediately to the DON (Director of Nursing) or the Administrator and that all of the staff have been educated on the reporting requirements. She stated that if staff cannot reach the DON or the Administrator by phone, they must make the notifications themselves (including to law enforcement). Review of a policy and procedure titled Abuse Prohibition and Prevention included a policy statement that the facility prevents abuse and exploitation of residents, each resident has the right to be free from mental/emotional, verbal, and sexual (abuse), and residents must not be subjected to abuse by anyone including other residents. The supervisor shall immediately intervene, correct and report identified situations where abuse is at risk for occurring. All employees will be oriented to their role in abuse prevention as mandated reporters and that abuse will not be tolerated in this facility. Facility staff are Mandatory Reporters and all mandated reporters will report reasonable suspicion of a crime against a resident when it is objectively reasonable for a person to entertain a suspicion of conduct that appears to be treatment resulting in mental suffering. Examples of crimes that would be reported include but are not limited to assault, and sexual abuse. The facility will report allegations of abuse even if there is no reasonable suspicion immediately-no later than 2 hours-for all abuse (actual, alleged or potential) to law enforcement.",2020-09-01
802,RIDGECREST HEALTHCARE,35125,16640 NORTH 38TH STREET,PHOENIX,AZ,85032,2019-05-02,609,E,1,0,I6RS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, facility documentation, and review of policies and procedures, the facility failed to report all alleged violations involving abuse not later than 2 hours after the allegation is made, by failing to report multiple allegations of verbal, mental and sexual abuse abuse of multiple residents on the Sedona Unit by one resident (#1) to the Administrator, the State Agency and APS (Adult Protective Services) within 2 hours. The sample size was one resident. Findings include: Resident #1 was admitted on (MONTH) 7, 2019 with [DIAGNOSES REDACTED]. An admission MDS (Minimum Data Set Assessment) dated (MONTH) 14, 2019 included that resident #1 had a BIMS (Brief Interview for Mental Status) score of 3 which indicated that the resident had severely impaired cognition. The assessment included that resident #1 was ambulatory with supervision, had delusions that put him at risk for illness or injury and interfered with his care and participation in social interactions. The assessment included that the resident was intrusive to others and that his behavior significantly disrupts the living environment. A psychiatric progress note dated (MONTH) 26, 2019 included that staff reported resident #1 had been hypersexual. The note included that resident #1 had been pulling out his penis in public, urinating outside in front of others, propositioning female staff and residents to engage in sexual activity with him, and going into female resident's rooms and staring at them while they sleep. The note included that the resident continued to exhibit these behaviors despite repeated redirection from staff members, and that his [MEDICAL CONDITION] have been more frequent and severe. The note included that medications had been reviewed and changes made to the resident's psychoactive medications. Review of records did not reveal any documented evidence that staff reports that the resident had had been pulling out his penis in public, and propositioning female residents to engage in sexual activity with him had been reported to the Administrator, the State Agency or APS. A behavioral progress note dated (MONTH) 12, 2019 for the P.M. shift included that resident #1 had been pacing in the hallway with his hands in his pants, and had asked a female resident for some pussy. Review of the clinical record did not reveal any additional information regarding the female peer, or if staff had intervened or reported the incident to to the Administrator, the State Agency or APS. A behavioral progress note dated (MONTH) 16, 2019 at 11:00 a.m. included that resident #1 was harassing all of the residents, walked up to a resident and pulled down his pants and exposed himself right next to a resident. The note included that resident #1 pulled his pants down a total of 3 times, stole food from another resident, and that he was getting uncomfortably close to many residents. The note also included he did not listen to any of us which included CNA's (Certified Nursing Assistants) and a nurse. Continued review of records (including the State Agency data base) did not reveal any documented evidence that the sexual abuse of multiple residents described in the behavioral note on (MONTH) 16, 2019 was reported to to the Administrator, the State Agency or APS. A health status note dated (MONTH) 21, 2019 at 9:01 p.m. included that resident #1 had made several sexual attempts towards other female residents, and that the resident had exposed his private parts five times to other residents and staff. The note included that the resident needed close monitoring around other resident's. Continued review of the clinical record did not reveal any additional documented information that that the sexual abuse of multiple residents described in the behavioral note on (MONTH) 21, 2019 was reported to to the Administrator, the State Agency or APS. Review of two investigative reports dated (MONTH) 25, 2019 included that during a clinical review on (MONTH) 22, 2019 a nurses progress note was found dated (MONTH) 21, 2019 at 9:00 p.m. that resident #1 had made sexual acts towards peers and flashed his private parts five times to staff and peers. The investigation was started and the Phoenix Police were notified on (MONTH) 22, 2019 of that incident. An interview was conducted on (MONTH) 1, 2019 at 2;14 p.m. with an RN (Registered Nurse/staff #93). He stated that he was the nurse on the afternoon shift on (MONTH) 21, 2019 and that resident #1 pulled his pants down and exposed himself to a male peer in a wheelchair, and walked around the dining room repeatedly exposing himself to peers making statements the he wanted someone to lick or suck on his penis, and that he pulled his penis out of his pants and showed it to other residents. The RN stated that it was his first day on the job, and although he had been provided abuse prevention training during orientation prior to his first day, he did not know what he was supposed to do, and he did not notify anyone. During an interview with the Administrator/staff #185 conducted on (MONTH) 1, 2019 at 2:45 p.m. she stated that the note describing the behavior of resident #1 on (MONTH) 21, 2019 was discovered the next day during the morning meeting, and that it was investigated and notifications were made at that time. During an interview conducted on (MONTH) 1, 2019 at 3:10 p.m. with the DSD (Director of Staff Development/staff #66) she stated that new hire staff are provided orientation prior to their first day working with residents that includes definitions of abuse, and to report all abuse allegations within 2 hours to the state Agency, Ombudsman, APS and the Administrator. She stated that is the facility policy. An interview was conducted on (MONTH) 2, 2019 at 8:50 a.m. with the ADON (Assistant Director of Nursing/staff #98) she stated that staff are to immediately report any allegations of abuse including sexual abuse immediately to the DON (Director of Nursing) or the Administrator and that all of the staff have been educated on the reporting requirements. She stated that if staff cannot reach the DON or the Administrator by phone, they must make the notifications themselves (including to the State Agency and APS). Review of a policy and procedure titled Abuse Prohibition and Prevention included a policy statement that the facility prevents abuse and exploitation of residents, each resident has the right to be free from mental/emotional, verbal, and sexual (abuse), and residents must not be subjected to abuse by anyone including other residents. The supervisor shall immediately intervene, correct and report identified situations where abuse is at risk for occurring. All employees will be oriented to their role in abuse prevention as mandated reporters and that abuse will not be tolerated in this facility. Facility staff are Mandatory Reporters and all mandated reporters will report reasonable suspicion of a crime against a resident when it is objectively reasonable for a person to entertain a suspicion of conduct that appears to be treatment resulting in mental suffering. Examples of crimes that would be reported include but are not limited to assault, and sexual abuse. The facility will report allegations of abuse even if there is no reasonable suspicion immediately-no later than 2 hours-for all abuse (actual, alleged or potential) to the State Survey Agency, the Ombudsman, and APS.",2020-09-01
803,RIDGECREST HEALTHCARE,35125,16640 NORTH 38TH STREET,PHOENIX,AZ,85032,2019-05-02,610,E,1,0,I6RS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, facility documentation, staff interviews, and review of policies and procedures, the facility failed to investigate an allegation of mental, verbal and sexual abuse that involved multiple residents on the Sedona Unit by one resident (#1). The sample size was one resident. Findings include: Resident #1 was admitted on (MONTH) 7, 2019 with [DIAGNOSES REDACTED]. An admission MDS (Minimum Data Set Assessment) dated (MONTH) 14, 2019 included that resident #1 had a BIMS (Brief Interview for Mental Status) score of 3 which indicated that the resident had severely impaired cognition. The assessment included that resident #1 was ambulatory with supervision, had delusions that put him at risk for illness or injury and interfered with his care and participation in social interactions. The assessment included that the resident was intrusive to others and that his behavior significantly disrupts the living environment. A psychiatric progress note dated (MONTH) 26, 2019 included that staff reported resident #1 had been hypersexual. The note included that resident #1 had been pulling out his penis in public, urinating outside in front of others, propositioning female staff and residents to engage in sexual activity with him, and going into female resident's rooms and staring at them while they sleep. The note included that the resident continued to exhibit these behaviors despite repeated redirection from staff members, and that his [MEDICAL CONDITION] have been more frequent and severe. The note included that medications had been reviewed and changes made to the resident's psychoactive medications. Review of records did not reveal any documented evidence that staff reports that the resident had had been pulling out his penis in public, and propositioning female residents to engage in sexual activity with him had been investigated by the facility. A behavioral progress note dated (MONTH) 12, 2019 for the P.M. shift included that resident #1 had been pacing in the hallway with his hands in his pants, and had asked a female resident for some pussy. Review of records did not reveal any additional information that the incident on (MONTH) 12, 2019 had been investigated by the facility. Review of a policy and procedure titled Abuse Prohibition and Prevention included a policy statement that the facility prevents abuse and exploitation of residents, each resident has the right to be free from mental/emotional, verbal, and sexual (abuse), and residents must not be subjected to abuse by anyone including other residents. The supervisor shall immediately intervene, correct and report identified situations where abuse is at risk for occurring. Facility staff are able to identify the different types of abuse-mental/verbal abuse and sexual abuse. All incidents of suspected abuse or alleged abuse will be promptly investigated by the assigned staff, who will be informed of the nature of the incident and continue the investigation process. Occurrences, patterns and trends will be assessed by Administrative staff, licensed staff, Interdisciplinary Team to determine the corrective action based on the results of the investigation.",2020-09-01
804,RIDGECREST HEALTHCARE,35125,16640 NORTH 38TH STREET,PHOENIX,AZ,85032,2018-09-12,600,E,1,1,JL4711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, resident and staff interviews, facility documentation, and policies and procedures, the facility failed to ensure that one resident (#51) was free from verbal abuse by a staff member, that one resident (#33) was free from abuse by a family member, that one resident (#55) was free from abuse by resident (#67), that resident #1 was free from physical abuse by one resident (#73), and that one resident (#2) was free from abuse by resident (#42). Findings include: -Resident #51 was admitted to the facility on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. Review of the admission MDS (Minimum Data Set) assessment dated (MONTH) 20, (YEAR), revealed a BIMS (Brief Interview for Mental Status) score of 10, indicating the resident had moderate cognitive impairment. Review of the facility's Reportable Event Report revealed the resident reported on 8/28/18 that on the weekend (8/26/18), a Certified Nursing Assistant (CNA/staff #166) was talking smack to him, and was using foul language and called him names. The resident reported that he was in the day room asking for his cigarette break, when staff #166 called him a mother f . The resident stated that he told her that she should say it to his face and not behind his back. The resident said that staff #166 replied that she would say it to his face and then called him a blind bastard. Per the report, two staff members (CNA/staff #142) and (CNA/staff #97) heard staff #166 tell the resident, I'll take you out for your f---ing smoke when I am finished. The investigation included that the allegation of abuse was unsubstantiated, but staff #166 was terminated, due to a violation of company policy. An interview was conducted with the administrator (staff #165) on (MONTH) 10, (YEAR) at 1:30 p.m. Staff #165 stated that two staff verified that staff #166 said to resident #51 that he would take him out for a f---ing cigarette when she was done. The administrator stated that she did not feel this was abusive but was a violation of facility policy, as no profanity is allowed in the facility. The administrator stated that staff #166 was terminated for using foul language. She also said that when staff #166 was initially interviewed she denied being verbally abusive, but today she admitted to using profanity. An interview was conducted with resident #51 on (MONTH) 10, (YEAR) at 1:45 p.m., who stated that he recalled the incident. The resident stated that the CNA (staff #166) said something like F--- you, I'm not taking you out, it's not my turn. I took you last time. The resident stated the CNA shouldn't have said that to him and he thought it was verbal abuse. An interview was conducted with a CNA (staff #142) on (MONTH) 10, (YEAR) at 3:30 p.m. Staff #142 stated that she was coming down the hallway and staff #166 was muttering, I can't take care of you right now. I have other patients to take care of. Staff #142 said that staff #166 then said I can't f---ing take him outside. Staff #142 stated that the resident is blind, but he heard what staff #166 said. Staff #142 stated that the resident stood up and said don't talk to me like that and then she intervened and took the resident outside for a cigarette, because she did not want the altercation to get any worse. An interview was conducted with staff #166 on (MONTH) 11, (YEAR) at 8:50 a.m. She said that she was with another resident, when resident #51 wanted a cigarette on (MONTH) 26, (YEAR). She said that she told the resident he would have to wait, as she was with another resident. Staff 3166 stated there were other staff in the day room who could have taken the resident outside for a cigarette. Staff #166 denied that she swore at the resident. Regarding an incident between resident #33 and a family member: -Resident #33 was admitted to the facility on (MONTH) 11, (YEAR), with [DIAGNOSES REDACTED]. The quarterly MDS assessment dated (MONTH) 10, (YEAR), included a BIMS score of 15, indicating the resident was cognitively intact. A social services progress note dated (MONTH) 4, (YEAR), included that this writer (social service assistant/staff #131) was called to the resident's room. Upon entering, a family member was yelling and threw a bag of chips and cough drops at the resident. The note included it was explained to the family member that this was not allowed and she would need to exit the building. According to a social services progress note dated (MONTH) 6, (YEAR), she had discussed the incident with the family member who stated that she was having a bad day and that this would not happen again. Review of facility documentation dated (MONTH) 4, (YEAR), revealed the administrator (staff #165) interviewed resident #33, who denied that the incident happened. The facility was unable to provide any documentation that this incident was investigated. An interview with staff #131 was conducted on (MONTH) 11, (YEAR) at 12:33 p.m. Staff #131 stated that she was on the 200 hallway, when a CNA (staff #23) asked her to go to the resident's room immediately. She said when she entered the room, a family member and the resident were arguing. She stated the family member was confrontational, and was yelling and cursing at the resident. She stated that she also saw the family member throw a bag of chips and cough drops at the resident. Staff #131 stated that she intervened and told the family member to leave the building. She said she then reported the incident to the administrator. She said that two days after the incident, the family member came back to the facility and admitted to her that she threw the bag of chips and cough drops at the resident. Staff #131 stated that she did not think this was abuse, because the resident and family member always had a volatile relationship. During an interview with a CNA (staff #23) conducted on (MONTH) 11, (YEAR) at 1:20 p.m., he stated that he was walking out from another room which was directly across from the resident's room, and saw the family member crouched down at the resident's dresser, which was located directly in front of the resident's bed. He said he saw the family member pulling and tossing clothes and items from the dresser drawer and that the resident and family member were arguing. He said the family member was loud and was heard by other residents in the hall. He stated that he immediately called staff #131 to intervene, because he was worried that the clothes/items tossed by the family member would hit the resident, and he had to protect the resident because this was abuse. An interview with the administrator (staff #165) was conducted on (MONTH) 11, (YEAR) at 2:00 p.m. Staff #165 stated that she interviewed the resident immediately after the incident was reported to her. She stated that the resident denied being abused by a family member. Regarding an altercation between resident #55 and #67: -Resident #55 was admitted to the facility on (MONTH) 18, (YEAR), with [DIAGNOSES REDACTED]. Review of an admission MDS assessment dated (MONTH) 26, (YEAR), revealed the resident had a BIMS score of 11, which indicated the resident had moderate cognitive impairment. -Resident #67 was admitted to the facility on (MONTH) 15, 2006, with [DIAGNOSES REDACTED]. Review of a quarterly MDS assessment dated (MONTH) 2, (YEAR), revealed the resident had a BIMS score of 15, which indicated the resident had no cognitive deficits. Review of a care plan revealed that resident #67 has the potential to demonstrate physical behaviors towards staff and peers, related to poor impulse control. The resident has a known trigger prior to becoming physically abusive, and seems to target others when agitated. He has a history of acting out physically, if he is unable to receive concrete responses to his inquiries and becomes frustrated by uncertainty. A goal included that the resident will demonstrate effective coping skills, as well as verbalize understanding of the need to control physically aggressive behavior. Interventions included the following: assess and anticipate needs, keep the resident a significant distance from peers that are known to cause him to become upset, attempt to provide the resident with clear, concise responses to requests and use positive phrasing and explain what can be done versus what cannot be done. A health status progress note dated (MONTH) 4, (YEAR), revealed that resident #67 was talking to a CNA (staff #136) about getting his hair cut. Staff #136 told the resident that she did not know when his hair would be cut. The resident then asked a licensed vocational nurse (staff #148) and she told him that she did not know when he would be getting his hair cut. At this time, resident #55 was propelling himself towards the nurses station, when resident #67 turned and punched resident #55 in the face, on the left side of his nose. Resident #67 was asked why he punched resident #55 and he stated, I don't know, I don't like him. Review of the facility's investigation revealed there was a resident to resident altercation, which was witnessed by staff #136 and staff #148 on (MONTH) 4, (YEAR) at approximately 9:30 a.m. Resident #67 was talking to staff #136 and #148, about getting his hair cut, when resident #55 propelled his wheelchair toward resident #67. Resident #67 then reached over and hit #55 in the nose. The report included that resident #67 said that he was talking to the nurse and checking to see when his hair cut was, when resident #55 wheeled up on him and he felt that resident #55 was getting in his business. The report also included that resident #55 stated that he was just wheeling around and did not realize he was close to resident #67. No injuries were observed. Per the report, the allegation of abuse was substantiated. An interview was conducted with staff #148 on (MONTH) 11, (YEAR) at 1:15 p.m. She stated that she was talking to resident #67 outside of the nurses station and he wanted to know when he could get his hair cut. She stated resident #55 started to wheel up to resident #67 and resident #67 then hit resident #55 in the face. She stated both residents did not sustain any injuries. An interview was conducted with staff #136 on (MONTH) 11, (YEAR) at 1:30 p.m. Staff #136 stated that she was talking to resident #67 about getting his hair cut, when resident #55 wheel up to resident #67 and then resident #67 hit resident #55 in the face, when he was within arms reach. Regarding an altercation between resident #1 and resident #73: -Resident #1 was admitted on (MONTH) 30, (YEAR), with [DIAGNOSES REDACTED]. Review of the admission MDS assessment dated (MONTH) 7, (YEAR), revealed the resident had a BIMS score of zero, which indicated severe cognitive impairment. Review of the nurse progress note dated (MONTH) 12, (YEAR), revealed that resident #1 told his power of attorney (POA) that resident #73 hit him on the right forearm. -Resident #73 was admitted on (MONTH) 20, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident had behaviors of verbal and physical aggression toward others. A care plan dated (MONTH) 14, (YEAR) included that resident #73 had dementia with behavioral disturbance, with manifestations of physical aggression. The care plan did not include any interventions to address the resident's behaviors of physical aggression. An admission MDS assessment for resident #73 dated (MONTH) 5, (YEAR) revealed the resident had a BIMS score of zero, which indicated severe cognitive impairment. Review of the facility's investigative report revealed that on (MONTH) 11, (YEAR), resident #1's POA reported to a nurse that she found the resident (#73) at resident #1's bedside and that he had hit resident #1 on the right forearm, while she was out of the room. Per the report, resident #73 confirmed that he hit his roommate on the arm. There were no witnesses and no injuries were found. An interview was conducted with a CNA (staff #124) on (MONTH) 11, (YEAR) at 2:22 p.m. She stated that a resident to resident physical altercation would be considered abuse. She stated that whenever it looks like residents might have an altercation, they try to occupy them and do activities. An interview was conducted with a LPN (staff #41) on (MONTH) 11, (YEAR) at 3:20 p.m. She stated that she was on duty when the altercation between resident #1 and resident #73 occurred. She said the POA of resident #1 reported to her that resident #1 told her that resident #73 hit him. She stated that resident #73 said that he hit resident #1, but did not tell her why. An interview was conducted with the Director of Nursing (staff #167), the Administrator (staff #165), and the Regional Clinical Director (staff #168) on (MONTH) 12, (YEAR) at 8:48 a.m. The Administrator and the DON acknowledged that they did not meet the regulatory requirements in preventing abuse between resident #1 and resident #73. Regarding an altercation between resident #2 and resident #42: -Resident #2 was admitted to the facility on (MONTH) 11, (YEAR), with [DIAGNOSES REDACTED]. Review of a quarterly MDS assessment dated (MONTH) 23, (YEAR), revealed the resident was severely impaired with cognitive skills for daily decision making. According to a care plan, resident #2 has a [DIAGNOSES REDACTED]. A goal included to maintain current level of functioning with no significant decline or complications. Interventions included to approach resident from front, face to face and use a slow gentle friendly approach. -Resident #42 was admitted to the facility on (MONTH) 14, 2005, with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated (MONTH) 17, (YEAR) revealed a BIMS score of 11, indicating the resident had moderate cognitive impairment. The MDS also included that the resident exhibited no verbal or physical behaviors and required extensive assistance with most activities of daily living. According to a care plan, resident #42 has a history of verbal abuse as evidenced by yelling profanities at peers and staff, and throwing items. Interventions included to use a calm approach, when throwing objects remove the objects and escort peers to immediate area and/or staff to position themselves between residents. Review of the facility's investigation revealed that on (MONTH) 28, (YEAR) at 6:05 p.m., resident #2 was sitting at the dining room table, when a CNA (staff #126) witnessed resident #2 pick up her glass of water and throw it. Per the report, some of the water landed on resident #42. The CNA rushed over to the table, but arrived just after resident #42 stood up and hit resident #2 on the cheek. An interview was conducted on (MONTH) 11, (YEAR) at 12:27 p.m. with CNA (staff #126), who stated that a couple weeks ago she witnessed resident #2 throw water in the dining room and some of the water landed on resident #42. She stated resident #42 then hit resident #2 on the face. She stated she rushed over and immediately separated the residents. She stated resident #2 has a history of throwing objects and was not intentionally trying to throw water at resident #42. Staff #126 said that resident's hitting each other was a type of physical abuse. An interview was conducted on (MONTH) 11, (YEAR) at 3:04 p.m. with a LPN (staff #24). Staff #24 stated residents hitting one another was abuse. He stated that resident #2 does exhibit a behavior of throwing her drinks on the floor, once she is done drinking. He stated that staff #126 notified him that while she was grabbing a meal tray in the dining room, she saw resident #2 throw water and the water landed on resident #42, and before she could intervene, resident #42 slapped resident #2. An interview was conducted on (MONTH) 12, (YEAR) at 11:33 a.m. with the Administrator and the Director of Nursing. They stated the resident to resident altercation was substantiated. Review of the Abuse Prohibition and Prevention policy revealed the facility prohibits and prevents abuse of residents. Each resident has the right to be free from verbal, physical and mental abuse. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, family members and other residents. The policy also included that facility staff are able to identify the different types of abuse, such as mental, sexual and physical abuse.",2020-09-01
805,RIDGECREST HEALTHCARE,35125,16640 NORTH 38TH STREET,PHOENIX,AZ,85032,2018-09-12,607,D,1,1,JL4711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews, facility documentation, and policies and procedures, the facility failed to implement their abuse policy regarding allegations of abuse for two residents (#'s 33 and 51). Findings include: -Resident #51 was admitted to the facility on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. Review of the facility's Reportable Event Report revealed resident #51 reported on 8/28/18 that on the weekend (8/26/18 at 9 p.m.), a certified nursing assistant (CNA/staff #166) was talking smack to him, and was using foul language and called him names. The resident stated that he was in the day room asking for his cigarette break, when staff #166 called him a mother f . He reported that he told staff #166 that she should say it to his face and not behind his back. The resident said that staff #166 replied that she would come and say it to his face and then called him a blind bastard. Per the report, two staff members (CNA/staff #142) and (CNA/staff #97) heard staff #166 tell the resident I'll take you out for your f---ing smoke when I am finished. The investigative report also included that staff #166 was suspended on 8/28/18, pending the investigation. However, the report did not include any evidence that staff #166 was removed from providing resident care for the remainder of her shift on (MONTH) 26, when the incident occurred. Review of the payroll punch detail for staff #166 revealed she continued to work the remainder of her shift on (MONTH) 26, (YEAR), and worked an entire shift on (MONTH) 27. The report also noted that the allegation of abuse was unsubstantiated and that staff #166 was terminated, due to a violation of company policy. Further review of the facility's Reportable Event Report revealed the incident which occurred on (MONTH) 26, (YEAR) at 9:00 p.m. was witnessed by staff, however, there was no documentation that staff immediately reported the allegation of abuse to the Administrator or to the Director of Nursing (DON), at the time of the incident. The report included the resident was the one who reported the incident to staff on (MONTH) 28, (YEAR). There was also no documentation that the incident was reported to the State Agency, within two hours after the allegation was made. An interview was conducted with the Administrator (staff #165) on (MONTH) 11, (YEAR) at 2:00 p.m. She stated that all staff should report allegations of abuse or witness abuse immediately to her, their supervisors, and to the DON. She said that since the staff member who witnessed the incident did not report it, they did not report it to the required agencies, within the required time frame. She stated that an allegation of abuse should be reported to the State Survey Agency, within two hours. Staff #165 further stated that when an allegation of abuse is made, the alleged perpetrator is suspended immediately pending the facility's investigation. Staff #165 said that staff #166 should have been suspended immediately on (MONTH) 26, (YEAR), and not allowed to work the remainder of her shift, or work on (MONTH) 27. -Resident #33 was admitted at the facility on (MONTH) 11, (YEAR) with [DIAGNOSES REDACTED]. A social services progress note dated (MONTH) 4, (YEAR) included this writer (staff #131) was called to the resident's room. Upon entering, a family member was yelling and threw a bag of chips and cough drops at the resident. The note incuded that it was explained to the family member that this was not allowed and she would need to exit the building. According to a social services progress note dated (MONTH) 6, (YEAR), she had discussed the incident with the family member who stated that she was having a bad day and that this would not happen again. Review of facility documentation dated (MONTH) 4, (YEAR) revealed the Administrator interviewed resident #33 and denied that the incident happened. The facility was unable to provide any documentation that the allegation of abuse was investigated or that the allegation of abuse was reported to the State Agency within 2 hrs after the allegation was made, nor documentation that Adult Protective Services (APS) was notified. During an interview with staff #165 conducted on (MONTH) 11, (YEAR), she stated that she interviewed the resident immediately after the incident was reported to her. She stated the resident denied that the incident happened, so she did not think the incident was reportable, so they did not do an investigation. During an interview with a CNA (staff #23) conducted on (MONTH) 11, (YEAR) at 1:20 p.m., he stated that he was walking out from another room which was directly across from the resident's room, and saw the family member crouched down at the resident's dresser, which was located directly in front of the resident's bed. He said he saw the family member pulling and tossing clothes and items from the dresser drawer and that the resident and family member were arguing. He said the family member was loud and was heard by other residents in the hall. He stated that he immediately called staff #131 to intervene, because he was worried that the clothes/items tossed by the family member would hit the resident and he had to protect the resident, because this was abuse. A later interview was conducted with staff #165 on (MONTH) 11, (YEAR) at 2:00 p.m. She stated that allegations of abuse or witnessed incidents of abuse are reported to her or the DON immediately, and she will then notify the State Agency, within 2 hours. She stated that APS is notified within 5 days of the incident when the final report is completed. Review of the Abuse Prohibition and Prevention policy revealed the administrator/designee is the facility's abuse coordinator and is responsible for coordinating and implementing their abuse prevention policies and procedures. The policy included that the facility prohibits and prevents abuse of residents. Each resident has the right to be free from verbal, physical and mental abuse. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, family members and other residents. The policy also included that facility staff are able to identify the different types of abuse, such as mental, verbal, sexual and physical abuse. The policy also included that the facility will report all abuse (actual, alleged or potential) immediately to the Administrator, and no later than 2 hours to the State Agency and APS. The policy stated the facility must have documentation of the report, including what was reported and the date and time of when the report was made to the State Agency. Further review of the Abuse policy revealed that all incidents or suspected or alleged abuse will be promptly investigated. The investigation and report shall include the following: -review all relevant documentation -conduct interviews with the person making the report, other residents, any witness to the alleged incident and the alleged perpetrator, and staff who have had contact with the resident during the period of alleged incident -review all events leading up to the alleged incident; and -findings of the investigation. The policy also stated that the facility will ensure that all residents are protected from physical and psychosocial harm during and after the investigation. If the suspected perpetrator is an employee, the employee will be removed immediately from care or from the vicinity of residents and will be suspended until the investigation is complete and the findings have been reviewed by the Administrator.",2020-09-01
806,RIDGECREST HEALTHCARE,35125,16640 NORTH 38TH STREET,PHOENIX,AZ,85032,2018-09-12,609,E,1,1,JL4711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews, facility documentation, and policies and procedures, the facility failed to report allegations of abuse involving eight residents (#'s 1, 2, 33, 42, 51, 55, 67 and 73) to the State Agency and/or Adult Protective Services (APS), within two hours after the allegations were made. The facility also failed to ensure that an allegation of abuse was immediately reported to the Administrator/designee involving one resident (#51). Findings include: -Resident #51 was admitted to the facility on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. Review of the facility's Reportable Event Report revealed the resident reported on 8/28/18 that on the weekend (8/26/18), a CNA (staff #166) was talking smack to him, and was using foul language and called him names. The resident stated that he was in the day room asking for his cigarette break, when staff #166 called him a mother f . He reported that he told staff #166 that she should say it to his face and not behind his back. The resident said that staff #166 replied that she would say it to his face and then called him a blind bastard. Per the report, two staff members (CNA/staff #142) and (CNA/staff #97) heard staff #166 tell the resident, I'll take you out for your f---ing smoke when I am finished. The investigation included the allegation of abuse was unsubstantiated, however, staff #166 was terminated, due to a violation of company policy. Further review of the facility's Reportable Event Report revealed that the allegation of verbal abuse which occurred on 8/26/18 was not reported within two hours to the State Agency and to Adult Protective Services as required. There was also no documentation that the allegation of abuse was immediately reported to the Administrator/designee by staff when the incident occurred on 8/26/18. An interview was conducted with the Administrator (staff #165) on (MONTH) 11, (YEAR) at 2:00 p.m. The Administrator stated that the staff who witnessed the incident on (MONTH) 26, (YEAR), never reported the incident as required. The Administrator stated that the resident reported the incident on (MONTH) 28, (YEAR), and then she reported the incident within two hours to the State Agency. The Administrator stated that she normally doesn't report to APS within two hours, but waits until the facility's investigation is complete, within five days of the allegation. -Resident #33 was admitted to the facility on (MONTH) 11, (YEAR), with [DIAGNOSES REDACTED]. A social services progress note dated (MONTH) 4, (YEAR), included that this writer (social service assistant/staff #131) was called to the resident's room. Upon entering, a family member was yelling and threw a bag of chips and cough drops at the resident. The note included it was explained to the family member that this was not allowed and she would need to exit the building. Review of facility documentation dated (MONTH) 4, (YEAR) revealed the Administrator (staff #165) interviewed resident #33 and denied that the incident happened. The facility was unable to provide any documentation that the allegation of abuse was reported to the State Agency within 2 hrs after the allegation was made, nor documentation that Adult Protective Services (APS) was notified. During an interview with staff #165 conducted on (MONTH) 11, (YEAR) at 12:30 p.m., she stated that she had knowledge of the incident between the resident and the family member, however, she stated the resident denied the incident ever happened, so she did not think the incident was reportable. A later interview was conducted with staff #165 on (MONTH) 11, (YEAR) at 2:00 p.m. She stated that allegations of abuse or witnessed incidents of abuse are reported to her or the Director of Nursing (DON) immediately, and she will then notify the State Agency, within 2 hours. She stated that APS is notified within 5 days of the incident when the final report is completed. -Resident #55 was admitted to the facility on (MONTH) 18, (YEAR), with [DIAGNOSES REDACTED]. -Resident #67 was admitted to the facility on (MONTH) 15, 2006, with [DIAGNOSES REDACTED]. Review of the facility's investigation revealed there was a resident to resident altercation, which was witnessed by staff #136 and staff #148 on (MONTH) 4, (YEAR) at approximately 9:30 a.m. Resident #67 was talking to staff #136 and #148, about getting his hair cut, when resident #55 propelled his wheelchair toward resident #67. Resident #67 then reached over and hit #55 in the nose. The report included that resident #67 said that he was talking to the nurse and checking to see when his hair cut was, when resident #55 wheeled up on him and he felt that resident #55 was getting in his business. The report also included that resident #55 stated that he was just wheeling around and did not realize he was close to resident #67. No injuries were observed. Per the report, the allegation of abuse was substantiated. Further review of the facility's investigation revealed that the incident occurred on (MONTH) 4, (YEAR) at 9:30 a.m., however, it was not reported to the State Agency until 12:45 p.m. on (MONTH) 4, (YEAR), which was more than two hours after the allegation of abuse was made. An interview was conducted on (MONTH) 12, (YEAR) at 1:11 p.m. with the DON (staff #167) and the Administrator (staff #165). They were unable to explain why the allegation of abuse was not reported to the State Agency, within the 2 hour timeframe. -Resident #1 was admitted on (MONTH) 30, (YEAR), with [DIAGNOSES REDACTED]. -Resident #73 was admitted on (MONTH) 20, (YEAR), with [DIAGNOSES REDACTED]. Review of the facility's investigative report revealed that on (MONTH) 11, (YEAR) at 5:45 p.m., the POA of resident #1 reported to a nurse that she found resident (#73) at resident #1's bedside and that he had hit resident #1 on the right forearm, while she was out of the room. Per the report, resident #73 confirmed that he hit his roommate on the arm. There were no witnesses and no injuries were found. Review of the facility's investigative report revealed that on (MONTH) 11, (YEAR), resident #1's POA reported to a nurse that she found resident #73 at resident #1's bedside and that he had hit resident #1 on the right forearm, while she was out of the room. Per the report, resident #73 confirmed that he hit his roommate on the arm. There were no witnesses and no injuries were found. Further review of the facility's investigative report revealed that the allegation of abuse was not reported to the State Agency until (MONTH) 12, (YEAR) at 8:07 a.m., which was more than two hours after the allegation was made. An interview was conducted with the DON (staff #167), the Administrator (staff #165), and the Regional Clinical Director (staff #168) on (MONTH) 12, (YEAR) at 8:48 a.m. The Administrator stated that when an abuse allegation is received, which would include any resident to resident physical altercations, they should report it to the State Agency within two hours. The Administrator and the DON acknowledged that they did not meet the regulatory requirements for reporting abuse for the incident between resident #1 and resident #73. Review of the Abuse Prohibition and Prevention policy revealed the facility will report all abuse (actual, alleged or potential) immediately to the administrator and no later than 2 hours to the State Agency and APS. The policy also included that facility must have documentation of the report, including what was reported and the date and time of when the report was made to the State Agency.",2020-09-01
807,RIDGECREST HEALTHCARE,35125,16640 NORTH 38TH STREET,PHOENIX,AZ,85032,2018-09-12,610,D,1,1,JL4711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews, facility documentation, and policies and procedures, the facility failed to ensure that an allegation of abuse was thoroughly investigated for one resident (#33) and failed to prevent the potential for further abuse, by failing to immediately remove one staff member from providing care following an allegation of verbal abuse involving one resident (#51). Findings include: -Resident #51 was admitted to the facility on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. Review of the facility's Reportable Event Report revealed resident #51 reported on 8/28/18 that on the weekend (8/26/18 at 9 p.m.), a certified nursing assistant (CNA/staff #166) was talking smack to him, and was using foul language and called him names. The resident stated that he was in the day room asking for his cigarette break, when staff #166 called him a mother f . He reported that he told staff #166 that she should say it to his face and not behind his back. The resident said that staff #166 replied that she would say it to his face and then called him a blind bastard. Per the report, two staff members (CNA/staff #142) and (CNA/staff #97) heard staff #166 tell the resident, I'll take you out for your f---ing smoke when I am finished. The investigative report also included that staff #166 was suspended on 8/28/18, pending the investigation. However, the report did not include any evidence that staff #166 was removed from providing resident care for the remainder of her shift on (MONTH) 26, when the incident occurred. Review of the payroll punch detail for staff #166 revealed she continued to work the remainder of her shift on (MONTH) 26, (YEAR), and worked an entire shift on (MONTH) 27. The investigative report further included that staff #166 was terminated, due to a violation of company policy. An interview was conducted with the Administrator (staff #165) on (MONTH) 10, (YEAR) at 1:30 p.m. The Administrator stated that staff #166 was terminated for using foul language. Staff #165 said that two staff verified that staff #166 stated to resident #51 that he would take him out for a f---ing cigarette when she was done. The Administrator further stated that she did not feel this was abusive, but was a violation of facility policy, as no profanity is allowed in the facility. The Administrator stated that when staff #166 was initially interviewed she denied being verbally abusive, but today she admitted to using profanity. An interview was conducted with staff #142 on (MONTH) 10, (YEAR) at 3:30 p.m. Staff #142 stated that she was coming down the hallway and staff #166 was muttering I can't take care of you right now. I have other patients to take care of. Staff #142 stated that staff #166 said, 'I can't f---ing take him outside. Staff #142 stated that the resident is blind, but he heard what staff #166 said. She said the resident stood up and said don't talk to me like that and then she intervened and took the resident outside for a cigarette, because she did not want the altercation to get any worse. Staff #142 further stated that she never reported the incident, but should have reported it right away. She also stated that there were others who witnessed the altercation. Another interview was conducted with staff #165 on (MONTH) 11, (YEAR) at 2:00 p.m. The Administrator stated that all staff should report allegations of abuse immediately to their supervisors, to the Administrator and to the Director of Nursing. Staff #165 stated that when an allegation of abuse is made, the alleged perpetrator is suspended immediately, pending the facility's investigation. The Administrator stated that staff who witnessed the alleged incident of verbal abuse should have reported it immediately. Staff #165 said that staff #166 should have been suspended immediately on (MONTH) 26, (YEAR), and not allowed to work the remainder of her shift and on (MONTH) 27. -Resident #33 was admitted to the facility on (MONTH) 11, (YEAR), with [DIAGNOSES REDACTED]. A social services progress note dated (MONTH) 4, (YEAR) included this writer (staff #131) was called to the resident's room. Upon entering, a family member was yelling and threw a bag of chips and cough drops at the resident. The note included that it was explained to the family member that this was not allowed and she would need to exit the building. According to a social services progress note dated (MONTH) 6, (YEAR), she had discussed the incident with the family member who stated that she was having a bad day and that this would not happen again. Review of facility documentation dated (MONTH) 4, (YEAR) revealed the Administrator (staff #165) interviewed resident #33 and denied that the incident happened. The facility was unable to provide any documentation that this incident was investigated. During an interview with staff #165 conducted on (MONTH) 11, (YEAR) at 12:30 p.m., she stated that she had knowledge of the incident between the resident and the family member. She said the resident denied that the incident ever happened, so she did not think the incident was reportable, and they did not do an investigation. Review of the Abuse Prohibition and Prevention policy revealed that all incidents or suspected or alleged abuse will be promptly investigated. The investigation and report shall include the following: -review all relevant documentation -conduct interviews with the person making the report, other residents, any witness to the alleged incident and the alleged perpetrator, and staff who have had contact with the resident during the period of alleged incident -review all events leading up to the alleged incident; and -findings of the investigation. The policy further included that the facility will ensure that all residents are protected from physical and psychosocial harm during and after the investigation. If the suspected perpetrator is an employee, the employee will be removed immediately from care or from the vicinity of residents and will be suspended until the investigation is complete and the findings have been reviewed by the Administrator.",2020-09-01
808,RIDGECREST HEALTHCARE,35125,16640 NORTH 38TH STREET,PHOENIX,AZ,85032,2018-09-12,695,D,0,1,JL4711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, and policies and procedures, the facility failed to ensure that one resident (#88) who was receiving oxygen had physician orders for its use. Findings include: Resident #88 was admitted to the facility on (MONTH) 27, (YEAR) and readmitted on (MONTH) 10, (YEAR), with [DIAGNOSES REDACTED]. An Admit/Readmit nursing assessment dated (MONTH) 10, (YEAR) included the resident had an oxygen saturation level of 92%, and was receiving oxygen via nasal cannula. A skilled evaluation note dated (MONTH) 10, (YEAR) at 9:31 p.m., included the resident had crackles on auscultation on the left side of the lungs and oxygen 2 liters per nasal cannula was being provided. However, there was no physician's order for the oxygen upon admission. An admission MDS (Minimum Data Set) assessment dated (MONTH) 17, (YEAR), revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15, which indicated the resident was cognitively intact. The MDS did not include that the resident was receiving oxygen therapy. Review of the skilled evaluation notes dated (MONTH) 20, and 21, (YEAR) revealed the resident was receiving 2 liters of oxygen via nasal cannula. Skilled notes dated (MONTH) 25, and 26, (YEAR) included the resident was on 3 liters of oxygen per nasal cannula. Another skilled evaluation note dated (MONTH) 27, (YEAR) included the resident had difficulty breathing, had shortness of breath, diminished lung sounds and was provided 2 liters of oxygen via nasal cannula. A note dated (MONTH) 28, (YEAR) also included the resident was provided oxygen per nasal cannula. Further review of the clinical record revealed there were no physician orders for oxygen or the oxygen flow rate, from admission through (MONTH) 29, (YEAR). According to the clinical record, the resident had an unplanned discharge on (MONTH) 30, (YEAR) to the hospital. The documentation also included the resident returned to the facility on (MONTH) 2, (YEAR). Review of the skilled evaluation notes dated (MONTH) 2, (YEAR) revealed documentation that the resident received 2 liters of oxygen via nasal cannula. A note dated (MONTH) 3, (YEAR) included the resident received 3 liters of oxygen via nasal cannula. Continued review of the skilled evaluation notes revealed the following entries: -September 4, (YEAR): The resident received 2 liters of oxygen via nasal cannula. -September 6, (YEAR): The resident had a non-productive cough and received 3 liters of oxygen via nasal cannula. -September 7 and 8, (YEAR): The resident received oxygen via nasal cannula. -September 9, (YEAR): The resident had a non-productive cough and received 2 liters of oxygen via nasal cannula. Further review of the clinical record revealed there was no physician's order for oxygen from the time of readmission through (MONTH) 10, (YEAR). An interview was conducted on (MONTH) 10, (YEAR) at 10:33 a.m. with resident #88. During the interview, the resident was observed to be receiving 2 liters of oxygen via nasal cannula. At this time, the resident stated that she receives 3 liters of oxygen. An observation of the resident was conducted on (MONTH) 11, (YEAR) at 10:03 a.m. The resident was observed to be receiving 2 liters of oxygen via nasal cannula. Another interview was conducted on (MONTH) 11, (YEAR) at 12:03 p.m. with resident #88. The resident stated that she has been receiving continuous oxygen since (MONTH) (YEAR). An interview was conducted on (MONTH) 11, (YEAR) at 12:12 p.m. with a RN (Registered Nurse/staff #118). Staff #118 stated that resident #88 was supposed to receive 2 liters of oxygen and the resident has been receiving that amount of oxygen for quite a while. The nurse reviewed the clinical record and stated the resident did not have a physician's order for oxygen. An interview was conducted on (MONTH) 11, (YEAR) with the Director of Nursing (staff #167). Staff #167 said a physician's order is needed for oxygen and the administration of oxygen is supposed to be documented on the MAR. Staff #167 reviewed the clinical record for resident #88 and was unable to locate a physician's order for oxygen. Review of the Oxygen policy revealed it is the policy of this facility to maintain adequate oxygenation to the respiratory compromised resident. A physician's order (for oxygen) must be obtained and verified, and written orders for oxygen therapy are to include the mode of delivery, liter flow rate and the duration of therapy. The policy also included that oxygen administration is to be documented on the treatment record every shift.",2020-09-01
809,RIDGECREST HEALTHCARE,35125,16640 NORTH 38TH STREET,PHOENIX,AZ,85032,2017-09-22,221,D,1,0,PJO011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, facility documentation and staff interviews, the facility failed to ensure that one resident (#90) was free from physical restraints. Findings include: Resident #90 was admitted to the facility on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 2, (YEAR), revealed the resident was rarely or never understood and had short and long term memory problems. The resident was also coded as having trouble falling asleep or staying asleep. The resident's behavioral care plan indicated the resident would purposefully put herself on the floor. The interventions included that whenever the resident does this, the nurse should check her for any injuries and document it in the behavior notes. Review of a fall care plan revealed the resident was at risk for falls related to dementia. Interventions included to have a floor mat next to the bed, keep the bed locked and in the low position, and to have a chair/bed alarm for safety each shift. The nursing notes from (MONTH) through (MONTH) 22, (YEAR) revealed that on several occasions, the resident had fallen from her bed to the floor. Review of a facility's investigation dated (MONTH) 26, (YEAR) revealed an allegation that a nurse (staff #232) had been barricading resident #90 in her bed during the night shift, by placing furniture and other items next to her bed to keep her from rising. According to the investigation, a family member reported that the resident had said that a nurse had placed furniture up against her bed at night. However, the family member did not believe the resident, because she had dementia and had delusions at times. The report also included a statement from a Certified Nursing Assistant (CNA/staff #68) which included that she worked with a nurse (staff #232) and witnessed her put a dresser, a nightstand and a wheelchair around the resident's bed. Staff #68 reported that she had seen this last on (MONTH) 21, (YEAR). She reported that the resident was screaming, so she went to check on her and a dresser, a wheelchair and a mechanical lift were all around the resident's bed. She said she put all of these items back. Staff #68 said that staff #232 had told her that she does this so she doesn't have to complete incident reports. Staff #68 indicated that she had reported this to various staff including the staffing coordinator, the unit manager and the Director of Nursing (DON), and nothing had changed. The report also included a statement from another CNA (staff #62) which included that she had witnessed furniture and floor mats against the resident's bed. She said staff #232 would take the floor mat and push it up to the side of the resident's bed and then put the dresser against it so the resident wouldn't put herself on the floor. She reported that she had last seen this approximately two weeks ago. Staff #62 reported that staff #232 told her that doing this keeps the resident safe. Per the statement by staff #62, she had reported it to the staffing coordinator and the DON. The report further included a statement by the nurse (Licensed Practical Nurse/LPN/staff #232), who was named in the allegation. She indicated that she did not put a mat against the bed, but said she had placed a wheelchair next to the resident's bed, but was informed that she should not do this, so she did not do it again. Per the report, a statement by the unit manager (staff #227) included that he had been told about this issue on two separate occasions, but the first time, a staff member told him that it used to happen and that it had been taken care of. The second time he was told about it, the staff member indicated that it had happened a long time ago. He told both staff members that if it was witnessed again, to let him know and he would address it. Further review of the investigation revealed that staff #232 was termed, as the allegation was substantiated. An interview was conducted at 9:10 a.m. on (MONTH) 20, (YEAR), with a CNA (staff #62). She stated that she had witnessed the nurse barricading the resident into bed on two occasions. She said the time frame between the two incidents was several months. She stated the first time the nurse placed a wheelchair next to the resident's bed on top of a floor mat. She said the second time there was a dresser next to the resident's bed and the mat was wedged between the dresser and the bed. Staff #62 stated that after the first time, she reported it to the staffing coordinator and thought something had been done to fix the issue, because she did not see it again for some time. A telephonic interview was attempted with staff #232 on (MONTH) 20, (YEAR), but she was unable to be reached. An interview was conducted with the unit manager (staff #227) at 9:00 a.m. on (MONTH) 21, (YEAR). He stated that he had been told that he should have reported this situation. He said two staff members told him about the nurse barricading the resident, but it was mentioned that it was a past problem and was not currently going on. He said that he told the nurses that if they saw it happen again to tell him and he would address it right away, as it would not be tolerated. He said that he never witnessed the situation and that if he had, he would have addressed it and would have taken it seriously. In an interview with the interim DON (staff #228) at 1:35 p.m. on (MONTH) 20, (YEAR), she said that she was not the interim DON at that time. She said that using items in the room to keep the resident in bed was not appropriate. An interview was conducted with another CNA (staff #68) at 8:40 a.m. on (MONTH) 22, (YEAR). She stated that staff #232 would put multiple items up against the resident's bed every night to keep her in bed. She said that she had reported this to several staff, including the DON at the time and her unit manager. She said the resident's bed was up against the wall and the nurse would put items all the way from the head of the bed to the foot of the bed, so the resident could not get out. She stated that this included the nightstand, other furniture, and even the television set at times. She said that she told staff #232 that she could not do this and told her to stop. She said the nurse did stop for a while, but started doing it again. She also said that the floor mat would be used as a way to keep the resident in bed, as the nurse would prop it against the bed with furniture. She stated she did notice that the resident was more agitated when this nurse was around and would be more aggressive when she was barricaded in her bed, and it made the resident want to get out of her bed even more. She said when she noticed this, she would remove the items and put them back and the resident would calm down. In an interview with the administrator (staff #13) at 10:50 a.m. on (MONTH) 21, (YEAR), she stated that the facility does not have a policy regarding physical restraints, as the facility does not use physical restraints on residents.",2020-09-01
810,RIDGECREST HEALTHCARE,35125,16640 NORTH 38TH STREET,PHOENIX,AZ,85032,2017-09-22,224,D,1,0,PJO011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews and policy review, the facility failed to prevent resident to resident altercations between two residents (#26 and #56), with known histories of aggressive behaviors. Findings include: -Resident #56 was admitted to the facility on (MONTH) 5, (YEAR), with [DIAGNOSES REDACTED]. Review of a quarterly MDS (Minimum Data Set) assessment dated (MONTH) 10, (YEAR), revealed resident #56 had a BIMS (brief interview for mental status) score of 6, indicating severe cognitive impairment. The MDS included that the resident required supervision and setup help with ADLs (activities of daily living). Per the MDS, the resident did not exhibit any behaviors. Review of the physician's orders [REDACTED]. The orders also included to monitor for the following behaviors: restlessness, agitation, threatening, combativeness, intrusive behaviors, self-isolation, delusions and verbal and physical aggression every shift. Review of a physician's progress note dated (MONTH) 16, (YEAR) revealed the resident had a history of [REDACTED]. The note included the resident had been more agitated recently and could be very aggressive during his manic phase. A physician's progress note dated (MONTH) 23, (YEAR) included that per staff, the resident had been experiencing increased behaviors of agitation, combativeness and refusing care. The note included that during this visit, the resident was severely agitated, was verbally and physically abusive and the assessment was unable to be completed. Review of a nursing noted dated (MONTH) 24, (YEAR) revealed the resident continues with increased verbal aggression towards staff and peers. The note further included that the resident attempted to hit/kick staff. Review of a nursing note dated (MONTH) 25, (YEAR) revealed resident #56 was standing at the dining room table across from resident #26 who was sitting at the table, when all of a sudden resident #26 reached across the table and punched resident #56 in the face. The residents were immediately separated. Resident #26 was placed on 15 minute checks and resident #56 was placed on 1:1 supervision, because he was seeking out resident #26 after the incident. A physician's orders [REDACTED].#56 to be on 1:1 observation. This order was eventually discontinued, but no discontinuation date was documented. Review of the comprehensive care plan dated (MONTH) 25, (YEAR) revealed resident #56 was the recipient of a punch in the face from another resident. The goal was that resident #56 will demonstrate effective coping skills. Interventions included analyzing key times, places, circumstances and triggers, and what de-escalates behaviors. Additional interventions included to assess and anticipate the resident's needs, and when the resident becomes agitated, intervene before agitation escalates. A quarterly MDS assessment dated (MONTH) 6, (YEAR) included the resident had a BIMS score of 11, which indicated the resident had moderate cognitive impairment. Per the MDS, the resident did not exhibit any verbal or physical behaviors. Review of a nursing note dated (MONTH) 11, (YEAR) revealed resident #56 was sitting at the table watching television, when resident #26 came up and hit him in the back of the head, with a closed fist. Per the note, the incident was unprovoked and resident #56 stated I was just sitting here watching TV and he hit me right here (rubbing the back of his head). The residents were separated, vital signs were taken, neurological checks were initiated and the physician's were notified. Review of the behavioral care plan dated (MONTH) 27, (YEAR) revealed resident #56 had behaviors of restless pacing, psychotic thinking, verbal and physical aggression, and refusing medications. The goal was that the resident would be able to attend and act appropriate in a day program, without incidents of harm to self or others. The interventions included visitation with family in the day room and brief verbal warnings followed by returning the resident to his room, when displaying verbal and physical aggression. According to the MARs (medication administration record) and TARs (treatment administration records) from (MONTH) (YEAR) through (MONTH) (YEAR), the resident was being monitored for behaviors every shift. The documentation showed that the resident exhibited behavior episodes multiple times each week. -Resident #26 was admitted to the facility on (MONTH) 21, (YEAR), with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. The physician's orders [REDACTED]. Review of a behavior note dated (MONTH) 25, (YEAR) revealed resident #26 was sitting at the dining table in the dayroom across from resident #56 who was standing up, when all of a sudden resident #26 reached across the table and punched resident #56 in the face. The residents were immediately separated and resident #26 was placed on 15 minute checks and resident #56 was put on 1:1, because he was seeking out resident #26 after the incident. Review of a behavioral care plan revealed resident #26 initiated an altercation with another resident (resident #56) and punched him in the face. The goal was that the resident would demonstrate effective coping skills. Interventions included for 15 minute checks as needed, monitor/document/report to physician if the resident becomes a danger to self and others, intervene before agitation escalates and engage calmly in conversation. A quarterly MDS assessment dated (MONTH) 14, (YEAR) included the resident had a BIMS score of 10, which indicated moderate cognitive impairment. Per the MDS, the resident did not exhibit any verbal or physical behaviors. Review of a behavior note dated (MONTH) 11, (YEAR) revealed resident #26 was playing bingo in the dayroom and won a piece of candy. After the resident was given the candy, he got up from his chair and started walking to his room, when he suddenly hit resident #56 in the back of the head, with a closed fist. The note included that resident #26 hit resident #56, because he had taken his candy. Review of the facility's investigation regarding the incident on (MONTH) 11, (YEAR) revealed statements from multiple staff members, who stated that resident #56 was watching TV and resident #26 stood up and punched the resident in the back of his head. The residents were separated. The report included that resident #26 stated that he hit resident #56, because he stole his candy. According to a physician's progress note dated (MONTH) 20, (YEAR), the resident's aggression on (MONTH) 11 with resident #56 was unpredictable, with no cues and no identifiable trigger at the time. The note also included that this was an isolated incident, but carries a risk due to the resident's unpredictability and lack of cues. A physician's progress note dated (MONTH) 27, (YEAR) revealed resident #26 was more delusional and had busted a window with his night stand. The room was cleared of furniture and any belongings he could use as weapons, and he was placed on 1:1 observation. Review of the (MONTH) through (MONTH) (YEAR) MAR/TARs revealed the resident exhibited behaviors of exit seeking, hallucinations and verbal and physical aggression, multiple times on a weekly basis. An interview was conducted with the Director of Nursing (DON/staff #228) on (MONTH) 21, (YEAR) at 8:51 a.m. She stated both incidents were unprovoked and they were completely random. She stated there had not been any other incidents with either resident outside of the two incidents with each other, and they were not preventable. An interview was conducted with a licensed practical nurse (LPN/staff #187) on (MONTH) 21, (YEAR) at 12:19 p.m. She stated that with resident-to-resident incidents, staff immediately separate the residents, medications are given if needed, and residents are put on 15 minute checks. She stated she did not know that these residents had any history of striking out at other residents, or had any history of physical aggression with each other. An interview was conducted with a certified nursing assistant (CNA/staff #32) on (MONTH) 21, (YEAR) at 12:24 p.m. He stated that resident #26 hit resident #56 on (MONTH) 11. He stated that he knows resident #56 has been up and down with his moods, and started being more confrontational for awhile. He stated if staff see resident #56 being confrontational or verbally aggressive, they will do things to distract him to calm him down, such as coloring and removing him from the situation. He stated that he was unaware of resident #26's aggressive behaviors towards other residents and of any aggressive history between these two residents. He stated it was a random incident. An interview was conducted with the behavioral unit manager (LPN/staff #148) on (MONTH) 21, (YEAR) at 12:31 p.m. He stated the incident (from (MONTH) 11) between resident #26 and #56 was an isolated incident and there had been no further incidents between them. Staff #148 stated that neither resident had a history of [REDACTED]. He stated it was an isolated incident and was not necessarily preventable. Another interview was conducted with staff #228 on (MONTH) 21, (YEAR) at 1:28 p.m. She stated that for residents with a known history of striking other residents, staff are expected to follow the facility process, which is to separate residents, assess for injuries, notify administrator and DON, and start an investigation. She stated this unit has specific behavioral care plans and more staff, and that these residents are more supervised to prevent issues like this from happening again. She stated behavioral rounds occur on a weekly basis, and staff conduct assessments to determine if a resident has had behaviors, and updates the care plans. She stated there was nothing that could be done to prevent the most recent occurrence between resident #26 and resident #56. She stated staff supervise these residents and they are kept at arm's length. Staff #228 stated this was an isolated incident between these two residents, with no incidents with other residents for either person since then. She stated the staff ensured that the residents were more separated after the first incident, but this incident could not have been prevented, because there were no triggers. However, the two residents had a previous altercation on (MONTH) 25, (YEAR), when resident #26 punched resident #56 in the face. Review of the Residents With Out of Control Behaviors policy revealed that all staff should receive didactic and on-the-job training to ensure knowledge and ability to anticipate and intervene with physically aggressive residents. The policy stated that staff should pay extra attention to increased restlessness, heightened irritability and tense posturing. The resident's behavior plan will take into consideration the knowledge of behaviors, behavioral approaches, supervision/monitoring guidelines, and activity/area restrictions. The policy further revealed the team reviews the resident's behavior plan as soon as possible after the physically aggressive behavior occurs, with the unit clinical director. Review of the abuse prevention and prohibition program policy revealed that abuse and neglect will not be tolerated in the facility at any time. The policy included to take proactive measures to prevent the occurrence of alleged abuse to any resident and that residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents or other individuals. The policy further included that supervisors shall immediately intervene, correct, and report identified situations where abuse and neglect is at risk for occurring. The facility conducts an ongoing review and analysis of abuse incidents and implements corrective actions to prevent future occurrences. The policy also included that resident assessments and care planning are performed to monitor resident needs and address behaviors that may lead to conflict.",2020-09-01
811,RIDGECREST HEALTHCARE,35125,16640 NORTH 38TH STREET,PHOENIX,AZ,85032,2017-09-22,241,D,1,0,PJO011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff and resident interviews, facility documentation and policy and procedures, the facility failed to ensure one resident (#161) was treated in a dignified manner. Findings include: Resident #161 was admitted to the facility on (MONTH) 18, (YEAR), with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 27, (YEAR) revealed the resident had a Basic Interview for Mental Status score of 5, which indicated the resident had severe cognitive impairment. The MDS also included the resident required supervision with activities of daily living. Review of the clinical record revealed that from (MONTH) (YEAR) through (MONTH) of (YEAR), resident #161 had multiple episodes of being verbally and physically abusive towards staff and other residents. The documentation included the resident would become easily agitated, argumentative and angry, and had attempted to hit other residents and staff. Review of a behavioral care plan revealed the resident had behavioral symptoms of disruptive yelling, intrusive wandering into peers rooms, physical abuse and verbal abuse by cursing and threats of harm and aggressive posturing. Interventions included the following: approach and reproach when upset; monitor interactions with peers; remain aware of the resident's whereabouts at all times; and use a calm and respectful tone and language during interactions. According to a facility investigation, a licensed practical nurse (LPN/staff #225) reported that she heard the resident ask a certified nursing assistant (CNA/staff #226) a question in the day room. Per the report, staff #226 replied to the resident and said, I don't want to hear your mouth, just shut up, I am not in the mood for your mouth today. The investigation included an interview with staff #226, who stated that the resident was cussing at him in Spanish and he became upset and told him to shut up. Resident #161 was interviewed on (MONTH) 19, (YEAR) at 10:00 a.m., and stated that he did not remember the incident. An interview was conducted with staff #225 on (MONTH) 20, (YEAR) at 2:15 p.m. Staff #225 stated that she heard the resident ask staff #226 a question and staff #226 told the resident, I don't have time for this . An interview was conducted with the Director of Nursing (DON/staff #109) on (MONTH) 21, (YEAR) at 9:15 p.m. The DON stated that if there is an incident of an employee not treating a resident with dignity, they do an investigation and other staff and residents would be interviewed who had worked with the identified staff member, in order to determine if there were any other incidents of residents not being treated with dignity. A phone interview was completed on (MONTH) 21, (YEAR) at 11:30 a.m. with staff #226. He denied that there was an incident between himself and the resident. He stated the incident was between himself and another employee. However, per the facility's investigation, staff #226 had stated that he became upset with the resident and told him to shut up. Review of the dignity policy and procedure revealed that all employees shall treat residents, families, visitors and fell ow workers with kindness, respect and dignity.",2020-09-01
812,RIDGECREST HEALTHCARE,35125,16640 NORTH 38TH STREET,PHOENIX,AZ,85032,2017-09-22,314,G,1,0,PJO011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on closed clinical record review, staff interviews and policy review, the facility failed to ensure the necessary treatment and services were provided to one resident (#44) to prevent pressure ulcers from developing. Findings include: Resident #44 was admitted to the facility on (MONTH) 27, 2013, with a most recent readmitted (MONTH) 23, (YEAR). [DIAGNOSES REDACTED]. A care plan included the resident was at risk for pressure ulcers related to decreased mobility, incontinence at times and diabetes mellitus. Interventions included to monitor skin during daily care and notify physician of changes. Another care plan revealed the resident was incontinent of bowel and bladder and was at risk for skin breakdown. Interventions included to assess skin condition during showers and ADLs (Activities of Daily Living), report changes or redness to nurse/physician and skin treatments as ordered. Review of a quarterly MDS (Minimum Data Set) assessment dated (MONTH) 14, (YEAR) indicated the resident was cognitively intact. The MDS also included that the resident was at risk of developing pressure ulcers, but did not have any current unhealed pressure ulcers. A Braden Scale for Predicting Pressure Sore Risk was conducted on (MONTH) 14, (YEAR), which indicated the resident was at low risk for developing a pressure ulcer. Review of the CNA (certified nursing assistant) shower documentation dated (MONTH) 10, (YEAR), revealed a body diagram in which the buttock was circled and a note stated slight redness. A weekly skin check dated (MONTH) 27, (YEAR) also included the resident had redness to the coccyx. However, review of the clinical record revealed no documentation that the physician was notified, nor that any treatments were provided and there was no documentation of any measurements of the redden area, from (MONTH) 10 through (MONTH) 27. Regarding the right ischial wound: A wound assessment dated (MONTH) 15, (YEAR) included the resident had an unstageable pressure ulcer to the right gluteal fold which measured 4.2 x 4.5 cm, with an immeasurable depth. Further documentation included that the specific location of the wound was on the right ischial tuberosity. The wound was described as having 50% red granulation tissue, 50% dark purple with defined edges and there was no undermining, tunneling, odor, or exudate noted. A physician's orders [REDACTED]. According to an IDT (interdisciplinary team) progress note dated (MONTH) 18, (YEAR), the resident had a new right ischial tuberosity DTI (deep tissue injury) pressure related, which was noted on (MONTH) 15, (YEAR). The next assessment of the right ischial wound was completed on (MONTH) 31, (YEAR), which was 16 days after the previous assessment. The documentation included that the right gluteal fold (right ischial tuberosity) wound was an unstageable pressure ulcer which measured 3.5 x 4.0 cm, with immeasurable depth and now had undermining from 8 to 4 o' clock at 1 cm. The wound base was described as 90% yellow adherent slough and 10% pink [MEDICATION NAME] tissue, with a small amount of purulent exudate. A wound assessment dated (MONTH) 5, (YEAR) included the right ischial wound measured 4.0 x 4.0 cm with 2.0 cm depth, and was a stage 3 pressure ulcer, with no muscle or bone exposed. However, the documentation also included that the wound bed was covered with 100% slough. A care plan revised on (MONTH) 6, (YEAR) revealed the resident had actual skin impairment to the right ischium. Interventions included to follow facility protocols for treatment, monitor and document location, size, and treatment of [REDACTED]. to the physician and treatment plan as ordered. A wound assessment dated (MONTH) 8, (YEAR) included the pressure ulcer measured 3.0 x 3.0 cm with undetermined depth and tunneling at 2 o' clock at 4.5 cm. The wound bed was described as having slough and pink/red granulation tissue, with a moderate amount of serosanguineous drainage, with a mild odor present. A wound assessment dated (MONTH) 15, (YEAR) included the wound measured 3.0 x 3.0 cm with undetermined depth and tunneling at 2 o' clock at 3.5 cm. The wound bed was described as having slough and pink/red granulation tissue, with a small amount of serous drainage and no odor. A physician's wound note dated (MONTH) 19, (YEAR) revealed the wound measured 3.0 x 3.0 cm with a necrotic base and no tunneling. The note included that the slough was removed from the ulcer base with forceps. The next wound assessment was completed 14 days later on (MONTH) 3, (YEAR). A physician's wound note included the right ischial ulcer measured 2.5 x 3.0 x 4.0 cm and had no necrotic tissue, no bone exposed and no slough. A wound assessment dated (MONTH) 7, (YEAR) described the wound as a stage 4 pressure ulcer to the right ischium measuring 2.0 x 2.0 x 4 cm, with a small amount of serosanguineous drainage and no odor, and the surrounding tissue was indurated. A wound assessment dated (MONTH) 14, (YEAR), described the wound as a stage 4 pressure ulcer to the right ischium measuring 3.0 x 3.0 x 4.0 cm, with a small amount of serosanguineous drainage with no odor, and the surrounding tissue was normal and the edges were distinct. A physician's wound note dated (MONTH) 17, (YEAR) describes the wound as a stage 4 measuring 3.0 x 3.0 x 4.0 cm, with no necrotic tissue or bone exposed and granular tissue present. Review of a nurse's progress note dated (MONTH) 17, (YEAR) revealed the wound physician assessed the resident's right ischial wound and a new treatment plan was received for a wound vac. physician's orders [REDACTED]. A wound assessment dated (MONTH) 22, (YEAR) included the stage 4 pressure ulcer to the right ischium measured 2.0 x 2.0 x 3.5 cm, with a small amount of serous drainage and no odor, and the surrounding tissue was normal and the edges were distinct. The note also included that the treatment had been changed to a wound vac three times weekly. A wound assessment dated (MONTH) 28, (YEAR), described the wound as a stage 4 pressure ulcer to the right ischium measuring 2.0 x 2.0 x 3.5 cm, with a small amount of serosanguineous drainage and no odor, and the surrounding tissue was normal and the edges were distinct. Review of the TAR (Treatment Administration Record) for (MONTH) through (MONTH) (YEAR) revealed changes in wound treatments. Further review revealed that there were several treatments where the nurse had documented a 9 in the space to indicate if the treatment was done. According to the TAR, a 9 indicated to see nurse notes. Review of the corresponding nurses notes from (MONTH) through (MONTH) (YEAR) revealed multiple notations that the wound treatments were to be done by the wound nurse. However, there was no corresponding documentation by the wound nurse that the treatments were done as ordered. A wound assessment dated (MONTH) 4, (YEAR), described the wound as a stage 4 pressure ulcer to the right ischium measuring 1.5 x 1.5 x 3.5 cm with a small amount of serosanguineous drainage and no odor and the surrounding tissue was normal and the edges were distinct. A physician's wound note dated (MONTH) 7, (YEAR) described the wound as a stage 4 which measured 1.5 x 1.5 x 3.5 cm, with poor, unhealthy tissue and exposed sharp bone. A physician's wound note dated (MONTH) 14, (YEAR) included the right ischium wound was a stage 4 and measured 1.5 x 1.5 x 3.5 cm, with more tunneling and undermining and exposed bone. The note further included that the resident may have possible osteo[DIAGNOSES REDACTED] and may need debridement. Review of a wound note by the wound nurse dated (MONTH) 17, (YEAR) at 8:56 a.m. revealed the wound had frequent episodes of bleeding. New orders were received for a change in wound treatment. The note also included that the wound physician will inform the facility when the resident can be admitted to the hospital for wound intervention. Another nurses noted dated (MONTH) 17, (YEAR) at 9:29 a.m. included that the IDT team met to discuss the resident's stage 4 pressure ulcer and that the treatment plan was changed by the wound physician, as the resident needs to be evaluated at the hospital for surgical debridement. Awaiting order to transfer the resident to the hospital. A nurse's note dated (MONTH) 17, (YEAR) at 9:20 p.m. included to send the resident out to the hospital for wound debridement. Per the clinical record documentation, the resident was discharged to the hospital on (MONTH) 17, (YEAR) and did not return to the facility. Regarding the left ischial pressure injury: A weekly skin check dated (MONTH) 28, (YEAR) described an area on the left inner buttock as moisture associated skin damage (MASD), which measured 0.5 x 0.2 cm and described another area as MASD to the left buttock, which measured 0.5 x 0.3 cm. There was no further description of these areas. A weekly skin check dated (MONTH) 3, (YEAR) indicated there were two open areas to the left buttock and that follow-up was needed. Shower documentation for (MONTH) 7, (YEAR) included a body diagram with a circle to the buttocks area with a note stating slight redness, open area. A weekly skin check dated (MONTH) 10, (YEAR), indicated there was an area of irregularity on the resident's left inner buttock, and another area described as moisture related also on the left buttock. The assessment indicated that follow up was needed. Shower documentation for (MONTH) 12, (YEAR) again indicated that the resident had slight redness and an open area on the buttocks. Further review of the clinical record revealed that from (MONTH) 28 through (MONTH) 13, (YEAR), there was no documentation that the physician was notified or that any treatment was provided to the buttocks from (MONTH) 28 through (MONTH) 13. Also, there were no measurements of the area since (MONTH) 28. A physician's orders [REDACTED]. Continued review of the clinical record revealed that from (MONTH) 15 through (MONTH) 24, (YEAR), there was no evidence that the area on the resident's left buttock was assessed or measured. A weekly skin check dated (MONTH) 24, (YEAR) indicated there was an area of irregularity on the resident's left inner buttock, and another area described as moisture related also on the left buttock. The assessment indicated that follow up was needed. However, there was no clinical record documentation of any follow up at this time. A wound assessment was completed on (MONTH) 27, (YEAR) and included that the resident now had a stage 3 pressure wound to the left gluteal fold, which measured 1.9 x 1.9 x 0.2 cm. The wound was described as circular in shape, with no undermining or tunneling, edges were defined and attached with 100% red granulation tissue. No exudate or odor was noted. A physician's orders [REDACTED]. In a dietary/nutritional progress note dated (MONTH) 27, (YEAR), the Registered Dietitian (RD/staff #234) recommended the resident receive 4 oz of Med Pass (a nutritional supplement) twice a day to provide extra calories and protein. However, review of the clinical record revealed an order for [REDACTED]. A wound physician's consult note dated (MONTH) 1, (YEAR) included the resident had a stage 3 left ischial pressure injury, which was pressure and moisture related. Per the wound assessment dated (MONTH) 1, (YEAR), the stage 3 pressure wound to left gluteal fold measured 1.9 x 1.9 x 0.2 cm. Additional documentation indicated that the specific location of the wound was the left ischial tuberosity. There was no undermining or tunneling noted, the wound edges were defined and attached and the wound base was 100% red granulation tissue. No exudate or odor noted. A progress note dated (MONTH) 8, (YEAR) included the left gluteal fold injury area appeared larger and that the wound nurse was notified. Another dietary/nutritional progress note dated (MONTH) 11, (YEAR) again included to add 4 oz Med Pass twice a day for additional calories and protein. The next wound assessment was not completed until (MONTH) 15, (YEAR). Per the assessment, the stage 3 left ishcial tuberosity pressure ulcer measured 1.5 x 2.0 x 0.2 cm, and had 80% red granulation tissue and 20% yellow adherent slough. No exudate, odor, undermining or tunneling were present. A physician's orders [REDACTED]. The next assessment of the left ischial tuberosity wound was 16 days later on (MONTH) 31, (YEAR). The wound assessment included the stage 3 pressure ulcer measured 0.9 x 1.0 x 0.2 cm and had 100% red granulation tissue with no exudate, odor, undermining, or tunneling. Review of the TAR for (MONTH) (YEAR) revealed changes in wound treatments. Further review revealed that there were several treatments where the nurse had documented a 9 in the space to indicate if the treatment was done. According to the TAR, a 9 indicated to see nurse notes. Review of the corresponding nurses notes in (MONTH) (YEAR) revealed a notation that the wound treatments were to be done by the wound nurse. However, there was no corresponding documentation by the wound nurse that the treatments were done as ordered. Review of the physician wound progress notes dated (MONTH) 5, (YEAR) revealed the left ischial wound measured 0.9 x 1.0 x 0.2. The note indicated that the ulcer was almost closed. The wound documentation dated (MONTH) 6, (YEAR), indicated that the left ischium wound had revolved. Regarding the right inner buttock pressure ulcer: A weekly skin check dated (MONTH) 28, (YEAR) included the resident had moisture associated skin damage on the right inner buttock, which measured 1.0 x 0.3 cm. A weekly skin check dated (MONTH) 3, (YEAR) indicated there was a small open area on the right buttock and that follow-up was needed. The documentation did not include a description of the wound bed. Review of the shower documentation for (MONTH) 7, (YEAR) revealed a body diagram which had a circled area on the buttocks, with a note stating slight redness, open area. A weekly skin check dated (MONTH) 10, (YEAR) indicated there was an area of irregularity on the resident's right inner buttock. The assessment indicated that follow up was needed. Shower documentation for (MONTH) 12, (YEAR) again documented the buttocks had slight redness, with an open area. Further review of the clinical record revealed there was no documentation the physician was notified or that treatments were provided from (MONTH) 28 through (MONTH) 13, (YEAR). A physician's orders [REDACTED]. A weekly skin check dated (MONTH) 24, (YEAR), indicated an area of irregularity on the resident's skin to the right inner buttock. There was no further description of the area. From (MONTH) 14 through (MONTH) 24, (YEAR), there was no clinical record documentation of any measurements of the redness to the right buttocks. Review of a wound assessment dated (MONTH) 25, (YEAR) revealed the resident had a stage 2 right inner buttock pressure ulcer, which measured 0.5 x 0.5 x 0.2 cm. The wound was described as having a circular shape, with no undermining or tunneling, edges were defined and attached with 100% red granulation tissue, no exudate or odor was noted. Additional notes indicated that the sacrum had blanchable dark redness. This was the first thorough assessment of the buttocks area since (MONTH) 10, when the buttocks was identified to have redness. A physician's orders [REDACTED]. A wound assessment dated (MONTH) 1, (YEAR) documented the resident had a stage 2 pressure ulcer to the right inner buttock, which measured 0.8 x 0.8 x 0.2 cm. The wound base was described as having 100% red granulation tissue and there was no undermining, tunneling, odor, or exudate noted. The note included that wound rounds were done with the physician. Between (MONTH) 1 and (MONTH) 15, (YEAR), there was no clinical record documentation that the right inner buttocks pressure ulcer had been thoroughly assessed. The next wound assessment was completed 14 days later on (MONTH) 15, (YEAR). The documentation included that the stage 2 pressure ulcer to the right inner buttock measured 1.0 x 1.0 x 0.1 cm and the wound base was 100% red granulation tissue and there was no undermining, tunneling, odor, or exudate noted. Further review of the clinical record revealed no documentation regarding the right inner buttock pressure ulcer until (MONTH) 2, (YEAR). A wound note dated (MONTH) 2, included that the right buttock stage 2 pressure injury had resolved. In an interview with the interim Director of Nursing (DON/staff #228) on (MONTH) 20, (YEAR) at 12:10 p.m., she stated it is the expectation that the physician be notified of any new open areas. An interview was conducted on (MONTH) 20, (YEAR) at 11:56 a.m., with the wound nurse (staff #50). Staff #50 stated that she does the wound assessments weekly, which includes a full assessment of the wound and measurements. Another interview was conducted on (MONTH) 21, (YEAR) at 10:56 a.m., with staff #50. She stated that if a CNA identifies a new area of concern during a skin check on a resident, they should immediately report it to the nurse on duty. Staff #50 stated that the nurse should then assess the wound and call the physician to determine the next step and that this should be documented in the progress notes. Staff #50 stated that when a new area of concern is identified, the physician has to be notified in order to have a treatment put into place right away. After reviewing the resident's clinical record, staff #50 stated that something should have been put into place right away when the open areas were identified. She stated that her process would have been to notify the resident's physician of the open area and then discuss a treatment plan and whether the resident should be seen by the wound physician as well. An interview with a CNA (certified nursing assistant/staff #22) was conducted on (MONTH) 22, (YEAR) at 9:12 a.m. She stated that she performs skin checks on residents during showers and if a new area is identified, it is written in the shower book, charted in the electronic charting system, and the nurse is notified right away. Another interview was conducted with the interim DON on (MONTH) 22, (YEAR) at 10:13 a.m. She stated that the nurse who identified the open areas on the weekly skin checks did not do what he should have done, as far as reporting to the physician regarding the newly identified open areas. During an interview with a Licensed Practical Nurse (LPN/staff #54) on (MONTH) 22, (YEAR) at 12:15 p.m., she stated that if a CNA were to report to her that a resident had a newly identified area of concern on the skin, she would contact the physician to inform them of the area and this would be charted. She also stated that if the wound nurse was available, she would inform her of the area and ask her to take a look at it. She also stated if she were to find a new area of concern on the resident's skin she would follow the same procedure. Review of a facility policy and procedure titled, Pressure Ulcer Risk Assessment included If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident, and often times become infected. The policy also included to Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. Immediately report any signs of a developing pressure ulcer to the supervisor. In a section regarding assessments the policy stated Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated .Staff will maintain a Stop and Watch while performing routine skin inspections daily or every other day as needed. Further, the policy described that a pressure ulcers onset for an at-risk resident can be within 2 to 6 hours, so need to be identified and interventions need to be implemented promptly in an attempt to prevent a pressure ulcer. Review of a facility policy titled, Medical Nutritional Therapy Recommendations included that recommendations which need nursing's or physicians attention will be forwarded to the nursing staff.",2020-09-01
813,RIDGECREST HEALTHCARE,35125,16640 NORTH 38TH STREET,PHOENIX,AZ,85032,2019-11-07,600,D,1,1,U9RV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, facility documentation, staff and resident interviews and policies and procedures, the facility failed to ensure that three out of five sampled residents (#16, #38 and #358) were free from physical abuse. The deficient practice could result in further abuse of residents. Findings include: -Resident #38 was admitted to the facility on (MONTH) 27, 2008, with [DIAGNOSES REDACTED]. Review of the clinical record revealed that resident #38 resided on a high acuity secured behavioral unit. A significant change Minimum Data Set (MDS) assessment dated (MONTH) 15, 2019, revealed a BIMS score of 11, which indicated the resident had moderate cognitive impairment. The MDS also included the resident was independent with transfers and required supervision with bed mobility, walking on the unit and eating. A behavioral care plan updated on (MONTH) 15, 2019 included the resident had disruptive behaviors related to [MEDICAL CONDITION], with a goal that the resident would have one or fewer episodes of disruptive behavior per week through the review period. De-escalation techniques included to eliminate environmental stressors and maintain a low stimulation environment in his room. An intervention included the resident had an assigned seat in the common room to watch television, as a television in his room had created behavioral disturbances in the past. A care plan revised on (MONTH) 20, 2019 included the resident had a history of [REDACTED]. A goal was that the resident would have no injury to self or others. Interventions were to report changes in behavior to the provider and to follow the behavioral care plan interventions. According to two nursing progress notes dated (MONTH) 22, 2019, resident #38 was hit on the back of the head by resident #16, and he denied pain or discomfort. Review of the nurse aide behavioral monitoring dated (MONTH) 22, 2019 revealed that resident #38 was in the day room watching TV, when resident #16 passed by and hit him on the back of the head. The note included that resident #38 responded by hitting resident #16 in the face, before the nurse aide could get to them. -Resident #16 was admitted to the facility on (MONTH) 15, 2006, with [DIAGNOSES REDACTED]. Review of the clinical record revealed that resident #16 resided on a high acuity secured behavioral unit. A care plan included the resident had the potential to demonstrate physical behaviors towards staff and peers related to poor impulse control, with a goal that the resident would demonstrate effective coping skills through the review date. Interventions included to anticipate the resident's needs and to keep the resident a significant distance from peers that were known to cause him to become upset. A quarterly MDS assessment dated (MONTH) 28, 2019, revealed a BIMS score of 12, which indicated the resident had moderate cognitive impairment. The MDS also included the resident required supervision with transfers, bed mobility, walking on the unit and eating. A behavioral care plan updated (MONTH) 13, 2019 included the resident had behaviors of aggression towards peers and staff, and would exhibit minimal behavior change or change in affect, prior to acting out. De-escalation techniques included eliminating environmental stressors and/or triggers to agitation and maintaining a homelike, low stimulation environment in his room. An intervention included to allow the resident the option to return to his room to de-escalate, if triggered in the common area by another resident. A nursing note dated (MONTH) 22, 2019 included that resident #16 was observed hitting resident #38 while walking by him in the day room. The resident denied pain or discomfort at that time. Review of the facility's investigative documentation dated (MONTH) 27, 2019 revealed that on (MONTH) 22, 2019 at approximately 6:35 p.m., resident #38 and #16 were in the day room when resident #38 told resident #16 to f*** off. Resident #16 then walked across the day room and hit resident #38 in the back of the head. Resident #38 stood up and the residents were face to face, when staff reached them. A witness statement written by a Certified Nursing Assistant (CNA/staff #52) was included in the report, which stated that both residents were saying, he hit me. The residents were separated, no injuries were noted, both residents were placed on fifteen minute checks and resident #16 received one-on-one supervision, while in the day room. The report included that the allegation of abuse against resident #16 was substantiated. An interview was conducted with a Licensed Practical Nurse (LPN/staff #19) on (MONTH) 5, 2019 at 2:27 p.m. She said she was the nurse on duty at the time of the incident. She said resident #16 and #38 were seated in the day room. She said resident #38 was doing some type of behavior that was irritating resident #16. She said resident #16 said something like stop and resident #38 said something like f*** off. She said resident #16 got up like he was walking to his room and as he passed resident #38, he hit him on the head. She said staff immediately helped resident #16 to his room, then they checked resident #38 and he was fine. She said the two residents stayed separated all evening. She said just as quickly as it started, it stopped and there had been no animosity between the residents the next day or since. An interview was conducted with a Certified Nursing Assistant (CNA/staff #52) on (MONTH) 6, 2019 at 8:41 a.m. She said she remembered that resident #16 hit resident #38, who then stood up and the residents were face to face. She said she was not sure if resident #38 hit resident #16 back. She said another staff member, CNA (staff #161) got between the residents and they were separated. An interview was conducted with resident #38 on (MONTH) 6, 2019 at 10:48 a.m. He said resident #16 was telling him to be quiet and he told resident #16 f*** off and shut your mouth. He said resident #16 then hit him on the head and he hit resident #16 in the face, while staff were getting between them. He said no other issues happened afterwards. An interview was conducted with the Director of Nursing (DON/staff #187) and the Administrator (staff #186) on (MONTH) 6, 2019 at 1:42 p.m. Staff #186 stated when an allegation of resident to resident abuse is made, staff should make sure the residents are separated and safe. She said the nurse should assess the residents involved. Staff #187 stated all residents involved and all staff on the unit would be interviewed. Staff #186 stated any other staff or residents who might be able to identify what caused the incident would also have an interview attempted. She said witness statements, observations and investigation findings would be reviewed as a team to determine the cause and how to prevent future occurrences. An interview was conducted with a CNA (staff #161) on (MONTH) 6, 2019 at 2:34 p.m. She stated that she was present when the incident occurred between the two residents. She stated resident #16 was agitated with resident #38 and he got up like he was leaving, so she started moving closer to the residents in anticipation of a problem. She said resident #16 hit resident #38 on the head and resident #38 immediately stood up. She said there was a chair between the two and resident #38 tried to hit resident #16 in the face by reaching over the chair. She said he made contact, but it was not very effective. She said by the time resident #38 got around the chair to resident #16, she and other staff had gotten between the residents. She said resident #16 went to his room after the incident. Regarding an incident between resident #16 and resident #358: -Resident #358 was admitted to the facility on (MONTH) 1, 2019, with [DIAGNOSES REDACTED]. Review of the admission MDS assessment dated (MONTH) 8, 2019, revealed a BIMS score of 14, which indicated the resident was cognitively intact. The MDS included the resident required supervision with bed mobility, transfers, walking on the unit and eating. A nursing progress note dated (MONTH) 23, 2019 revealed the resident was sitting at his assigned table for a meal, when a chair was thrown by resident #16 and grazed the resident's (#358) right arm. Per the note, resident #358 said I was just sitting here eating my dinner and the chair hit my pinky. No injuries were noted. -Review of the clinical record for resident #16 revealed a nursing progress note dated (MONTH) 23, 2019, which included that at approximately 5:30 p.m., resident #16 attempted to sit in a chair by resident #38 in the day room/dining room. Staff attempted to redirect resident #16 away from resident #38, but resident #16 walked over to his table, picked it up and threw it, and then picked up his chair and threw it. The chair grazed the arm of resident #358. Resident #16 then went to his room and slammed the door. Review of the facility's investigation report revealed that on (MONTH) 23, 2019 at approximately 5:30 p.m., resident #16 was walking across the day room to take a seat by the window and was redirected by staff back to his seat near the hallway. As he returned back to his seat, he picked up his tray table and threw it. Then he picked up his chair and threw it. He then went into his room and slammed the door. The chair grazed the arm of resident #358. Resident #358 said he was hit by the chair, but it did not hurt. Resident #16 was placed on one to one supervision in the day room and a medication review and labs were ordered. The report included that a CNA (staff #128) was in the dining room picking up dinner trays with other staff members, when the resident threw the table and chair. Review of the facility's daily staff assignment sheet dated (MONTH) 23, 2019, revealed that staff #128 was assigned as the one to one on the unit during the time of the incident. An interview was conducted with the Director of Nursing (DON/staff #187) and the Administrator (staff #186) on (MONTH) 6, 2019 at 1:42 p.m. Staff #186 stated that when an allegation of resident to resident abuse is made, staff should make sure the residents are separated and safe. She stated if a resident who is on one to one supervision became physically aggressive, she would expect interventions such as calling the crisis line and trying medication and behavior stabilization. She said she would also consider moving the resident to a different unit. She said the reason these were not considered for resident #16, such as moving to a different unit or calling the crisis line was because the resident's behavior was an outburst related to a trigger that was identified immediately and not directed toward another resident. An interview was conducted with a CNA (staff #128) on (MONTH) 6, 2019 at 2:38 p.m. She stated she remembered the incident in the dining room. She said resident #16 was not happy about something, then he knocked down his table and picked up his chair and threw it, sort of hitting the resident in front of him. She said after that the nurse and other staff intervened and escorted resident #16 back to his room. She said staff made sure the resident who had been hit was not hurt. Another interview was conducted with the Director of Nursing on (MONTH) 7, 2019 at 8:53 a.m. She said based on the daily staff assignment sheet and the CNA documentation from (MONTH) 23, 2019, staff #128 had been assigned as the one to one for resident #16 during the time of the incident. A follow up interview was conducted with staff #128 on (MONTH) 7, 2019 at 9:28 a.m. She stated she did not remember if resident #16 had one to one supervision at the time. She said she may have been assigned to provide one to one supervision, but she did not recall specifically. She said that when she walked away from the resident, that is when he began to throw things. She said she remembered this because she recalled thinking it was fortunate that she had moved away, because if not she would have been struck. A follow up interview was conducted with the Director of Nursing on (MONTH) 7, 2019 at 9:44 a.m. She stated her expectation is the staff member providing one to one supervision should keep the resident within eyesight at all times and to provide all needed care for the resident. She said the staff member providing one to one supervision should have no other assignments on the unit. She said if the resident was in the dining room, the one to one staff could help with cleaning up meal trays, as long as the resident was still within sight. She said it was not an expectation that the staff member should clean up trays, but it was just natural to want to help other staff. She said her overall expectation for a one to one staff member would be to keep the resident within eyesight and to monitor the resident's mood and behaviors. Review of the facility's Abuse Prohibition and Prevention policy revealed that each resident has the right to be free from abuse, including physical abuse and that residents must not be subjected to abuse by anyone, including other residents. The policy included that staff would be trained to prevent, identify and report allegations of abuse. The facility would ensure that all residents were protected during and after investigations, including separating residents and increasing supervision as needed. The policy further included that all incidents of alleged abuse would be promptly investigated and reported to the appropriate authorities.",2020-09-01
814,RIDGECREST HEALTHCARE,35125,16640 NORTH 38TH STREET,PHOENIX,AZ,85032,2019-11-07,607,D,1,1,U9RV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, facility documentation, staff interviews and policy review, the facility failed to implement their policy regarding investigating an allegation of abuse involving resident (#16) and resident (38). The sample size was one of five sampled residents. The deficient practice could result in further abuse investigations not being thoroughly completed, resulting in possible causes not being identified and corrective action taken. Findings include: -Resident #16 was admitted to the facility on (MONTH) 15, 2006, with [DIAGNOSES REDACTED]. -Resident #38 was admitted to the facility on (MONTH) 27, 2008, with [DIAGNOSES REDACTED]. Review of the facility's investigative report revealed that on (MONTH) 22, 2019 at approximately 6:35 p.m., resident #38 and #16 were in the day room when resident #38 told resident #16 to f*** off. Resident #16 walked across the day room and hit resident #38 in the back of the head. Resident #38 stood up, and the residents were face to face when staff reached them. A witness statement written by a Certified Nursing Assistant (CNA/staff #52) was included in the report, which stated that both residents were saying he hit me. However, further review of the investigative report revealed no evidence of an investigation into the allegation that resident #38 hit resident #16. Furthermore, the report did not include evidence of an interview or witness statement from one of the staff members who had witnessed the incident (staff #161). The report included that the residents were separated, no injuries were noted, both residents were placed on fifteen minute checks and resident #16 received one-on-one supervision while in the day room. The report further included that the allegation of abuse against resident #16 was substantiated. The report did not include findings regarding an allegation of abuse against resident #38. An interview was conducted with the Director of Nursing (DON/staff #187) and the Administrator (staff #186) on (MONTH) 6, 2019 at 1:42 p.m. Staff #187 stated that when investigating an allegation of abuse, all residents involved and all staff on the unit would be interviewed. Staff #186 stated that to ensure the investigation was thorough, any other staff or residents who might be able to identify what caused the incident would also have an interview attempted. She also said the investigation would consider the environment and try to look at all of the angles. She said witness statements, observations and investigation findings would be reviewed as a team to determine the cause, how to prevent future occurrences, and to ensure the investigation was thorough. Staff #187 said factors such as medication changes, diagnostic lab results and resident behavior cycles would be considered. Staff #186 said this incident occurred prior to her starting work at the facility, and she could only comment on the current process of investigating, which included interviewing all staff on the unit and a daily practice of reading behavior monitoring documentation from the previous day in the morning meetings. An interview was conducted with a CNA (staff #161) on (MONTH) 6, 2019 at 2:34 p.m. She stated she witnessed the incident and she remembered that resident #16 hit resident #38 and resident #38 hit resident #16 back. She said she did not remember writing a witness statement, but she gave her report to the nurse and the nurse had written things down. She said she also thought she had been called and interviewed regarding the incident. Review of the facility's abuse prohibition and prevention policy revealed that the investigation and report would include interviews with the alleged victim, the alleged perpetrator, with any witnesses to the alleged incident, with facility staff members who had contact with the residents during the period of the alleged incident, and a review of all events leading up to the alleged incident. Regarding reporting the allegations, the policy stated the facility would report allegations of abuse to the State Survey Agency even if there was no reasonable suspicion of the allegation.",2020-09-01
815,RIDGECREST HEALTHCARE,35125,16640 NORTH 38TH STREET,PHOENIX,AZ,85032,2019-11-07,610,D,1,1,U9RV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, facility documentation, staff and resident interviews and policy review, the facility failed to ensure that an allegation of abuse involving two residents (#16 and #38) was thoroughly investigated. The deficient practice could result in inaccurate findings and possible abuse not being identified. Findings include: -Resident #16 was admitted to the facility on (MONTH) 15, 2006, with [DIAGNOSES REDACTED]. Review of the clinical record revealed that resident #16 resided on a high acuity secured behavioral unit. A nursing note dated (MONTH) 22, 2019 revealed that resident #16 was observed hitting resident #38, while walking by him in the day room. Review of the nurse aide behavioral monitoring dated (MONTH) 22, 2019, revealed that resident #16 was going to his normal seat when another resident (#38) suddenly got in his face. The documentation included that resident #16 reported that resident (#38) hit him in the face. -Resident #38 was admitted to the facility on (MONTH) 27, 2008, with [DIAGNOSES REDACTED]. Review of the clinical record revealed that resident #38 resided on a high acuity secured behavioral unit. Review of two nursing progress notes dated (MONTH) 22, 2019, revealed that resident #38 was hit on the back of the head by another resident (#16) and he denied pain. Review of the nurse aide behavioral monitoring dated (MONTH) 22, 2019, revealed that resident #38 was in the day room watching TV, when another resident (#16) passed by and hit him on the back of the head. The note included that resident #38 responded by hitting resident #16 in the face before the nurse aide could get to them. Review of the facility's investigative report dated (MONTH) 27, 2019, revealed that on (MONTH) 22, 2019 at approximately 6:35 p.m., resident #38 and #16 were in the day room when resident #38 told resident #16 to f*** off. Resident #16 walked across the day room and hit resident #38 in the back of the head. Resident #38 stood up and the residents were face to face, when staff reached them. A witness statement written by a Certified Nursing Assistant (CNA/staff #52) was included in the report, which included that both residents were saying he hit me. However, further review of the investigative report revealed no evidence of an investigation into the allegation that resident #38 hit resident #16 on the back. Furthermore, the report did not include evidence of an interview or witness statement from one of the staff members who had witnessed the incident (staff #161), and the report did not include evidence that the nurse aide behavioral monitoring documentation had been reviewed, as part of the investigation. The report further revealed that the residents were separated, no injuries were noted, both residents were placed on fifteen minute checks and resident #16 received one-on-one supervision, while in the day room. Per the report, the allegation of abuse against resident #16 was substantiated. The report did not include findings regarding an allegation of abuse against resident #38. An interview was conducted with a Licensed Practical Nurse (LPN/staff #19) on (MONTH) 5, 2019 at 2:27 p.m. She said she was the nurse on duty at the time of the incident. She said residents #16 and #38 were seated in the day room. She said resident #38 was doing some type of behavior that was irritating resident #16. She said resident #16 said something like stop, and resident #38 said something like f*** off. She said resident #16 got up and as he passed resident #38, he hit him on the head. She said staff immediately assisted resident #16 to his room. She stated that resident #38 was checked and he was fine. An interview was conducted with a CNA (staff #52) on (MONTH) 6, 2019 at 8:41 a.m. She said that resident #16 hit resident #38, who then stood up and the residents got face to face. She said she was not sure if resident #38 hit resident #16 back. She said another staff member (staff #161) got between the residents and they were separated. An interview was conducted with resident #38 on (MONTH) 6, 2019 at 10:48 a.m. He said resident #16 was telling him to be quiet and he told resident #16 f*** off and shut your mouth. He said resident #16 hit him on the head and then he hit resident #16 on the face, while staff were getting between them. An interview was conducted with the Director of Nursing (DON/staff #187) and the Administrator (staff #186) on (MONTH) 6, 2019 at 1:42 p.m. Staff #187 stated that when investigating an allegation of abuse, all residents involved and all staff on the unit would be interviewed. Staff #186 stated that to ensure the investigation was thorough, any other staff or residents who might be able to identify what caused the incident would also have an interview attempted. She further said the investigation would consider the environment and try to look at all of the angles. She said witness statements, observations and investigation findings would be reviewed as a team to determine the cause, how to prevent future occurrences, and to ensure the investigation was thorough. Staff #187 said factors such as medication changes, diagnostic lab results and resident behavior cycles would be considered. Staff #186 said this incident occurred prior to her working at the facility, and she could only comment on the current process for investigating, which included interviewing all staff on the unit and a daily practice of reading behavior monitoring documentation from the previous day in the morning meetings. An interview was conducted with a CNA (staff #161) on (MONTH) 6, 2019 at 2:34 p.m. She stated she was present when the incident occurred between the two residents. She stated resident #16 was agitated with resident #38. She said resident #16 got up like he was leaving, so she started moving closer to the residents in anticipation of a problem. She said resident #16 then hit resident #38 on the head and resident #38 immediately stood up. She said there was a chair between the two, and resident #38 tried to hit resident #16 in the face by reaching over the chair. She said he made contact, but it was not very effective. She said by the time resident #38 got around the chair to resident #16, she and other staff had gotten between the residents. She said that she did not remember writing a witness statement, but she gave her report to the nurse and the nurse had written things down. She said she also thought she had been called and interviewed regarding the incident. Review of the facility's Abuse Prohibition and Prevention policy revealed that each resident has the right to be free from abuse, including from other residents. Regarding investigations of allegations of abuse, the policy included that the investigation and report would include interviews with the alleged victim, the alleged perpetrator, with any witnesses to the alleged incident, with facility staff members who had contact with the residents during the period of the alleged incident, and a review of all events leading up to the alleged incident. The policy included that all incidents of alleged abuse would be promptly investigated and reported to the appropriate authorities and that the investigation report would document the findings of the investigation.",2020-09-01
816,RIDGECREST HEALTHCARE,35125,16640 NORTH 38TH STREET,PHOENIX,AZ,85032,2019-11-07,641,D,0,1,U9RV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, review of the Resident Assessment Instrument (RAI) manual, and policy and procedures, the facility failed to ensure the Minimum Data Set (MDS) assessments for two residents (#55 and #408) accurately reflected their status. Findings include: -Resident #55 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of an annual MDS assessment dated [DATE], revealed that resident #55 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. The MDS also included that the resident does not smoke. However, review of the clinical record revealed smoking assessments dated 1/29/18, 7/29/18, 12/22/2018, 3/22/2019 and 6/22/2019, which included that resident #55 smokes. Resident #55 was unable to be interviewed, due to severe cognitive impairment. During an interview with the MDS Coordinator (staff #60) on 11/5/19 at 8:44 a.m., she stated the resident has never smoked. However, she reviewed the smoking assessments and confirmed that the MDS dated [DATE] was inaccurate, as the resident did smoke. -Resident #408 was admitted on (MONTH) 2, 2019 with [DIAGNOSES REDACTED]. A MDS Entry Tracking Record dated (MONTH) 2, 2019 included that resident #408 had been admitted from an acute hospital. A Skilled Evaluation dated (MONTH) 2, 2019 included that resident #408 was readmitted with multiple skin wounds, including an open area to the left ischium. A written Care Plan initiated on (MONTH) 3, 2019 included a focus that the resident has a DTI (Deep Tissue Injury) to the left ischium. The goals included that the DTI on the left ischium would show signs of healing and there would be no complications. A Skin/Wound Note dated (MONTH) 5, 2019 revealed the resident was a new admission and had been admitted with a DTI to the Left Ischium. A Discharge Return Anticipated MDS assessment dated (MONTH) 8, 2019, included the resident had been discharged to an acute hospital. The assessment included in Section M (Skin Conditions) that the resident was coded with a 0 for Unstageable-Deep tissue: suspected deep tissue injury in evolution. A MDS Entry Tracking Record dated (MONTH) 16, 2019 included that resident #408 had been readmitted from an acute hospital. An Assessment Summary dated (MONTH) 16, 2019 included the resident had been readmitted with multiple skin wounds, including an open area to the left ischium. A Skin/Wound Note dated (MONTH) 17, 2019 revealed the resident was readmitted and continued to have a healing open DTI to his left ischium. A Discharge Return Anticipated MDS assessment dated (MONTH) 20, 2019 included the resident had been discharged to an acute hospital. The assessment included in Section M (Skin Conditions) that the resident was coded with a 0 for Unstageable-Deep tissue: suspected deep tissue injury in evolution. During an interview conducted on (MONTH) 5, 2019 at 1:57 p.m. with the MDS Coordinator (staff #60), she stated that she collects information for the MDS assessments from multiple sources including nursing notes, wound assessments and skin wound notes. Staff #60 stated the DTI was mentioned in the nursing assessments and should have been included in the discharge MDS assessments on (MONTH) 8, and (MONTH) 20, 2019. Review of a policy titled, Resident Assessment Instrument (RAI/MDS) revealed the Resident Assessment instrument will be completed timely and accurately per Federal Guidelines, and will serve as a foundation for the comprehensive care planning process.",2020-09-01
817,RIDGECREST HEALTHCARE,35125,16640 NORTH 38TH STREET,PHOENIX,AZ,85032,2019-11-07,689,D,1,1,U9RV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, facility documentation and staff interviews, the facility failed to ensure that adequate supervision was provided to one resident (#16) with physically aggressive behaviors, regarding an incident involving another resident (#358). The deficient practice could result in further incidents and possibly resulting in injury to residents. Findings include: -Resident #358 was admitted to the facility on (MONTH) 1, 2019, with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 8, 2019, revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. A nursing progress note dated (MONTH) 23, 2019, revealed resident #358 was sitting at his assigned table for a meal and that a chair thrown by another resident (#16) grazed the resident's right arm. Per the note, the resident said I was just sitting here eating my dinner and the chair hit my pinky. No injuries were noted. -Resident #16 was admitted to the facility on (MONTH) 15, 2006, with [DIAGNOSES REDACTED]. Review of the clinical record revealed that resident #16 resided on a high acuity secured behavioral unit. A care plan included the resident had the potential to demonstrate physical behaviors towards staff and peers related to poor impulse control, with a goal that the resident would demonstrate effective coping skills through the review date. Interventions included to anticipate the resident's needs and to keep the resident a significant distance from peers that were known to cause him to become upset. Review of a quarterly MDS assessment dated (MONTH) 28, 2019, revealed a BIMS score of 12, which indicated the resident had moderate cognitive impairment. The MDS also included the resident required supervision with transfers, bed mobility, walking on the unit and eating. A behavioral care plan updated (MONTH) 13, 2019, included the resident had behaviors of aggression towards peers and staff, and the resident would exhibit minimal behavior change or change in affect, prior to acting out. Behavioral triggers included vague responses to questions and not understanding unit guidelines. De-escalation techniques included eliminating environmental stressors and/or triggers to agitation, and maintaining a homelike, low stimulation environment in his room. Interventions included the resident may only respond positively to unit structure or guidelines if he was able to understand the reason for the guideline and tolerate any delay in getting his needs met, provide clear, concrete answers to questions and use positive phrasing to prevent the resident from interpreting responses as overly restrictive. Review of a facility's incident report revealed that resident #16 hit another resident (not resident #358) on the head on (MONTH) 22, 2019 at approximately 6:35 p.m. The report included that resident #16 was placed on one to one supervision, while in the day room and fifteen minute safety checks while in his room. The report did not indicate the duration of the one to one supervision or the fifteen minute safety checks. Review of the facility's daily staff assignment sheets revealed they did not include that a staff member was assigned for one to one supervision on (MONTH) 22 starting at 10:00 p.m. to 6:00 a.m. on (MONTH) 23. One staff member was assigned to provide one to one supervision on the unit for the 6:00 a.m. to 2:30 p.m. shift on (MONTH) 23, and another staff member was assigned for one to one supervision on the 2:00 p.m. to 10:30 p.m. shift. However, the assignment sheets did not include the name of the resident associated with the one to one supervision, nor did they include specific details regarding the level of supervision to be provided, such as one to one supervision or visual supervision. Review of the nurse aide behavioral monitoring for the 10:00 p.m. to 6:00 a.m. shift on (MONTH) 22, 2019, revealed that resident #16 slept throughout the night and was only up to use the bathroom. Review of the documentation for fifteen minute safety checks for resident #16 revealed safety checks were done every fifteen minutes on (MONTH) 22, 2019, except for the period between 2:00 p.m. through 5:15 p.m. There was also a page of safety checks following the page dated (MONTH) 22, 2019, which documented that safety checks were done every 15 minutes for an entire day, however the page was not dated. A nursing progress note dated (MONTH) 23, 2019, revealed that at approximately 5:30 p.m., resident #16 attempted to sit in a chair by another resident (not resident #358) in the day room/dining room. Staff attempted to redirect resident #16 away from the other resident, but resident #16 walked over to his table, picked it up, threw it, then picked up his chair and threw it. The chair grazed the arm of resident #358. Resident #16 then went into his room and slammed the door. Review of the facility's investigation report revealed that on (MONTH) 23, 2019 at approximately 5:30 p.m., resident #16 was walking across the day room to take a seat by the window and was redirected by staff back to his seat near the hallway. As he returned back to his seat, he picked up his tray table and threw it. Then he picked up his chair and threw it. Then he went into his room and slammed the door. The chair grazed the arm of resident #358. Both residents and the staff members on the unit were interviewed. Resident #358 said he was hit by the chair but it did not hurt. Resident #16 was placed on one to one supervision in the day room and a medication review and labs were ordered. The report included a witness statement from a Certified Nursing Assistant (CNA/staff #128), which included that staff #128 was in the dining room picking up dinner trays with other staff members when the resident threw the table and chair. Review of the facility's daily staff assignment sheet dated (MONTH) 23, 2019, revealed that staff #128 was assigned on the unit to provide the one to one at the time of the incident. An interview was conducted with the Director of Nursing (DON/staff #187) on (MONTH) 6, 2019 at 1:42 p.m. She stated that during an investigation of resident to resident abuse, one of the interventions to consider would be increased supervision, particularly for the alleged aggressor. She said if a resident on one to one supervision became physically aggressive, she would expect interventions such as calling the crisis line and trying medication and behavior stabilization. She said she would also consider moving the resident to a different unit. She said moving the resident to a different unit or calling the crisis line was not considered for resident #16 after he exhibited physical aggression while receiving one to one supervision was because the resident's behavior was an outburst related to a trigger that was identified immediately and not directed toward another resident. She said resident #16 had been known to cycle through behaviors, and there had been no other incidents from this incident to the present time where resident #16 had been the aggressor. She said for the undated fifteen minute safety check page, the page had been located between pages dated (MONTH) 22 and 24, 2019, and the documentation had been done in order of date. An interview was conducted with staff #128 on (MONTH) 6, 2019 at 2:38 p.m. She stated she remembered the incident regarding resident #16 throwing a chair in the dining room. She said resident #16 was not happy about something, then he knocked down his table and picked up his chair and threw it, sort of hitting a resident in front of him. She said after that the nurse and other staff intervened and escorted the resident back to his room. Another interview was conducted with staff #187 on (MONTH) 7, 2019 at 8:53 a.m. She said based on the daily staff assignment sheet and the CNA documentation of care provided on (MONTH) 23, 2019, staff #128 had been assigned as the one to one for resident #16 during the time of the incident. A follow up interview was conducted with staff #128 on (MONTH) 7, 2019 at 9:28 a.m. She stated she did not remember if resident #16 had one to one supervision at the time. She said she may have been assigned to provide one to one supervision, but she did not recall specifically. She said she remembered that as soon as she walked away from the resident, that is when he began to throw things. She said she remembered this because she recalled thinking it was fortunate that she had moved away, because if not she would have been struck. A follow up interview was conducted with staff #187 on (MONTH) 7, 2019 at 9:44 a.m. She stated her expectation for a staff member providing one to one supervision should include keeping the resident within eyesight at all times and to provide all needed care for the resident. She said the staff member providing one to one supervision should have no other assignments on the unit. She said if the resident was in the dining room, the one to one staff could help with cleaning up meal trays, as long as the resident was still within sight. She said it was not an expectation that the staff member should clean up trays, but it was just natural to want to help other staff. After reviewing the facility's policy for resident supervision, she stated her overall expectation for a one to one staff member would be to keep the resident within eyesight and to monitor the resident's mood and behaviors. However, review of the facility's policy for resident supervision and monitoring revealed different levels of supervision which included one to one supervision, visual supervision, periodic checks and general supervision. The policy stated the following: -One to one supervision included assigned staff would stay within close proximity, no more that two arm's length, of the resident at all times. The assigned staff member would have no other assigned duties. One to one supervision required a physician's orders [REDACTED].>-Visual supervision included the resident would be in visual contact of the assigned staff member at all times. The staff member assigned to maintain visual contact may be assigned to other duties, including visual supervision of other residents.",2020-09-01
818,RIDGECREST HEALTHCARE,35125,16640 NORTH 38TH STREET,PHOENIX,AZ,85032,2019-11-07,761,E,0,1,U9RV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and policy review, the facility failed to ensure that medications were discarded when expired. Findings include: In an interview with a licensed practical nurse (LPN/staff #183) conducted on (MONTH) 7, 2019 at 8:45 a.m., she stated that she checks for expired items in her cart every time she administers medication/treatments to a resident. She stated the Director of Nursing (DON) and central supply staff also conduct weekly checks for expired items in the medication rooms and carts. She said that all expired items are discarded. During a medication room observation on the Sunset unit conducted on (MONTH) 7, 2019 at 9:26 a.m. with the Director of Staff Development (registered nurse/staff #57), there were 19 individually packed [MEDICATION NAME] creams with an expiration date of (MONTH) 2019, and there were 12 individual [MEDICATION NAME] packs with an expiration date of (MONTH) 2019, which were located in the top drawer of a treatment cart, which was inside the medication room. During the observation, an interview was conducted with staff #57, who stated that the treatment cart is used by the wound nurse who is responsible for checking the cart for expired items. However, staff #57 did not know how frequent this is done. Staff #57 also stated that the DON checks the medication rooms and carts at least weekly for expired items. An interview with a registered nurse (staff #24) was conducted on (MONTH) 7, 2019 at 9:46 a.m. She stated the floor nurses check the medication carts for expired items sporadically. She said that staff #57 and the pharmacist check the medication rooms and carts for expired items at least once a month. She said expired items are brought to the DON or the Director of Staff Development for destruction. During an interview with the wound nurse (staff #188) conducted on (MONTH) 7, 2019 at 10:04 a.m., staff #188 stated that she has her own treatment cart. She said she does not check the treatment carts in the medication rooms for expired items, because she does not use them. She further stated the nurses and the unit managers check the treatment carts in the medication room for expired items, but did not know how frequent it is done. In an interview with the DON (staff #187) conducted on (MONTH) 7, 2019 at 10:27 a.m., she stated that staff #57 and the unit managers check the medication rooms for expired items on a weekly basis, and she conducts random checks of the medication rooms and carts to ensure that expired items are discarded. Review of the policy on Medication Storage revealed that medications and biologicals are stored safely, securely and properly, following manufacturer's recommendations or those of the supplier. Per the policy, outdated, contaminated or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal and reordered from pharmacy, if current order exists.",2020-09-01
819,LIFE CARE CENTER OF NORTH GLENDALE,35126,13620 NORTH 55TH AVENUE,GLENDALE,AZ,85304,2020-01-08,550,D,0,1,PE8E11,"Based on observation, staff interviews, and policy review, the facility failed to ensure a resident was treated in a dignified manner. The deficient practice could negatively impact the psychosocial well-being of residents. Findings include: A random observation was conducted of a resident's room on January 2, 2020 at 12:11 p.m. A Certified Nursing Assistant (CNA), who was in the resident's room, was overheard calling the resident a feeder. The resident's roommate was also observed in the room when the CNA made the statement. An interview was conducted with a CNA (staff #1[AGE]) on January 7, 2020 at 10:54 a.m. The CNA stated all residents are to be treated with respect and called by their names. She stated that calling a resident a feeder would be considered offensive and not right. The CNA also stated they are not to use that term. During an interview conducted with a Licensed Practical Nurse (LPN/staff #215) on January 7, 2020 at 11:13 a.m., the LPN stated all staff are to treat residents with respect and dignity. The LPN further stated calling a resident a feeder would not be acceptable. Review of the facility's policy regarding dignity with an effective date of May 6, 2019, revealed all residents will be treated with dignity and respect. Examples of treating residents with dignity and respect include addressing residents by the name or pronoun of the resident's choice, avoiding the use of labels for residents such as feeders.",2020-09-01
820,LIFE CARE CENTER OF NORTH GLENDALE,35126,13620 NORTH 55TH AVENUE,GLENDALE,AZ,85304,2020-01-08,645,D,0,1,PE8E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy review, the facility failed to ensure one resident (#[AGE]), who remained in the facility longer than 30 days, Preadmission Screening and Resident Review (PASARR) level I screening was updated. The deficient practice could result in necessary specialized services not being provided for residents who need it. Findings include: Resident #[AGE] was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review the care plan initiated February 13, 2019 revealed the resident was at risk for change in mood or behavior. Interventions included medications as ordered and psychiatric consult as indicated. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] included the [DIAGNOSES REDACTED]. The assessment also included the resident received antipsychotic medications during the 7 day look-back period. The discharge MDS assessment dated [DATE] revealed the resident was discharged to an acute hospital. Review of the facility's PASARR level I screening document dated September 9, 2019 revealed the resident did not have any serious mental illness (SMI) such as [MEDICAL CONDITIONS] disorder, [MEDICAL CONDITIONS]/delusional disorder, [MEDICAL CONDITION] disorder ([MEDICAL CONDITION]), or paranoid disorder. The screening included the resident met the criteria for 30 day convalescent care and that the nursing facility must update the level I at such time that it appears the resident's stay will exceed 30 days. The screening also included a level II referral was not necessary. Review of the clinical record revealed the resident was readmitted to the facility on [DATE]. Further review of the clinical record revealed no evidence the PASARR level I was updated once the resident's stay exceeded 30 days. An interview was conducted with a Hospital Liaison (staff #10) on January 8, 2020 at 8:35 a.m. Staff #10 stated that when a PASARR level I screening document is marked as meeting the criteria for a 30 day convalescent care stay and the resident stays over 30 days, she feels that a new PASARR should have been completed. She further stated that since the PASARR level I screening was not updated for resident #[AGE], the policy and expectation for completing PASARRs was not met. An interview was conducted with the Social Services Director (staff #61) on January 8, 2020 at 10:55 a.m. with the hospital liaison (staff #10) in attendance. Staff #61 stated if they anticipate a resident would be staying for 30 days and then stayed longer; the PASARR should have been updated to reflect the resident would be staying longer than 30 days. She stated that they did not meet expectation for revision of the PASARR for resident #[AGE]. Staff #61 also stated that there were no adverse effects identified and the resident would not be appropriate for level two services. Review of the facility policy's for the PASARR with an effective date of May 6, 2019, revealed the PASARR is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care. The policy did not address anticipated admissions of 30 days or less.",2020-09-01
821,LIFE CARE CENTER OF NORTH GLENDALE,35126,13620 NORTH 55TH AVENUE,GLENDALE,AZ,85304,2020-01-08,658,D,0,1,PE8E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff and pharmacy interviews, and policy review, the facility failed to meet professional standards of quality, by failing to ensure an expired medication was not administered to one resident (#36). The deficient practice could result in residents receiving medications with altered effectiveness. Findings include: Resident #36 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During a medication administration observation conducted with a Licensed Practical Nurse (LPN/staff #154) on January 6, 2020 at 7:47 a.m., the LPN was observed to administer a [MED] 6.25 milligrams tablet to the resident for hypertension. Review of the medication card for the [MED] revealed a label that included an expiration date of May 4, 2020 and printed information on the medication card that included an expiration date of August 31, 2019. There were 18 of the original 30 tablets remaining in the medication card. Review of the Medication Administration Record [REDACTED]. During an interview conducted with a pharmacy technician (staff #220) on January 6, 2020 at 9:07 a.m., she reviewed the medication card and stated the [MED] expired on August 31, 2019. An interview was conducted with a pharmacist (staff #221) on January 6, 2020 at 9:24 a.m. The pharmacist stated that it is not recommended to give any medication past the expiration date as it may decrease the effectiveness of the medication. He stated that administering the resident the expired medication would be a sub therapeutic dose at most and that there would probably be no harm. The pharmacist also stated the nurse should be looking for the expiration date, and that if two dates are present, the nurse should use the older date as the expiration date. An interview was conducted with the Licensed Practical Nurse (LPN/staff #154) on January 6, 2020 at 9:34 a.m. She stated that she is expected to check the expiration date prior to administering a medication. After reviewing the medication card, she stated that she should have used August 31, 2019 as the expiration date. The LPN stated the expectation is not to administer a resident an expired medication and acknowledged that the [MED] she administered to the resident was expired. She stated that the risk of an allergic reaction is increased if a resident is administered a medication past the expiration date. During an interview conducted with the nurse practitioner (staff #222) on January 6, 2020 at 9:45 a.m., she stated that the medication had not been expired very long. She also stated the expired medication may not have been as effective, but that it would not have caused any harm. Staff #222 further stated the resident's blood pressure is being monitored. An interview was conducted with the Director of Nursing (DON/staff #6), the Administrator (staff #224), and the Regional Director of clinical services (staff #223) on January 8, 2020 at 2:29 p.m. The DON stated that they have a monthly auditing process in place to check for expired medications. Regarding the [MED] medication card, she stated that there was a discrepancy between the printed expiration date and the expiration date on the sticker (label). The DON stated her expectation is that the staff check the expiration date before administering the medication and not administer an expired medication. She stated that there is always a potential risk when an expired medication is administered. She also stated the nurse practitioner was consulted and felt there was no real risk to the patient since the expiration date was not that long ago. Review of the facility's policy for oral drug administration reviewed August 16, 2019, included checking the expiration date on the drug and that if the drug is expired, return it to the pharmacy and obtain a new drug.",2020-09-01
822,LIFE CARE CENTER OF NORTH GLENDALE,35126,13620 NORTH 55TH AVENUE,GLENDALE,AZ,85304,2020-01-08,661,D,1,1,PE8E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff and family interviews, review of community provider documentation and policy review, the facility failed to ensure the discharge information for one resident (#211) contained a complete recapitulation of the resident's stay, a complete assessment of the resident's status at discharge, and instructions to treat burn wounds. The deficient practice could disrupt continuity of care, resulting in medical complications. Findings include: Resident #211 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of a nurse progress note dated November 1, 2019 revealed this writer was summoned to the resident's room by a family member who stated the resident spilled his coffee. The note included the resident was assessed and had redness with 2 small blisters to the inner thigh area. The resident was cleaned and new orders were received. A physician's orders [REDACTED]. Review of a physician's orders [REDACTED]. This order was discontinued by a RN (staff #[AGE]) and was not discontinued by the physician. An interview was conducted on January 6, 2020 at 2:12 p.m. with a Registered Nurse (RN/staff #[AGE]), who was the nurse who discharged the resident on November 2, 2019. She stated that she did not know resident #211 and did not receive report on him, as he was not her resident. She said that she did the discharge to help another nurse. She said that she did not know the resident [MEDICAL CONDITION] that she should not have discontinued the treatment order. She said if she had known that the resident had burns/blisters, she would have left the wound treatment on the orders. Review of the discharge summary information signed on November 2, 2019, revealed it did not include the presence of a burn injury or any instructions for ongoing treatment. The summary did not include any information in the section for recapitulation of the resident's stay. In addition, the order summary report dated November 2, 2019 (included with the discharge paperwork and sent home with the family and resident) did not include the order for the xeroform dressing two times a day to the blisters on the bilateral thighs. According to a discharge summary nurse progress note dated November 2, 2019, the resident transitioned home as planned with his belongings and scripts for medications. The note did not include any documentation of the status of [MEDICAL CONDITION] the thighs or the need for ongoing treatment. An interview was conducted with a family member on [DATE] at 1:24 p.m. She stated that the resident and family were not sent home with any care instructions or treatment for [REDACTED]. She stated that she did not realize the extent of the injuries, and she was present when the resident was discharged , but the staff said nothing about them. She stated they looked at the areas a day or two after the resident returned home and when they saw the extent of the wounds, they took the resident to the doctor who said that the injuries were second to third degree burns. Continued in the interview with staff #[AGE] on January 6, 2020 at 2:12 p.m., she stated that the resident's skin should be checked before discharge and if the resident had any wounds she would discuss and educate the resident/family on how to do the wound care and would give them any supplies needed. She said that she did not know the resident [MEDICAL CONDITION] that she did not check the resident's skin before discharge. She said that she should have discharged the resident with instructions and materials to treat the burn. Staff #[AGE] stated that she did not speak with the family about [MEDICAL CONDITION] treatment needs and did not send any supplies for the care. She confirmed that the order summary report dated November 2, 2019 were the orders sent with the resident on discharge and that the wound treatment orders were not included. She stated that normally, she only prints the orders that have prescriptions. She stated that she did not follow the expectations for the discharge process, as she was not really thorough and as a result, the resident could have gotten an infection from going home without wound treatment and education. Review of a community provider physician visit note dated November 6, 2019, revealed the patient was burned with hot coffee in his inner thighs and groin area. Physical exam included the resident's left thigh and right inner thigh had [DIAGNOSES REDACTED], blistering and ulcerations. The assessment included that the resident had partial thickness burn to lower limb/left and was advised to keep clean and dry, for [MEDICATION NAME] cream to apply two times a day, and if it worsened would consider dermatology/wound care. The note also included the resident had second [MEDICAL CONDITION] right lower limb. An interview was conducted with the provider (staff #225) on January 7, 2020 at 10:36 a.m. He stated that the resident should have been sent home with education and a treatment for [REDACTED]. He stated it was probably routine for the facility staff to do a skin assessment at discharge. He stated that another issue for this resident was that he had no home health benefits and that would impact follow up after discharge. An interview was conducted with a RN (staff #26) on January 8, 2020 at 9:45 a.m. She stated that the facility protocol is for the night shift to do a skin assessment and document on the skin sheet prior to discharge. She stated that if no skin assessment was done, the facility expectation/policy was not met. She stated that the presence of [MEDICAL CONDITION] the treatment order for the xeroform should have been included in the discharge paperwork and on the orders at the time of discharge for continuation of care. She said as the resident did not go home with a wound treatment order, supplies or education, the wound would not have been treated. She stated that the discharge summary was not completed fully and did not meet facility expectations/policy. An interview was conducted with the Director of Nursing (DON/staff #6), the Administrator (staff #224) and the Regional Director of Clinical Services (staff #223) on January 8, 2020 at 2:25 p.m. The DON stated that she expects all sections of the discharge summary to be completed and that the summary should include any care needed after the resident discharges. She stated that she would have expected the wound care education to be in place and include any treatments. She said that the discharge of resident #211 did not meet her expectations regarding the discharge process. Review of a facility policy regarding the Discharge Summary revealed that social services and nursing staff as members of the interdisciplinary team (IDT), participate in developing a discharge summary, when a resident is discharged to a private residence, another nursing facility or another type of residential facility. The policy included that the discharge summary provides a recapitulation of the resident's stay and the resident's status at the time of discharge to ensure continuity of care. Facilities will complete the discharge summary located in the electronic medical system, unless state policy requires the use of a state-mandated discharge summary form. The policy stated that when the facility anticipates discharge, a resident must have a discharge summary that includes but is not limited to, the following: A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results; a final summary of the resident's status; reconciliation of all pre-discharge medications with the resident's post-discharge medications; a post-discharge plan of care that is developed with the participation of the resident and with the resident's consent and the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post discharge plan of care must indicate any arrangements that have been made for the resident's follow up care, and any post-discharge medical and non-medical services. The policy further included that reconciliation of medications was a process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care. The policy stated that the discharge summary is documented in the resident's medical record according to facility policy. The procedure includes that a final summary of the resident's status would include skin conditions and special treatments and procedures. The procedure stated that the following information, along with the discharge summary, is sent to the receiving provider of care and will include all special instructions or precautions for ongoing care, as appropriate, and any other documentation, as applicable to ensure a safe and effective transition of care.",2020-09-01
823,LIFE CARE CENTER OF NORTH GLENDALE,35126,13620 NORTH 55TH AVENUE,GLENDALE,AZ,85304,2020-01-08,684,D,1,1,PE8E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, facility documentation, staff and family interviews, review of community provider documentation, professional literature and policies and procedures, the facility failed to ensure that care and treatment were provided in accordance with professional standards for one resident (#211) who sustained a burn, and for one resident (#142) with a left hip wound. The deficient practice could result in complications related to skin issues. Findings include: -Resident #211 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. A nurse's progress note dated November 1, 2019 revealed this writer was summoned to the room by the patient's family member who stated the resident had spilled his coffee and that the resident's shorts were soiled. The resident was assessed and noted redness with two small blisters to the inner thigh area. The resident was cleaned, his shorts were changed and new orders were received. Review of the facility's incident report regarding the burn which occurred on November 1, 2019 at 6:33 p.m., revealed the resident was drinking coffee and spilled on bilateral thighs. Immediate action taken to address the burn included the following: the nurse assessed the resident's thighs and noted redness and two small blisters, applied xeroform dressing after consulting with wound nurse; wound care orders received; provider/family informed at bedside; and will continue to monitor for any significant changes. However, there was no documentation of any measures to cool the burn area immediately following the incident. A physician's orders [REDACTED]. Under order type the documentation noted Orders (no doc req) and the scheduling details indicated the treatment was to be done at 6:00 a.m. and 2:00 p.m. Review of a discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BI[CONDITION]) score of 15, which indicated the resident's cognition was intact. Review of the November 2019 Treatment Administration Record (TAR) revealed that the order for xeroform dressing to bilateral thigh blisters two times a day was not included on the TAR. As a result, there was no clinical record documentation that the ordered treatment was administered on November 1, except as mentioned on the incident report which stated the xeroform was applied (on the evening shift on November 1). There was also no documentation that the treatment was administered on November 2 at 6 a.m. as ordered or that it was done prior to discharge. Further review of the clinical record revealed there was no documentation of any additional assessments of the burn area(s) on November 1, other than the initial assessment, or any assessment that was done on November 2, prior to discharge. A nurse progress note/discharge summary dated November 2, 2019 at 10:55 a.m. included the resident was transitioned home as planned, with his belongings and prescriptions for medications. The noted included that the resident and family were reminded to follow up with the primary care provider within a week and was stable upon discharge. The noted stated the resident was transported home by family. Review of a community provider physician visit note dated November 6, 2019, revealed the patient was burned with hot coffee in his inner thighs and groin area. Physical exam included the resident's left thigh and right inner thigh had [DIAGNOSES REDACTED], blistering and ulcerations. The assessment included that the resident had partial thickness burn to lower limb/left and was advised to keep clean and dry, for [MEDICATION NAME] cream to apply two times a day, and if it worsened would consider dermatology/wound care. The note also included the resident had second [MEDICAL CONDITION] right lower limb. An interview was conducted with a family member on [DATE] at 1:14 p.m. She stated that she was in the room with the resident at the time of the spill and that his private parts were red where he got burned. She stated that the nurse came in to evaluate the wounds and put cream on the resident. An interview was conducted on January 7, 2020 at 10:36 a.m., with the resident's physician (who was responsible for his care while at the facility/staff #225). He stated that the nurse notified him of the coffee burn of resident #211 and he ordered the treatment on November 1, 2019. He stated that ideally, staff should have done some first aid to the burn area, by applying cool cloths at the time of the burn. An interview was conducted with a Registered Nurse (RN/staff #26) on January 8, 2020 at 9:45 a.m. She stated that a family member came out of the room and said the resident had spilled his coffee. She stated when she entered the room she got him clean up. She said that she did not use cool water or apply cool compresses. She said when she got him into bed, she noticed that he was a little red and a small blister or two was forming on his thigh. She stated that she put a little [MEDICATION NAME] on it, but did not have an order yet, and called the wound nurse. She stated the wound nurse gave her an order to initiate xeroform and she notified the provider of the burn and got a treatment order. She stated that it happened at the end of her shift so she did not apply the xeroform, and that she passed it onto the next nurse to apply the treatment. She stated the documentation that the treatment was completed should have been on the MAR, TAR or in the progress notes. She stated that she did not enter the treatment order in a way which it would show up on the MAR/TAR, as she did not select TAR in the order type section, and therefore; the nurse would not have seen to do the treatment as scheduled. She stated that she did not meet facility expectations in putting the order in the computer so that a treatment would show on the TAR to be completed. An interview was conducted with the Director of Nursing (DON/staff #6), the Administrator (staff #224), and the Regional Director of Clinical Services (staff #223) on January 8, 2020 at 2:25 p.m. The DON stated that the nurse told her that she had obtained a xeroform order. The Administrator stated that based off the information they had, they believe the nurse acted appropriately. Review of an article dated July 3, 2019 by the Mayo Clinic revealed that first aid for a burn included to cool the burn. The article stated that the burned area should be held under cool (not cold) running water or to apply a cool, wet compress until the pain eases. Review of a policy regarding the Incident Management Process revealed we react promptly and efficiently when incidents occur, responding to the resident's immediate medical needs and protecting the resident and others from further incident. The policy included that when incidents occur, we report the facts to those who need to know, enhancing our ability to provide comprehensive treatment and respond competently to the circumstance. The policy stated that we investigate and follow-up on incidents that occur in our facility in order to determine causal factors and possible trends and implement reasonable resident specific and facility-wide interventions in an effort to reduce the risk of recurrence. A policy on treatment orders included that after observation/evaluation of the affected skin area, the physician is notified. As appropriate, the physician writes a treatment order that includes at least the following: site of wound, name of cleanser, name of ointment, type of dressing, and number of times to perform the treatment/duration of treatment. The policy stated that physician's orders [REDACTED]. According to the DON, they did not have a specific policy regarding first aid for burns. -Resident #142 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was discharged from the facility on [DATE]. Review of the Wound Care Services Consult note dated [DATE] revealed the resident was seen for a wound consultation regarding multiple wounds, which included MASD (moisture associated skin damage) and non blanchable wound (hip?) and sacrum. Per the note, the resident had bilateral buttocks incontinence associated skin injury and a left hip laceration. The left hip laceration was described as a surface laceration with a red base, scant serosanguinous drainage, and the peri wound was pink, dry and intact. The note further included that the resident had multiple clinical risk factors contributing to altered skin integrity and delayed wound healing. The plan was for wound care to the left hip with [MEDICATION NAME] dressing for antimicrobial action, exudate management, wound hydration, autolytic debridement and decrease in frequency of dressing change. The admission note dated [DATE] included the resident was alert to name, with confusion to time and place. The note included the resident had a dry scabbed area to the left hip. The note did not incude any measurements, or the specific location on the left hip. The undated admission paperwork included the resident was alert and oriented x 2 and had a red left hip. The documentation did not include any measurement of the red area to the left hip, nor a specific location. Review of the admission orders [REDACTED]. The nursing admission collection tool signed by a nurse on December 6 and [DATE], included the resident had an indwelling urinary catheter, required extensive assistance with bed mobility, and required total assistance with toileting, bathing, personal hygiene, ambulation and transfers. Per the assessment, the resident uses a mechanical lift for transfers. The documentation also included that the resident's skin was intact and there was a scabbed area on the left hip, with a pink periwound. There were no measurements or a specific location of where the scab was located on the left hip. The Skin Integrity care plan dated [DATE] included the resident was at risk for break in skin integrity. The goal was to maintain intact skin with no skin breaks. Interventions included treatment as ordered, weekly skin checks, pressure reducing mattress and cleaning and drying skin after each incontinent episode. Review of the clinical record revealed there was no documentation of any wound treatment to the left hip, which was done from admission on December 6 through December 9, 2019. Also, there were no further assessments that were done of the left hip on December 8 or 9. The wound observation tool dated December 10, 2019 completed by a registered nurse included the resident had an abrasion of unknown injury to the left anterior thigh, with 100% adherent yellow slough, no drainage, and no tunneling or undermining was present. Per the assessment, the wound measured 0.5 cm x 4.5 cm and the depth was unable to be determined. Under overall impression, it was documented that the resident was admitted with this wound, and that this was the first observation and that the physician was notified. Under additional comments it stated, wound care to follow. The current treatment plan included the following: clean with wound cleanser, pat dry, apply [MEDICATION NAME] to wound bed, apply oil [MEDICATION NAME] on top, cover with small corvsite dressing daily and as needed if soiled. According to a skin/wound note dated December 10, 2019 which was completed by the same registered nurse who completed the above wound observation tool dated December 10, the resident had an abrasion of unknown origin to the left anterior medial upper thigh, which measured 0.5 cm x 4.5 cm with depth unable to be determined. However, this note included that the wound bed had 50% soft black eschar and 50% adherent yellow slough. A physician's orders [REDACTED]. The admission MDS assessment dated [DATE] included the resident had a Brief Interview for Mental Status score of 15, indicating the resident had intact cognition. The weekly skin integrity data collection notes dated December 13 and 20, 2019, included the resident had skin a condition to the left upper thigh. No other description of the wound was documented. Further review of the clinical record revealed there was no evidence that the wound to the left anterior thigh was thoroughly assessed from December 11, through December 25, 2019, which included the type of wound, any measurements, a description of the wound bed and wound edges, condition of the surrounding skin or if any drainage was present. The Wound Observation Tool dated December 26, 2019 revealed the resident had an abrasion of unknown origin to the left anterior thigh, which measured 0.5 cm x 3.5 cm with depth unable to be determined and the wound bed had 100% adherent yellow slough with no drainage. Overall impression included that the wound was improving. According to the December 2019 Treatment Administration Record (TAR), the [MEDICATION NAME] treatment to the left hip was provided from December 11 through 31. The Wound Observation Tool dated January 2, 2020 revealed the abrasion of unknown origin to the left anterior thigh was healed. During the survey, no wound treatment observation was conducted, as resident #142 was discharged from the facility on [DATE]. An interview was conducted on January 8, 2020 at 9:20 a.m. with a licensed practical nurse (LPN/staff #1[AGE]), who stated that skin issues are identified from reports from residents/family or certified nursing assistants (CNA's) during cares. She stated on admission, a head to toe assessment is conducted and every skin issue should be identified and documented in the clinical record. She said she will observe the skin and will describe and document what is seen. She stated that she will describe the wound as a rash, a skin tear or abrasion, but she cannot say or document the type of wound, nor can she measure the wound. She stated that she will report her findings to the wound nurse, who will then conduct a wound assessment and document the type and measurements of the wound. Staff #1[AGE] said the wound nurse will determine whether the treatment implemented is appropriate or not. She stated the treatments are done by the nurses, but the wound nurse does the treatment for [REDACTED]. She stated when treatments are done, they should be documented by the nurses on the TAR. In an interview with another LPN (staff #15) conducted on January 8, 2020 at 10:42 a.m., staff #15 stated when she receives a report of a skin issue, she will assess the wound and document what she sees. She stated that she can say what type of wound it is and she can measure the length and width of the wound, but not the depth. She said that she can also apply standing treatment orders. She said she would notify the wound nurse, who will assess the wound within a day and she will notify the physician of the wound. She stated treatments to wounds are provided by the nurses on the floor and should be documented in the TAR. She further stated that all refusal of treatments will also be documented in the TAR. In an interview with a registered nurse (staff #26) conducted on January 8, 2020 at 12:59 p.m., she stated when a skin issue is brought to her attention, she will document what she sees. She said that she will notify the wound nurse who will assess the wound, determine the type of wound, measure the wound and recommends treatment. She stated treatments are provided by the floor nurses and should be documented in the TAR. She stated if the resident refuses treatment it will also be marked in the TAR. She said if the wound is worsening, she will notify the physician and the wound nurse, and will document it in the progress notes. During an interview with the unit manager (staff #68) conducted on January 8, 2020 at 10:19 a.m., she stated that resident #142 was admitted to the facility for respite care which ended up to be longer than usual. She stated the resident came in with wounds to her buttocks and left hip, which healed prior to discharge. An interview with one of the wound nurses (staff #213) was conducted on January 8, 2020 at 1:24 p.m. She stated that she sees all residents admitted to the facility the day following admission, regardless of whether the resident has a wound or not. She stated that she reviews the assessment notes done by the admitting nurse, reviews the treatment orders from the hospital and consults with the physician for treatment orders. She stated that she conducts an assessment of the wound, documents her assessment in the Skin/Wound note and checks for treatment orders. She said the nurses can assess and describe what they see, but they cannot identify or stage the wound. She stated that every resident with a wound must have a treatment order on the day of admission. She said when a resident is admitted at night, the nurse on duty will assess the wound and provide treatment, until she can assess the wound the following day. She said treatment orders are initiated on the same day the wound was identified or when the treatment order changes. She said that she lays eyes on all residents with wounds on a weekly basis and that the wound physician alternates with the wound NP (nurse practitioner) in seeing residents with complicated or complex wounds, such as wounds that are getting bigger or non healing. She stated examples of factors that could contribute to worsening of wounds are poor nutrition, noncompliance, decline in health, refusals and presence of comorbidities. She stated when a resident refuses and is noncompliant with treatment, it will be documented by her and the floor nurses in the clinical record. She said the management of wounds is a team approach. Staff #213 further stated that she only assessed the wound to left thigh once on December 10, 2019 during the entire stay of the resident at the facility, because the wound was followed by another wound nurse after her assessment on December 10. At this time, a review of the clinical record of resident #142 was conducted with staff #213. She stated that based on the wound assessments, the left thigh was resident #142 was admitted to the facility with an abrasion wound to the left thigh. She stated that based on the wound assessments, the left thigh wound was assessed on December 10, 2019 and treatment orders were put in place on December 10. She further stated that she could not say if treatments were provided to the left thigh prior to December 10. She stated that based on the clinical record, the wound resolved prior to discharge. An interview was conducted on January 8, 2020 at 2:53 p.m., with the Director of Nursing (DON/staff #6), the Administrator (staff #224) and corporate resource (staff #223). Regarding resident #142, staff #6 stated the resident was admitted on [DATE] with multiple wounds. At this time, a review of the clinical record was conducted with staff #6. Staff #6 stated that based on the clinical record, the wound treatment for [REDACTED]. She stated that she does not know why there was a delay in the assessment and obtaining a treatment order from admission (on December 6) through December 10, when the wounds were assessed and a treatment was ordered. Another interview with staff #6 was conducted on January 8, 2020 at 3:42 p.m. She stated that the facility follows the guidelines from the WOCN (Wound, Ostomy, Continence Nurses) Society to describe wounds. She stated that she is not an expert on wounds. Staff #6 reviewed the clinical record and stated that the resident's wound to the left anterior thigh was present on admission Review of a policy on Skin Integrity included to provide associates and licensed nurses with procedures to manage skin integrity, complete wound assessment/documentation, and provide treatment and care of skin and wounds utilizing professional standards of the Wound, Ostomy, Continent Nurses Society. The policy also included that a skin assessment/inspection occurs on admission and readmission and weekly by a licensed nurse. Skin observations also occur throughout points of care provided by CNA's during ADL care (bathing, dressing, incontinent care, etc.). Any changes or open areas are reported to the Nurse. CNA's will also report to nurse if topical dressing is identified as soiled, saturated or dislodged. Nurse will complete further inspection/assessment and provide treatment if needed.",2020-09-01
824,LIFE CARE CENTER OF NORTH GLENDALE,35126,13620 NORTH 55TH AVENUE,GLENDALE,AZ,85304,2020-01-08,685,D,0,1,PE8E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, clinical record review, and policy review, the facility failed to ensure one resident (#127) was provided consistent assistance with hearing aids. The deficient practice could result in residents not being provided assistance with devices to maintain hearing ability. Findings include: Resident #127 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Monthly Summary dated November 24, 2019, revealed that the resident was alert and had adequate hearing with the use of hearing aids. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's cognitive skills for daily decision making was moderately impaired. The assessment also revealed the resident's ability to hear with the use of hearing aids was moderately difficult; the speaker had to increase the volume and speak distinctly. The care plan with a review date of December 27, 2019, revealed the resident had a communication problem related to hearing loss. An intervention was to use and maintain bilateral hearing aids. The care plan did include the resident refused or had resistance to wearing the hearing aids. Review of the Kardex Report dated January 8, 2020, revealed a care area for communication that did not include the use of hearing aids. Review of the progress notes did not reveal evidence staff were offering to assist the resident in putting in her hearing aids or that the resident was refusing to wear the hearing aids. During an interview conducted with the resident on [DATE] at 8:43 a.m., the resident stated that she could not hear what was being said. The resident stated that she is supposed to wear hearing aids which may be in her drawer and that she would like to have the hearing aids put in. She said that she often forgets to wear them. Another interview was conducted with the resident on January 8, 2020 at 10:47 a.m. The resident was observed not wearing her hearing aids. The resident said that it is a bother to put them in but that she would like to wear them if someone would help her put them in. An interview was conducted on January 8, 2020 at 10:48 a.m. with Certified Nursing Assistant (CNA/staff #1[AGE]), who stated the resident talks but cannot hear well. She stated you have to talk loud when speaking to the resident. The CNA also stated the resident does not have hearing aids. After locating an empty plastic cup labeled hearing aids, the CNA searched for the resident's hearing aids. She located the resident's hearing aids in a gray container on a shelf above the resident's drawers. The CNA then stated she thinks she saw the resident wearing hearing aids a while back, but was not able to state when. She also stated that she thinks the resident has an order for [REDACTED]. The CNA further stated that she has never documented the resident's refusal to wear her hearing aids. On January 8, 2020 at 11:26 a.m., an interview was conducted with a Licensed Practical Nurse (LPN/staff #35), who stated that the needs/services of each resident is in the Kardex Report for the CNAs to review. She said the CNAs use the Kardex Report to review the needs/services of each resident and to check off the care that was provided. She reviewed the care area for communication on the Kardex Report and saw wearing hearing aids or that the resident refuses to wear them was not on the Kardex Report. She then stated that they are not required to list hearing aids as a task, so the CNAs would not be checking off that the hearing aids were offered or that the resident was refusing to wear them. The LPN stated that she expected staff to offer the hearing aids to the resident and the resident could decide if she wanted to wear them or not. After reviewing the resident's care plan, the LPN stated that she could not find the resident refusing to wear her hearing aids in the care plan. She said that she would talk to the Director of Nursing to see if there is a care plan that addressed the resident refusal to wear the hearing aids or if there was documentation the resident was refusing to wear her hearing aids. An interview was conducted on January 8, 2020 at 3:59 p.m. with the Director of Nursing (DON/staff #6), who said that the resident's refusal to wear her hearing aids is in the resident's care plan. The DON was made aware that staff and the surveyor reviewed the care plan during an interview and could not find documentation of the refusal in the care plan. The DON replied the resident does not want to wear her hearing aids. The DON also did not provide documentation that the resident was being offered her hearing aids and was refusing to wear them. Review of the care plan with an review date of December 27, 2019, now included a care plan that the resident was resistive to wearing hearing aids. Interventions included allowing the resident to make her own decisions about treatment regimen; educating the resident, family, and staff about possible outcomes of not complying with treatment of [REDACTED]. Review of the facility's policy Activities of Daily Living revised April 22, 2019, revealed that the purpose of the policy is to ensure needed care and services that are resident centered are identified and provided, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet the resident's physical, mental, and psychosocial needs. The resident will receive assistance as needed to complete activities of daily living (ADL).",2020-09-01
825,LIFE CARE CENTER OF NORTH GLENDALE,35126,13620 NORTH 55TH AVENUE,GLENDALE,AZ,85304,2020-01-08,686,E,1,1,PE8E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews and policies and procedures, the facility failed to provide care and services for two (#142 and #308) of 3 sampled residents. The deficient practice resulted in the worsening of pressure ulcers. Findings include: -Resident #142 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was discharged from the facility on [DATE]. The Wound Care Services Consult note dated [DATE], which was two days prior to admission included the resident was seen for a wound consultation related to MASD (Moisture-associated skin damage), non blanchable wound to sacrum. The note included the resident had multiple clinical risk factors contributing to altered skin integrity and delayed wound healing. Under assessment it was documented the resident had incontinence associated skin injury to bilateral buttock which was present on admission. The buttocks area was described as follows: blanchable [DIAGNOSES REDACTED], moist irregular shaped with 3 open skin areas with small amount of serosanguinous drainage, and periwound pink was dry and intact. The plan was for application of [MEDICATION NAME] (topical skin protectant) to sacrococcygeal/buttocks for protective healing barrier from intermittent incontinence and trapped moisture and friction/sheer. Provide pressure injury prevention measures to serve as an adjunct to local skin care and to manage/affect issues related to mobility, weakness and fatigue, altered nutritional status and uncontrolled moisture. This assessment did not include any measurements of the sacrum/buttocks area. An admission note dated [DATE] included the resident was alert to name and had confusion regarding time and place. Per the note, the resident was incontinent of bowel, had a Foley catheter in place and had redness to the buttocks. No further description of the area was documented. The undated admission paperwork included the resident was alert and oriented x 2 and had red excoriated buttocks. The Braden Scale for Predicting Pressure Ulcer Risk dated [DATE] revealed a score of 15, indicating the resident was at mild risk for pressure ulcer development, despite having a redness/excoriation to the buttocks. Review of the Baseline Care Plan dated [DATE] revealed the resident was at risk for skin breakdown, with a goal to maintain intact skin with no skin breaks through the next review. Interventions included cleaning and drying skin after each incontinent episode, pressure reducing mattress, treatment as ordered and weekly skin checks. However, the care plan did not address that the resident had skin breakdown to the sacrum/buttocks area. A physician's order dated [DATE] included for [MED] cream 13%, apply to sacral area topically every day and night shift for wound care. Review of a nursing admission collection tool signed by the nurse on December 6 and [DATE], revealed the resident had an indwelling urinary catheter, required extensive assistance with bed mobility, required total assistance with toileting, bathing, personal hygiene, ambulation and uses a mechanical lift for transfers. The documentation included the resident had redness to the buttocks. A comprehensive pressure ulcer care plan dated [DATE] included the resident had a pressure injury to the right buttocks and had the potential for pressure injury development related to a history of immobility. The goal was for the wound to show signs of healing and be free from infection. Interventions included administering medications and treatment as ordered; assess wound perimeter, wound bed and healing progress; weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate; report improvements and decline to the physician; and follow facility policies/protocols for the prevention/treatment of [REDACTED]. Despite documentation that the resident had redness/pressure injury to the right buttocks, the clinical record revealed no evidence the wound to the right buttocks was thoroughly assessed from admission on December 6, through December 9, 2019, which included the stage of the pressure ulcer, a description of the wound bed and wound edges, description of the surrounding skin, if any tunneling/undermining were present and any drainage. There was also no evidence in the clinical record that the physician was notified that the resident had a pressure injury to the right buttocks from December 7 or 8, 2019. Review of a History and Physical dated December 9, 2019 by the physician revealed the following: Resident was alert and oriented to month and president and was moderately overweight; [MED] to the sacrum twice daily was listed as one of the medications and that the resident's skin was warm and dry with no rashes noted. The physician assessment did not include any details or description of the sacrum area. According to the December 2019 MAR (medication administration record), the [MED] was administered from December 6-10. Review of a skin/wound note dated December 10, 2019 revealed the resident was alert and oriented x 2 and was able to make needs known. Per the note, the resident had an unstageable pressure injury to the right buttocks, which measured 3 cm (centimeters) x 7 cm x UTD (unable to determine), and had no odor or signs and symptoms of infection. A Wound Observation Tool was completed on December 10, 2019, which was four days after admission. The documentation included the resident had an unstageable pressure ulcer to the right buttocks due to slough/eschar, which was present on admission. Under overall impression, it was documented that this was the first observation of the wound. The wound bed was described as having granulation tissue, 50% adherent yellow slough, no drainage and measured 3 cm x 7 cm. It also included that the physician was notified of the wound status. The treatment plan included clean the area with wound cleanser, apply [MEDICATION NAME] to the wound bed, cover with oil [MEDICATION NAME] gauze, cover with large corvsite dressing daily and as needed. A physician's order dated December 10, 2019 included to discontinue the [MED]; and to clean right buttocks with wound cleanser, pat dry, apply [MEDICATION NAME] to wound bed, cover with oil [MEDICATION NAME] gauze, cover with large corvsite dressing every day shift for a [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set) assessment dated [DATE] included the resident had a BI[CONDITION] (Brief Interview for Mental Status) score of 15, which indicated the resident had intact cognition. Per the MDS, the resident was at risk of developing pressure ulcers and had 1 unhealed unstageable pressure ulcer, due to slough/eschar, which was present on admission. However, there was no clinical record documentation on admission that the resident had an unstageable pressure ulcer. The weekly skin integrity data collection notes dated December 13 and 20, 2019 included the resident had a skin condition to the right buttocks. The documentation did not include the type of wound, stage of the wound, any measurements, nor a description of the wound bed, wound edges or surrounding tissue. Further review of the clinical record revealed there was no evidence that the pressure ulcer to the right buttocks was thoroughly assessed from December 11 through December 25, 2019, which included the type of wound, stage of the wound, any measurements, nor a description of the wound bed, wound edges or surrounding tissue. The Wound Observation Tool dated December 26, 2019 revealed the resident had an unstageable pressure ulcer to the right buttocks due to slough/eschar and was improving. The wound bed was described as having granulation tissue and 40% adherent yellow slough, with a small amount of serous drainage. The pressure ulcer measured 3 cm x 4 cm and depth was unable to be determined. According to the Wound Observation Tool dated January 2, 2020, the resident had a stage 3 pressure ulcer to the right buttocks which was present on admission and was now healed and resolved. During the survey, there was no wound treatment observation conducted, as resident #142 was discharged from the facility on [DATE]. During an interview with the unit manager (staff #68) conducted on January 8, 2020 at 10:19 a.m., she stated that resident #142 was admitted to the facility for respite care, which ended up to be longer than usual. She stated the resident came in with wounds to her buttocks and left hip, which healed prior to discharge. An interview with the wound nurse (staff #213) was conducted on January 8, 2020 at 1:24 p.m. Regarding resident #142, staff #213 stated that she only assessed the wound to the right buttock once on December 10, 2019 during the entire stay of the resident at the facility, because the wound was then followed by another wound nurse after her assessment on December 10. At this time, a review of the clinical record of resident #142 was conducted with staff #213. She stated that resident #142 was admitted to the facility with a pressure wound to the right buttocks. She said an assessment of the wound was conducted on December 10, 2019 and treatment orders were put in place on December 10. However, she stated that she could not say whether treatment was provided to the right buttocks prior to December 10. She stated that based on the clinical record, all wounds resolved prior to discharge. An interview with the Director of Nursing (DON/staff #6) was conducted on January 8, 2020 at 2:53 p.m., and the administrator (staff #224) and a corporate resource (staff #223) were present during the interview. Regarding resident #142, staff #6 stated the resident was admitted on [DATE] with multiple wounds. At this time, a review of the clinical record of resident #142 was conducted with staff #6. Staff #6 stated that based on the clinical record, the wound treatment for [REDACTED]. She stated she does not know why there was a delay in the assessment and obtaining a treatment order from admission (on December 6) through December 10, when the wounds were assessed and a treatment was ordered. Staff #223 stated the resident came in the facility with redness on the buttocks. She stated there was a physician's order on [DATE] for application of [MED]. Review of the treatment order provided by staff #223 revealed the treatment was for the sacral area and not for the right buttocks for resident #142. -Resident #308 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A hospital physician note dated August 14, 2019 included the resident had a left AKA (above knee amputation) and a left sacral decubitus ulcer. Clinical impression included a pressure injury to the sacral region, with unspecified injury stage. The Braden Scale for Predicting Pressure Ulcer Risk dated August 20, 2019 included a score of 15, which indicated the resident was at mild risk for pressure ulcer development. A baseline care plan dated August 20, 2019 identified that the resident had a break in skin integrity, however, the care plan did not reflect a pressure ulcer to sacral area or buttocks area. The goal was to minimize risk for symptoms of infection. Interventions included educating the resident and/or family regarding skin problem and treatment; pressure reducing mattress; treatment as ordered and weekly skin checks. Review of the clinical record revealed there was no documentation that the resident was admitted on [DATE], with a pressure ulcer to the sacral area or buttocks area. The nursing admission collection tool dated [DATE] included the resident was alert and oriented to person and situation, and required total assistance with bed mobility, transfers, bathing and required extensive assistance with toileting and personal hygiene. Review of the Wound Observation Tool dated [DATE], revealed the resident had an unstageable pressure ulcer to the left buttocks, which had 100% thick yellow/tan adherent slough and measured 2 x 2.3 cm., and had a stage 3 pressure ulcer to the sacrococcygeal that was present on admission, which measured 3 cm x 2 cm x 0.2 cm, with beefy red granulation tissue, small amount of serous drainage, and no tunneling or undermining. The assessment included that this was the first observation of the wounds and that the physician was notified. Per the assessment, the treatment to the sacral area included to cleanse the area with wound cleanser, pat dry, apply fibrocal, cover with [MED], secure with bordered gauze, apply skin prep to periwound daily and as needed, if soiled. A NP (nurse practitioner) progress note dated [DATE] included a chief complaint of a stage 3 pressure wound to the left sacral area with full thickness skin loss, and an unstageable wound to the left buttocks. Per the note, the resident was being followed by the wound clinic as outpatient and was admitted to the facility for wound care. The plan was to consult with wound physician, provide wound care and to turn resident every 2 hours for skin integrity. The skin/wound note dated [DATE] included the resident had [DIAGNOSES REDACTED]. Per the note, the resident had a stage 3 pressure injury to the sacrococcygeal area, which measured 3 cm x 2 cm x 0.2 cm. The resident was repositioned to sideline, LAL/AP (low air loss/alternating pressure) and support surface were ordered, wound consult and treatments were in place. The urinary incontinence tool dated [DATE] included the resident had a functional type of incontinence and had an indwelling urinary catheter. A comprehensive pressure ulcer care plan was developed on [DATE], which included the resident had a pressure ulcer to left buttock and had the potential for pressure injury development related to a history of pressure injuries, cancer and immobility. The goal was for the pressure injury to show signs of healing and remain free from infection. Interventions included administering medications and treatments as ordered; assess wound healing and measure length, width and depth where possible and document weekly status of wound perimeter, wound bed/type of tissue, exudate and healing progress; reporting improvements and declines to the physician; avoid positioning the resident on the pressure injury; follow the facility policies/protocols for the prevention/treatment of [REDACTED]. However, the care plan it did not reflect that the resident had a stage 3 pressure ulcer to the sacral area. A skilled nursing note dated [DATE] included documentation of Dakin's (wound antiseptic) to the sacrum area. However, there was no physician's order for this treatment in August 2019. According to the physician orders dated [DATE], the following orders were included: -Offloading donut to prevent pressure necrosis of the sacrum -Clean sacrococcygeal with wound cleanser, pat dry, apply fibrocal, cover with [MED], secure with bordered gauze, apply skin prep to periwound daily and as needed if soiled every night shift for a [DIAGNOSES REDACTED]. -In-house wound consult by physician or NP wound provider Review of the August 2019 Treatment Administration Records revealed the treatment order for the sacrococcygeal pressure ulcer was not transcribed onto the TAR. As a result, there was no documentation that the treatment was done from August 21-23. A physician progress notes [REDACTED]. Physical examination included pressure wound to the left sacrum area. The plan was to continue with wound care and supportive treatment and disposition was unclear. The NP progress note dated August 26, 2019 included the resident had a stage 3 pressure ulcer of the sacral region, with full thickness skin loss. Review of the 5-day MDS assessment dated [DATE] revealed the resident had a BI[CONDITION] score of 9, indicating moderate cognitive impairment. The MDS included the resident required extensive assistance of two persons with bed mobility, transfers, dressing, toilet use and personal hygiene. Per the MDS, the resident was at risk of developing pressure ulcer/injuries and had one unhealed stage 3 pressure ulcer. Further review of the August 2019 TAR revealed that the treatment order (from August 21) to cleanse the sacrococcygeal with wound cleanser, pat dry, apply fibrocal, cover with [MED], secure with bordered gauze, apply skin prep to periwound daily and as needed every night shift for a [DIAGNOSES REDACTED]. As a result, there was no documentation that the wound treatment had been provided from August 24-27. There was also no corresponding documentation as to why the treatments were not provided as ordered. A wound physician note dated August 27, 2019 included the resident had a history of [REDACTED]. The resident had been admitted to the hospital, due to worsening decubitus of the sacrum and was transferred to the facility for treatment. Examination included sacral flap incision noted with an area of dehiscence at the mid to lower sacral flap incision line, necrotic soft eschar noted on the wound bed, with minimal granulation. Under assessment, it included a stage IV sacral decubitus ulceration status [REDACTED]. The plan included alternating pressure/low air loss mattress, turning the resident per facility protocol and begin dressing with [MEDICATION NAME] cream/gauze, secure with tape daily and as needed. Another Braden Scale for Predicting Pressure Ulcer Risk dated August 27, 2019, revealed a score of 15 indicating the resident was at mild risk, despite having a stage 4 pressure ulcer. The Wound Observation Tool dated August 28, 2019 revealed the resident had a stage 3 pressure to sacrum, which measured 0.5 cm x 0.4 cm x 0.2 cm with [MEDICATION NAME] and granulation tissue and a small amount of serous drainage. Per the documentation the wound was improving. The skilled nursing note dated August 29, 2019 revealed the resident remained with skilled wound care and had ordered treatment in place. Review of a Care Management note dated August 30, 2019 revealed the family insisted on looking at the resident's wound. Per the note, wound care was done and new dressing was placed, and there were no signs and symptom infection on all 3 areas. The documentation did not include the specific areas of the 3 wounds. Continued review of the August 2019 TAR revealed there was no documentation that the wound treatment (from August 21) to cleanse the sacrococcygeal with wound cleanser, pat dry, apply fibrocal, cover with [MED], secure with bordered gauze, and apply skin prep to periwound daily and as needed had still not been transcribed onto the TAR. As a result, there was no documentation that the wound treatment had been provided on August 28 and 29. A physician's order dated August 30, 2019 included to discontinue the order to cleanse the sacrococcygeal with wound cleanser, pat dry, apply fibrocal, cover with [MED], secure with bordered gauze, and apply skin prep to periwound daily and as needed. The reason documented was per family request and wound care keeps getting missed. Further review of the clinical record and the TARs revealed no documentation of any wound treatment that was done to the sacrococcygeal on August 31 and on September 1, 2019. A physician's order September 2, 2019 included to clean the sacrococcygeal with wound cleanser, pat dry, apply fibrocal, cover with [MED], secure with bordered gauze, and apply skin prep to periwound daily and as needed if soiled, every day shift. Per the September 2019 TAR, the treatment was administered on September 3, but was discontinued on September 4. The Wound Observation Tool dated September 4, 2019 included the resident had an unstageable DTI (deep tissue injury) to the sacrum, which measured 2.5 cm x 2.5 cm and depth was unable to be determine, and had 50% dark purple tissue with a small amount of serous drainage. Per the documentation, the wound had worsened and there was maceration of the periwound. It also included the resident refused to go back to bed during the day and enjoyed sitting in the wheelchair with a ROHO cushion in place. A physician's order dated September 4, 2019 included to clean the sacrococcygeal with wound cleanser, pat dry, apply [MEDICATION NAME] to wound bed, cover with [MEDICATION NAME] and large bordered gauze dressing, change daily every day shift and as needed for a pressure injury. The documentation on the September 2019 TAR showed that this treatment was administered on September 4, but was discontinued on September 5. The NP note dated September 5, 2019 revealed the resident had a unstageable sacral decubitus ulceration with mild granulation, with serosanguinous drainage and had no warmth or inflammation. The plan was to continue [MEDICATION NAME] gauze dressings and cover with gauze and tape daily. Further review of the clinical record revealed documentation that on September 6, 2019, the resident was discharged from the facility. The undated discharge summary included the resident had an unstageable pressure ulcer to the sacral region with treatment ordered. An interview was conducted on January 8, 2020 at 9:20 a.m. with a licensed practical nurse (LPN/staff #1[AGE]), who stated that skin issues are identified from reports from residents/family or certified nursing assistants (CNA's) during cares. She stated on admission, a head to toe assessment is conducted and every skin issue should be identified and documented in the clinical record. She said she will observe the skin and will describe and document what is seen. She stated that she will describe the wound as a rash, a skin tear or abrasion, but she cannot say or document the type of wound such as a pressure ulcer, nor can she measure the wound. She stated that she will report her findings to the wound nurse, who will then conduct a wound assessment and document the type, stage and measurements of the wound. Staff #1[AGE] said the wound nurse will determine whether the treatment implemented is appropriate or not. She stated the treatments are done by the nurses, but the wound nurse does the treatment for [REDACTED]. She stated when treatments are done, they should be documented by the nurses on the TAR. In an interview with another LPN (staff #15) conducted on January 8, 2020 at 10:42 a.m., staff #15 stated when she receives a report of a skin issue, she will assess the wound and document what she sees. She stated that she can say what type of wound such as if it is a pressure wound or not; and she can measure the length and width of the wound but not the depth. She said that she can also apply standing treatment orders. She said she would notify the wound nurse, who will assess the wound within a day and she will notify the physician of the wound. She stated treatments to wounds are provided by the nurses on the floor and should be documented in the TAR. She further stated that all refusal of treatments will also be documented in the TAR. At this time, another LPN (staff #35) joined the interview. Staff #35 stated that when a resident is assessed to be at risk for developing pressure ulcers, interventions will be put in place such as check and change frequently and turning and repositioning. However, staff #35 stated that turning and repositioning is not documented in the clinical record, but it is a standard of practice. Staff #35 also stated when a resident is at risk, is incontinent, has wounds and refuses to be turned, the resident will be encouraged and interventions such as use of cushion and specialized mattress will be implemented. She stated refusals for turning and repositioning will be documented by the nurses in the progress notes. An interview was conducted on January 8, 2020 at 11:38 a.m. with a registered nurse (one of the wound nurses/staff #54), who was the nurse who changed the dressing of resident #308 on August 30. He stated the resident had wounds to the buttocks which did not look bad. He stated that he was new as a wound nurse and was in training at the time of the incident and that he could not tell whether the wounds actually improved or got worse. In an interview with a registered nurse (staff #26) conducted on January 8, 2020 at 12:59 p.m., she stated when a skin issue is brought to her attention, she will assess the wound and document what she sees. She stated that she cannot tell or document whether the wound is a pressure ulcer/injury or not. She stated that she will notify the wound nurse who will assess the wound, say the type of wound, measures the wound and recommends treatment. She stated treatments are provided by the floor nurses and should be documented in the TAR. She stated if the resident refuses treatment it will also be marked in the TAR. She said if the wound is worsening, she will notify the physician and the wound nurse, and will document it in the progress notes. An interview with another wound nurse (staff #213) was conducted on January 8, 2020 at 1:24 p.m. She stated that she sees all residents admitted to the facility the day following admission, regardless of whether they have a wound or not. She stated that she reviews the assessment notes done by the admitting nurse, reviews the treatment orders from the hospital and consults with the physician for treatment orders. She stated that she sees the newly admitted residents, conducts an assessment of the wound, documents her assessment in the Skin/Wound note and checks for treatment orders. She said the nurses can assess and describe what they see, but they cannot identify or stage the wound. She stated the floor nurses know the basic treatment for [REDACTED]. She said when a resident is admitted at night, the nurse on duty will assess the wound and provide treatment, until she assesses the wound the following day. She said treatment orders are initiated on the same day the wound was identified or when the treatment order changes. She said she lays eyes on all residents with wounds on a weekly basis and that the wound physician alternates with the wound NP (nurse practitioner) in seeing residents with complicated or complex wounds, such as wounds that are getting bigger or nonhealing. She stated examples of factors that could contribute to worsening of wounds are poor nutrition, noncompliance, decline in health, refusals and presence of comorbidities. She stated when a resident refuses and is noncompliant with treatment, it will be documented by her and the floor nurses in the clinical record. She said the management of wounds is a team approach. She stated that if treatment is provided it should be documented in the clinical record. At this time, the clinical record of resident #308 was reviewed with staff #213. She stated the resident's wounds were assessed on [DATE], which was the day after admission. She stated the resident had an unstageable pressure wound to the left buttocks and had a stage 3 pressure wound to the sacrococcygeal area and that treatment was provided daily. However, she stated that she could not say whether the pressure wounds of resident #308 worsened or not, because she only saw resident #308 once during the resident's stay at the facility. She further said that orders should be implemented. An interview with the Director of Nursing (DON/staff #6) was conducted on January 8, 2020 at 2:53 p.m., the Administrator (staff #224) and corporate resource (staff #223). Regarding resident #308, the DON stated the resident was admitted to the facility with multiple wounds, received treatments for the wounds and that the wounds improved, prior to discharge. She stated she does not know why the wound to the sacrococcygeal area which was documented as improving on August 28, worsened on September 4, 2019. She stated that resident #308 had a lot of comorbidities, had an awkward amputation and was noncompliant with treatment. However, there was only one documentation of the resident refusal of treatment. She stated that she does not know why treatment provided was not documented in the clinical record. In another interview with the DON (staff #6) conducted on January 8, 2020 at 3:42 p.m., she stated that the facility follows the guidelines from the WOCN (Wound, Ostomy, Continence Nurses) Society to describe wounds. According to the 2019 WOCN guidelines, a pressure injury is defined as localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Further review of the WOCN guidelines revealed the following stages of pressure injury: -Stage 1 Pressure Injury described as non-blanchable [DIAGNOSES REDACTED] of intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury; -Stage 2 Pressure Injury described as a partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions); -Stage 3 Pressure Injury described as a full-thickness skin loss, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury; -Stage 4 Pressure Injury described as a full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obsc",2020-09-01
826,LIFE CARE CENTER OF NORTH GLENDALE,35126,13620 NORTH 55TH AVENUE,GLENDALE,AZ,85304,2020-01-08,689,D,1,1,PE8E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, facility documentation, staff and family interviews, review of community provider documentation and policies and procedures, the facility failed to ensure the resident's environment remained as free of accident hazards as is possible, by failing to re-assess one resident (#211) for safety with handling hot liquids after developing tremors. The deficient practice could result in further injuries to residents. Findings include: Resident #211 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the hospital discharge orders dated October 24, 2019 revealed for [MEDICATION NAME] (anticonvulsant and anti-neuralgic) 100 milligram (mg) capsule by mouth three times daily as needed. Review of the facility's admission orders [REDACTED]. A nurse progress note dated October 24, 2019 revealed the resident was alert and oriented times four. According to a provider history and physical dated October 25, 2019, the resident had good tone, moved all extremities and had no tremors. The note included that the resident had [MEDICAL CONDITION] and remained on [MEDICATION NAME]. An occupational therapy (OT) evaluation and plan of treatment dated October 25, 2019 revealed the resident was independent in self feeding and that fine motor and gross motor coordination was intact. A physical therapy (PT) evaluation and plan of treatment dated October 25, 2019 revealed the resident's gross motor coordination was impaired and had decreased mobility, balance and safety requiring skilled PT intervention. Review of a provider's progress note dated October 28, 2019 revealed the resident moved all extremities and no tremors were noted. The note included that the resident had [MEDICAL CONDITION] and remained on [MEDICATION NAME], which was prescribed as needed. However, review of the Medication Administration Record [REDACTED]. A PT note dated October 30, 2019 now stated that the resident was unable to gait train, due to tremors and trembling and that nursing was notified and was aware. According to a nurse progress note dated October 30, 2019, the resident was complaining of bilateral upper and lower extremity tremors, and had spilled his coffee two times due to shaking. The note included the doctor was notified and new orders were received to obtain a complete blood count (CBC), a comprehensive metabolic panel (CMP), and to give [MEDICATION NAME] (diuretic) 1 mg extra dose at noon. The note stated Reinforce safety instructions with patient to use call and wheelchair for mobility at this time for fall precautions. The above nurses progress note, nor the clinical record contained any documentation as to whether the resident sustained [REDACTED]. A physician's progress note dated October 30, 2019 revealed the resident appeared somewhat sleepy and had jerking movements. The note included a review of the records revealed that the [MEDICATION NAME] was supposed to be as needed, but was being given scheduled. The note stated the provider felt that it was medication induced and the [MEDICATION NAME] was discontinued. A physician's order dated October 30, 2019 included to discontinue [MEDICATION NAME] 100 mg by mouth three times a day for [MEDICAL CONDITION]. A new order dated October 30, 2019 included for [MEDICATION NAME] capsule 100 mg by mouth every eight hours as needed for [MEDICAL CONDITION]. Review of a PT note dated October 31, 2019 revealed the resident continued with tremors and trembling and the family reports to not ambulate resident today for safety. Despite documentation the resident had spilled coffee two times on October 30 and continued to have tremors on October 31, there was no clinical record documentation that the resident was re-assessed for safety with handling hot liquids. Review of a care plan initiated on October 31, 2019 revealed the resident had a skin injury related to hot coffee spill to the thighs. A goal was that the resident would have no complications from skin injury. The interventions included to avoid scratching, treatment as ordered, keep clean and dry, and monitor for signs and symptoms of infection. However, there was no clinical record documentation that the resident sustained [REDACTED]. In addition, there was no evidence that the resident's care plans were revised to reflect the presence of tremors related to hot coffee spills and they did not identify that the resident was at increased risk for injury and implement additional safety measures. Review of a PT note dated November 1, 2019 revealed the medical doctor spoke to the patient during the session and stated he believed the unsteady and jerky movements were attributed to a medicine, which had since been discontinued. Under complexities/barriers impacting the session it included limited by unsteadiness and jerky motions and medication to be withheld. A provider's progress note dated November 1, 2019 revealed a family member confirmed that the [MEDICATION NAME] really made the resident sleepy and the provider advised to discontinue. The note included the resident appeared somewhat sleepy and had jerking movements, which the provider felt was medication induced. A care management nurse's progress note dated November 1, 2019 discussed the possibility of the resident remaining in the facility until November 4, 2019 per doctor, due to medication changes and increased tremors. A nurse's progress note dated November 1, 2019 revealed this writer was summoned to the room by the resident's family member who stated the resident spilled his coffee and his shorts were soiled. The resident was assessed and was noted to have redness with 2 small blisters to the inner thigh area. The resident was cleaned, a call was placed to provider and will continue to monitor. Review of the facility incident report regarding the burn which occurred on November 1, 2019 at 6:33 p.m., the resident was drinking coffee and spilled the coffee onto bilateral thighs. The nurse assessed the thighs and noted redness and two small blisters. The report further included that there were no predisposing factors other than the resident had lost his grip on the coffee mug. However, the clinical record contained documentation by various sources that the resident had been exhibiting shaking/tremors since October 30 and had also spilled his coffee twice on October 30. A nurse's progress note/discharge summary dated November 2, 2019 at 10:55 a.m., included the resident was transitioned home as planned, with his belongings and prescriptions for medications. The noted included that the resident and family were reminded to follow up with the primary care provider within a week and was stable upon discharge. Review of a discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BI[CONDITION]) score of 15, which indicated intact cognition. Review of a PT discharge summary signed on November 5, 2019 for dates of service of October 25 to November 1, 2019 revealed the resident declined in function over the last few days of therapy, due to medication change and the medication still being in his system. The note stated the medical doctor reported on the last day that he felt the resident would return to his prior level of function, once the medication left his system. Review of a community provider physician note dated November 6, 2019 revealed the resident was burned with hot coffee on his inner thighs and groin area. The physical exam included the resident's left thigh and right inner thigh had [DIAGNOSES REDACTED], blistering and ulcerations. The assessment included the resident had partial thickness burn to lower limb/left and for [MEDICATION NAME] cream to be applied two times a day and if it worsened, would consider dermatology/wound care. The note also included a second degree burn to right lower limb. Further review of the resident's care plan revealed it was revised on November 15, 2019. However, the resident was discharge on November 2, 2019. Despite this, the care plan included the resident had a potential/actual impairment to skin integrity with a goal that the resident would maintain or develop clean and intact skin. The interventions included to assess the location, size and treatment of [REDACTED]. An interview was conducted with a family member on [DATE] at 1:24 p.m. She stated that they were giving the resident [MEDICATION NAME] and he developed shaky movements over a couple of days. She stated they constantly gave the resident scalding coffee. She stated that she was unaware of the coffee spills which occurred before the day he got burned. She stated that if they knew it was a hazard, why did they give him scalding hot coffee. An interview was conducted with a Certified Nursing Assistant (CNA/staff #201) on January 6, 2020 at 1:43 p.m. She stated if a resident was having shaking or tremors, they would be at risk [MEDICAL CONDITION] hot fluids and she would check with the nurse to see if the resident was safe to have hot liquids. She said if a resident was at risk for a spills/burns staff were not to give a resident coffee in their room. An interview was conducted with a Registered Nurse (RN/staff #46) on January 7, 2020 at 10:20 a.m. He stated if a resident had tremors, the resident would be at an increased risk for spilling hot liquids and getting burned. After reviewing his note from October 30, 2019 where he wrote Reinforce safety instructions with patient to use call and wheelchair for mobility at this time for fall precautions he stated that he reinforced safety and told the resident to call staff for assist with feeding. He stated that he felt the spilling of the coffee was an isolated incident. An interview was conducted with the Medical Doctor (staff #225) on January 7, 2020 at 10:36 a.m. He stated that he talked with the family as the resident was having sedation and tremors and he felt it was related to the scheduled [MEDICATION NAME], so he stopped the medication. He stated that [MEDICATION NAME] was known to cause tremors. He stated that he did not believe he had changed the medication to be administered scheduled. He stated that when the resident became sleepy he looked at the discharge orders from the hospital and that it was a transcription error. He stated the dose ordered was not a high dose, but it would build in the system and the resident developed a common adverse side effect from the medication being given routinely. He stated the resident received six days of the [MEDICATION NAME]. An interview was conducted with a RN (staff #26) on January 8, 2020 at 9:45 a.m. She stated that she remembered when resident #211 spilled his coffee (on November 1). She stated there was nothing that made her think he was at risk for a burn and that she did not observe any tremors. She stated that she answered the resident's call light and he asked to coffee. She stated a family member was there and he had just finished his dinner. She stated that she got him the coffee and put it on the table in his room and she left. She stated that the family came out and said that the resident had spilled his coffee. An interview was conducted with the Director of Nursing (DON/staff #6), Administrator (staff #224), and the Regional Director of Clinical Services (staff #223) on January 8, 2020 at 2:25 p.m. When asked about the facility's process for assessing resident's for burn risk from hot beverages, the DON stated that all of the residents are assessed/evaluated on admission and if they are identified as at risk, they would determine the precautions needed individually. She stated that they always want to prevent accidents. She said that resident #211 was alert and oriented and independent with decisions. She stated that she would not base all future care on one incident of a spill. The Administrator stated that for this resident, it would be hard to say if staff did what they could to prevent the incident. She stated that maybe the facility staff could have put a lid on the cup. Review of the facility policy on Reducing the Risk [MEDICAL CONDITION] Residents from Hot Beverages revealed to place hot beverages away from the edge of the table but within reach of the resident's dominant hand; the temperature of hot beverages should be between 145 and 155 degrees at delivery, and to ensure that residents are satisfied with temperatures at delivery. The policy stated to use an individualized approach with each resident to ensure safety including: place safety lids on cups if appropriate; use ice or milk to cool a hot beverage if the resident is agreeable; and explain to the resident that he or she is being served a hot beverage and inform the resident where it has been placed. Review of a policy for the incident management process revealed that the facility strives to provide a safe environment for all residents, promoting optimal lifestyles and sustaining the best possible quality of life. The policy included that the facility educates their associates to follow safe practices as outlined in facility policies and procedures and that they encourage active participation in promoting safety awareness practices, within the facility and the community.",2020-09-01
827,LIFE CARE CENTER OF NORTH GLENDALE,35126,13620 NORTH 55TH AVENUE,GLENDALE,AZ,85304,2020-01-08,695,D,0,1,PE8E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#142) had an order for [REDACTED]. Findings include: Resident #142 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission Minimum Data Set assessment dated [DATE], revealed a score of 15 on the Brief Interview for Mental Status which indicated the resident was cognitively intact. The assessment also included the resident did not receive oxygen therapy during the look-back period. During an observation conducted on January 2, 2020 at 11:23 a.m., the resident was observed lying in her bed with oxygen on at 2 liters per minute (LPM) via nasal cannula. Another observation was conducted of the resident on [DATE] at 8:51 a.m. The resident was observed lying in bed receiving oxygen at 2 LPM via nasal cannula However, review of the clinical record revealed no order for oxygen at 2 LPM via nasal cannula. In an interview conducted with a licensed practical nurse (LPN/staff #15) on January 8. 2020 at 10:42 a.m., the LPN stated an order is required for residents who use oxygen. She stated the only time oxygen is applied without an order is during an emergency. She stated regarding resident #142, she would call the physician and obtain an order for [REDACTED].>An interview was conducted on January 8, 2020 at 12:59 a.m. with a registered nurse (RN/staff ##26), who stated residents who use oxygen must have an order for [REDACTED]. During an interview conducted with the Director of Nursing (DON/staff #6) on January 8, 2020 at 2:53 p.m., the DON stated residents receiving oxygen need to have a physician order [REDACTED]. Review of the facility's policy titled Oxygen Administration/Safety/Storage/Maintenance revised December 3, 2018 revealed the purpose of the policy is to assure oxygen is administered and stored safely. The facility's policy regarding physician orders [REDACTED].",2020-09-01
828,LIFE CARE CENTER OF NORTH GLENDALE,35126,13620 NORTH 55TH AVENUE,GLENDALE,AZ,85304,2020-01-08,725,E,0,1,PE8E11,"Based on resident and staff interviews, facility documentation, and policy review, the facility failed to ensure there was sufficient nursing staff to meet the needs of residents. The deficient practice resulted in residents' needs not being met. The census was 1[AGE]. Findings include: During the survey, 7 out of 35 residents reported concerns of not having enough staff. Residents reported that they have waited up to an hour for call lights to be answered. They stated they have waited 20 minutes to an hour waiting for assistance with toileting resulting in one resident having a bowel movement in the brief, residents urinating in briefs and lying in wet briefs, and residents who needs assistance getting up without assistance. Residents stated they hope the staffing shortage will be addressed. Review of the Facility Assessment Tool dated September 11, 2019, revealed the type of care required by the resident population that the facility provides included responding to requests for assistance to the bathroom/toilet promptly in order to maintain continence and promote resident dignity. The assessment tool included the general approach to staffing to ensure they have sufficient staff to meet the needs of the residents at any given time is 1.45 to 1.6 hours per patient day (PPD) for licensed nurses providing direct care and 1.6 to 1.8 hours PPD for nurse aides. The assessment tool also included the facility team reviews the acuity and residents needs in the mornings and that as areas of need are identified, steps are taken to ensure the necessary staff are obtained to ensure the residents receive the care necessary for healing, safety and comfort. Review of the facility census dated December 25, 2019, revealed there were 52 residents on Station Two. The Daily Nursing Staff Posting dated December 25, 2019, revealed 5 Licensed Practical Nurses (LPNs) were scheduled to work the overnight shift, 10:00 p.m. to 6:00 a.m. A review of the staffing schedule dated December 25, 2019 revealed 2 of the 5 LPNs (staff #7 and staff #120) were scheduled to work the overnight shift on Station Two. Review of the Punch Detail Time Card dated December 25, 2019 revealed staff #120 clocked out at 4:00 a.m. on December 26, 2019 which resulted in the LPN only working 5.98 hours of the 8 hour shift. Review of the Punch Detail Time Cards dated December 26, 2019 revealed the two day shift LPNs (staff #124 and staff # 154) for Station Two clocked in for work at 6:07 a.m. and 6:27 a.m., respectively. An interview was conducted with the Staff Coordinator (staff #66) on January 7, 2020 at 9:08 a.m. She said that she is in charge of schedules, monitoring hours and documenting hours worked for all staff. Staff #66 said that staffing is based on the daily census and the census for each station. Regarding the overnight shift for December 25, 2019, staff #66 reviewed the schedule, Time Cards for the LPNs and the Unit manager, and the Time Clock Correction form for salary staff that provides direct care when needed and stated that after staff #120 left, staff #7 was the only nurse working Station Two. She stated that two nurses were required to work that station. Staff #66 stated that when staff leaves early, she is contacted so she can find staff to cover the rest of the shift. She stated that she would call staff scheduled for the next shift to see if staff can come in early or the assistance director of nursing may cover the shift. She stated they are short staffed and not able to cover shifts for nurses and CNAs on a monthly basis. Staff #66 also stated that she contacts the Director of Nursing (DON) when she is not able to find staff coverage for a shift. An interview was conducted on January 7, 2020 at 2:42 p.m. with staff #33, who stated that for residents who require 2 staff for transfers; there is not always a second staff readily available resulting in residents having to wait. Staff #33 stated sometimes staff will transfer the resident without a second staff if the resident is able to assist with the transfer. Staff #33 stated that when a staff comes out of a room from assisting a resident and there are call lights on, one does not know how long the call lights have been on and will just answer a call light. Staff #33 stated the facility was short staffed at Christmas time because staff wanted time off. An interview was conducted on January 8, 2020 at 3:59 p.m. with the DON (staff #6) and the Corporate Resource Staff (#223) with another surveyor present. Staff #6 stated that staffing is based on acuity and residents' needs. The DON stated that she determines if residents' needs are being met by concerns voiced by the staff, residents, and family members, and review of documentation. She stated that when she receives a complaint, she speaks to the resident, family, and the staff to try and determine if there is a problem. The DON stated that they do not observe and monitor call light wait time on a regular basis. She stated if there is a call light response time concern, she will conduct an observation. She stated they have no expectation regarding call light response time. She further stated call light response time depends on the specific issue and resident. The DON said that she rather staff take their time to ensure a resident is receiving safe care. The DON further said it is the responsibility of the CNA to prioritize how and when to respond to call lights. She stated that it is her expectation that when a CNA is finished providing care for a resident and comes out of the resident's room to find multiple call lights on, the CNA would go to each resident's room to determine what type of assistance is needed and prioritize based on the most important need. Review of the facility's policy regarding staffing effective April 24, 2019, revealed the facility maintains adequate staff on each shift to meet residents' needs. The policy included the facility utilizes the Facility Assessment as the foundation to determine staffing levels necessary to ensure that residents' needs are met.",2020-09-01
829,LIFE CARE CENTER OF NORTH GLENDALE,35126,13620 NORTH 55TH AVENUE,GLENDALE,AZ,85304,2020-01-08,732,E,0,1,PE8E11,"Based on review of facility documentation, staff interviews and policy review, the facility failed to ensure that the Nurse Staffing information was posted on a daily basis, which included the actual hours worked by licensed and unlicensed nursing staff. Findings include: Review of the Daily Posted Nurse Staffing information from September 2019 through December 2019, revealed they did not contain the total actual hours worked by licensed and unlicensed staff. During an interview conducted on January 2, 2020 at 9:05 a.m. with the Staffing Coordinator (staff #66), the Daily Nurse Staffing information was observed to be posted on the first floor within view. The Daily Nurse Staffing posting contained information that included the date, the census number, and the total number of licensed and unlicensed staff working for each shift. However, it did not include the total number of actual hours worked. Staff #66 stated that she is the person responsible for completing the Daily Nurse Staffing Schedule for each day and that the schedules are posted on the first and third floor. A second interview was conducted on January 7, 2020 at 9:08 a.m., with staff #66. During this time, the Daily Posted Nurse Staffing information for September 2019 through December 2019 was reviewed with staff #66. She stated that she has never documented the total number of actual hours worked on the Daily Posted Nurse Staffing Schedule and asked if she was supposed to do that. Review of the facility Staffing Policy effective April 24, 2019, revealed that the Daily Posted Staffing Schedule must include the total number and the actual number of hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered Nurses, Licensed Practical Nurses and Certified Nurse Aides.",2020-09-01
830,LIFE CARE CENTER OF NORTH GLENDALE,35126,13620 NORTH 55TH AVENUE,GLENDALE,AZ,85304,2020-01-08,758,E,0,1,PE8E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy review, the facility failed to ensure that monitoring for target behaviors related to the use of an antipsychotic medication was completed for one resident (#96). The deficient practice could result in a lack of identifying if targeted symptoms were improving or declining. Findings include: Resident #96 admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of a care plan dated November 19, 2019 revealed the resident used a [MEDICAL CONDITION] medication related to disease process, with a goal that the resident would remain free of [MEDICAL CONDITION] drug related complications, including movement disorder, discomfort, [MEDICAL CONDITION], gait disturbance, constipation/impaction or cognitive/behavioral impairment. The interventions included to administer [MEDICAL CONDITION] medication as ordered by the physician and observe for effectiveness each shift; discuss with medical doctor and family regarding the ongoing need for use of the medication and review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy; and observe for occurrence of target behavior symptoms of visual hallucinations, pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document per facility protocol. A psychiatric note dated November 20, 2019 included the resident was started on [MEDICATION NAME] for visual hallucinations and behavioral issues by internal medicine. The note included a [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had short and long term memory problems, was disoriented, and was moderately impaired with cognitive skills for daily decision making. The MDS included for daily use of an antipsychotic medication. A psychiatric note dated November 27, 2019 revealed the resident was receiving [MEDICATION NAME] and included monitoring for changes in behavior and mood. Review of the Medication Administration Record [REDACTED]. A psychiatric note dated [DATE] included the resident was receiving [MEDICATION NAME] and was being monitored for changes in behavior and mood. A psychiatric note dated December 18, 2019 revealed the resident was to continue receiving [MEDICATION NAME] and for monitoring for changes in behavior and mood. Review of the MAR for December 2019 revealed the resident received [MEDICATION NAME] from December 1 through December 31, 2019. Review of the MAR for January 2020 (printed on January 7, 2020) revealed the resident received [MEDICATION NAME] from January 1 through January 6, 2020. However, review of the clinical record revealed there was no documentation of daily monitoring for the target behavior of visual hallucinations related to [MEDICATION NAME] use, from admission on November 18, 2019 through January 6, 2020. An interview was conducted with a Licensed Practical Nurse (LPN/staff #68) on January 7, 2020 at 2:05 p.m. She stated that the target behavior is part of the order and is determined by assessing what the resident is experiencing. She stated the behaviors should be monitored each shift on the MAR. On review of the January MAR for resident #96, she said that there was no behavior monitoring being documented and that the lack of monitoring did not meet the facility's expectations regarding an antipsychotic medication. She stated that if staff did not monitor, they would not know if the medication was effective in treating the target behavior. An interview was conducted with the Director of Nursing (DON/staff #6), the Administrator (staff #224), and the Regional Director of Clinical Services (#223) on January 8, 2020 at 2:25 p.m. The DON stated the nurses are expected to monitor each shift on the MAR for the target behavior for each different type of [MEDICAL CONDITION] medication, to see if the medication is effective. She said the lack of behavior monitoring on the MAR for resident #96 did not meet her expectations. Review of a policy regarding [MEDICAL CONDITION] Medication Use revealed that a [MEDICAL CONDITION] medication is any medication that affects the brain activities associated with mental processes and behavior. The policy included that [MEDICAL CONDITION] medications to treat behaviors will be used appropriately to address specific underlying medical or psychiatric causes of behavioral symptoms. The policy stated that facility staff should monitor the resident's behavior pursuant to facility policy, using a behavioral monitoring chart or behavioral assessment record for residents receiving [MEDICAL CONDITION] medication for organic mental syndrome with agitated psychotic behavior(s). The policy included that facility staff should monitor behavioral triggers, episodes, and symptoms and should document the number and/or intensity of symptoms and the resident's response to staff interventions.",2020-09-01
831,LIFE CARE CENTER OF NORTH GLENDALE,35126,13620 NORTH 55TH AVENUE,GLENDALE,AZ,85304,2020-01-08,759,D,0,1,PE8E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record, staff interviews and policies and procedures, the facility failed to ensure the medication error rate was not 5% or greater, by failing to administer medications as ordered for one resident (#36). The medication error rate was 7.69%. The deficient practice could result in possible side effects/complications from receiving medications that are not administered as ordered. Findings include: Resident #36 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Regarding the [MED] medication: Review of the Medication Administration Record [REDACTED]. During a medication administration observation conducted on January 6, 2020 at approximately 7:47 a.m. with a Licensed Practical Nurse (LPN/staff #154) , the LPN was observed to administer [MED] laxative sennosides two 8.6 milligrams (mg) tablets by mouth to resident #36. An interview was conducted with the LPN (staff #154) on January 6, 2020 at 9:44 a.m. She acknowledged that she gave two tablets of the [MED] laxative sennosides 8.6 mg and that she should have given the [MED] with the [MEDICATION NAME] [MED] as ordered. She stated that this was a medication error as it was the wrong medication. She stated that as a result of the medication error, the medication would not be as effective with the constipation portion of the treatment. Regarding the [MEDICATION NAME] propionate nasal spray: Review of the MAR for January 2019 revealed an entry for [MEDICATION NAME] propionate suspension 50 mcg one spray in each nostril one time a day for allergies [REDACTED].>During this same medication administration observation conducted at 8:10 a.m., staff #154 was observed to give the bottle of [MEDICATION NAME] propionate nasal spray (50 micrograms per spray) to resident #36, without any verbal direction for dosage. The resident was then observed to administer two sprays to the right nostril and two sprays to the left nostril, without the LPN intervening and instructing the resident that the spray was ordered as one spray in each nostril. Following the observation, an interview was conducted with staff #154. She stated that the [MEDICATION NAME] nasal spray was ordered for one spray in each nostril. She stated that she did not notice that the resident sprayed the medication twice into each nostril. She said that since the resident sprayed the medication twice into each nostril, she received more than the dose ordered and that it was a medication error. She stated that as a result of the error, the resident could have adverse side effects or an allergic reaction to the medication. She stated that she did not follow expectations for following physician's orders [REDACTED]. An interview was conducted with the Director of Nursing (DON/staff #6), the Administrator (staff #224), and the Regional Director of Clinical Services (staff #223) on January 8, 2020 at 2:25 p.m. The DON stated that she expects staff to follow the seven rights of medication administration, to always double check and when in doubt, toss it out. She stated that resident #36 had not been assessed for self-administration of medications. She said that she does not think that resident #36 would be able to retain the knowledge for self-medication administration. Review of the policy on Oral Drug Administration revealed to verify the order on the patient's medical record by checking it against the practitioner's order, and to compare the drug label to the order in the patient's record. A Medication Related Errors policy included that a dose error would be dispensing a dose that is greater than or less that the amount ordered by the physician/prescriber, and that a medication error wound be dispensing a medication to a resident, other than what's ordered by the physician/prescriber.",2020-09-01
832,LIFE CARE CENTER OF NORTH GLENDALE,35126,13620 NORTH 55TH AVENUE,GLENDALE,AZ,85304,2020-01-08,880,D,0,1,PE8E11,"Based on observations, clinical record review, staff interviews and policy review, the facility failed to ensure one staff member followed infection control procedures regarding the handling of medications. The deficient practice could place residents at increased risk for infections. Findings include: An observation of medication administration was conducted on January 6, 2020 at 8:15 a.m., with Licensed Practical Nurse (LPN/staff #154). On the medication cart, there was a medication cup which contained medications for a resident. The LPN was observed to tip over the medication cup and one of the tablets spilled out onto a mouse pad, which was on top of the cart. The LPN was then observed to place the medication back into the cup with her bare hand and then administered the medication to the resident. Following the observation, an interview was conducted with staff #154. She stated that she should have thrown away the medication that spilled out of the cup and gotten a new pill for the resident. She stated that getting a new pill was important for infection control. An interview was conducted with an Assistant Director of Nursing (ADON/staff #40) on January 6, 2020 at 8:42 a.m. She stated that when the medication spilled from the cup onto the mouse pad, the nurse should have wasted the medication. She said the nurse should not have picked up the medication with her fingers and returned it to the cup for administration. She stated that when you touch a medication with your bare hands, you have contaminated the medication, and that the medication was dirty as soon as it landed on the mouse pad, so you would not have wanted to give it to the patient. Review of a policy regarding their Infection Control Plan revealed the risks of infections will vary based on the facility's geographic location, the community environment, the types of programs and services provided, the characteristics and behaviors of the population served, and results of surveillance activities. The risk analysis section included the infection control risk assessment tool is formally reviewed at least annually and whenever significant changes occur in any of the following factors: the care, treatment and services provided. Under establishing priorities and setting goals, the policy stated examples of goals might include minimizing the risk of transmitting infections associated with the use of procedures, medical equipment, and medical devices. Under implementing strategies to achieve the goals, the policy stated that interventions implemented may include methods to reduce the risks associated with procedures, medical equipment and medical devices. Review of the policy on Infection Prevention and Control Education revealed that the purpose was to educate associates and licensed independent practitioners regarding the infection prevention and control plan and processes used to decrease the risk of infection. Review of the Oral Drug Administration policy revealed that it did not address what action to take if medication is dropped/spilled, and did not address the handling of medications.",2020-09-01
833,LIFE CARE CENTER OF NORTH GLENDALE,35126,13620 NORTH 55TH AVENUE,GLENDALE,AZ,85304,2018-10-31,550,D,0,1,SCA611,"Based on observations, staff interviews, and policy, the facility failed to ensure residents were treated with dignity during dining. Findings include: -On (MONTH) 22, (YEAR) at 12:24 p.m., a dining observation was conducted of the 4th floor dining room and the assisted dining room. Numerous residents were observed to have their food plates placed on the table in the plastic serving palate/warming palate and on plastic trays. An interview was conducted with the 4th floor unit Registered Nurse (RN) manager (staff #37) on (MONTH) 24, (YEAR) at 11:45 a.m. The RN stated that the residents' food plates needed to be taken out of the serving palates/warming palates and placed on the table. The manager also stated that it was not very homelike to serve the food in the palates or on the trays. -During a dining observation conducted of the 3rd floor dining room on (MONTH) 25, (YEAR) at 8:26 a.m., two residents were observed to have their food plates in warming palates on the table. An interview was conducted with the Certified Nursing Assistant (CNA/staff #54) who was in the 3rd floor dining room observing residents. The CNA stated that he was new and thought he had been shown to leave the residents' plates on the warming palate. During an interview conducted with the RN charge nurse (staff #38) on (MONTH) 25, (YEAR) at 8:28 a.m., the RN stated that it was a hit or miss that sometimes the staff remove the plates from the warming palates and sometimes they do not. The charge nurse stated that the residents' plates should not be served in the palates. An interview was conducted with the 3rd floor RN (staff #17) on (MONTH) 25, (YEAR) at 8:44 a.m. who was at the door of the 3rd floor dining room. He stated that if he had seen the residents' plates in the palates, he would have instructed the CNA to removed the plates from the palates or removed them himself. The facility's policy regarding resident dignity revealed the facility would promote residents' independence and dignity during dining.",2020-09-01
834,LIFE CARE CENTER OF NORTH GLENDALE,35126,13620 NORTH 55TH AVENUE,GLENDALE,AZ,85304,2018-10-31,576,E,0,1,SCA611,"Based on resident and staff interviews and policy and procedure, the facility failed to ensure residents' mail was delivered upon receipt of the mail by the facility. Findings include: On (MONTH) 24, (YEAR) at 2:25 p.m., a meeting was conducted with residents who participated in the Resident Council. During the meeting residents stated that mail was delivered to the facility on Saturdays, but that the facility did not distribute the Saturday mail until Monday. During an interview conducted with a receptionist (staff #235) on (MONTH) 29, (YEAR) at 8:32 a.m., the receptionist stated that mail is delivered to the facility on Saturdays and that the mail is placed in the business office. An interview was conducted with the business office employee (staff #240) on (MONTH) 29, (YEAR) at 8:35 a.m. Staff #240 stated that the Saturday mail is placed in the business office so that it can be sorted by the business office staff to make sure that facility mail such as checks, are not delivered to the residents. Staff #240 stated that once the Saturday mail is sorted, the mail is delivered to the Activity Department along with the Monday mail. Staff #240 could not explain how mail address solely to the facility could be delivered to the residents. On (MONTH) 29, 2019 at 8:42 a.m., an interview was conducted with the Activity Director (staff #221). Staff #221 stated that residents' mail delivered to the facility on Saturdays is delivered to the Activity Department on Monday along with the Monday's mail. Staff #221 stated that she was not sure why the mail was not delivered to the residents on Saturday but that the residents have a right to receive their mail when it arrives to the facility. Staff #221 further stated it could be disappointing to a resident to be expecting a card or mail from a family member or friend, such as a birthday card, and it was not delivered upon receipt by the facility. The facility's policy regarding Resident Rights revealed the resident has a right to send and receive mail and to receive letters, packages and other materials delivered to the facility promptly and unopened.",2020-09-01
835,LIFE CARE CENTER OF NORTH GLENDALE,35126,13620 NORTH 55TH AVENUE,GLENDALE,AZ,85304,2018-10-31,578,E,0,1,SCA611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy and procedures, the facility failed to ensure there was documentation that one resident (#146) was reassessed for decision making abilities and that her goals and wishes were reassessed, prior to making a change in the resident's Advance Directives. Findings include: Resident #146 was admitted to the facility on (MONTH) 11, 2012, with [DIAGNOSES REDACTED]. Review of the clinical record revealed an Advanced Directive form, which was signed by the resident dated (MONTH) 15, 2013. The Advance Directive form indicated that the resident chose a full code status. An Advanced Directive dated (MONTH) 28, 2014 also revealed the resident was a full code status, indicating the resident wanted resuscitation should an emergent situation arise. Review of the care plan conference records dated (MONTH) 10, (YEAR) and (MONTH) 11, (YEAR) revealed documentation that the resident was a full code. A physician's progress note dated (MONTH) 14, (YEAR) included the resident was her own Medical Power of Attorney (MPOA) and participated in her own medical management. The note included the resident had an advanced directive, and in the section for intubation and resuscitation it was marked yes. A Significant Change in Status Minimum Data Set (MDS) assessment dated (MONTH) 4, (YEAR), revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. A social service progress note dated (MONTH) 17, (YEAR) included the resident was alert, was able to make her needs known and remained independent with decisions related to her daily routine. The note also included that the resident had elected a full code status. Review of the physician order [REDACTED]. Review of an Advance Directive care plan revealed the resident was a full code. The goal included the resident's Advance Directives were in effect and their wishes will be carried out. Approaches included notify physician of resident's wishes regarding life-prolonging procedures and initiate emergency response/CPR. A face sheet dated (MONTH) 10, (YEAR) included documentation that the resident was listed as the responsible party and was a full code. A nurse practitioner progress note dated (MONTH) 14, (YEAR), revealed the resident was alert and oriented times 4. Further review of the resident's clinical record revealed an Advance Directive form, which was dated (MONTH) 20, (YEAR). The documentation included that the resident was a DNR (Do Not Resuscitate) status. This form was signed by the resident's family member. The reason listed as to why the resident did not sign the document stated the resident was blind. A physician's orders [REDACTED]. There was also a red DNR status form in the resident's chart. Despite a change in the resident's DNR status on (MONTH) 20, (YEAR), there was no clinical record documentation that the resident had been reassessed, in order to determine if the resident's decision making abilities had changed, nor any documentation that the resident's goals and wishes were reassessed regarding her Advance Directives, as a result of a significant change in the resident's medical condition. A nursing progress note dated (MONTH) 22, (YEAR) included that the nurse practitioner discussed wound management with the resident and was encouraged to follow up with the vascular center, and that the resident had agreed to do so. The note also included the resident refused the compression stockings and was informed of the possible adverse effects of not applying compression and not elevating her legs. Nursing progress notes dated (MONTH) 27, (YEAR) and (MONTH) 9, (YEAR) revealed the resident was alert and oriented times three and was able to make her needs and wants known. A quarterly MDS assessment dated (MONTH) 3, (YEAR) included the resident had a BIMS score of 14, which indicated that the resident was cognitively intact. A nursing progress note dated (MONTH) 5, (YEAR) revealed the resident was alert and oriented and able to make her needs known. Review of a social services assistant progress note dated (MONTH) 15, (YEAR), revealed the resident had elected a full code status (instead of a DNR). The note also included resident #146 was alert, oriented, confused, forgetful, blind, and was able to make her needs known and was independent with decisions related to her daily routine. The note further included Family/resident have elected full code status. Review of a care plan conference record dated (MONTH) 24, (YEAR), revealed the resident's Advance Directive status was changed to DNR on (MONTH) 20, (YEAR). Nursing notes dated [DATE] revealed the nurse was unable to obtain an oxygen saturation, the resident appeared to be non-responsive to verbal and tactile stimuli, including a sternal rub, vitals signs were unable to be obtained, and the resident's skin was cold. A second nurse and the Registered Nurse supervisor were called and vital signs were checked and could not be obtained. A physician's orders [REDACTED]. Clinical record documentation included that the resident had expired at 10:39 p.m. on [DATE]. An interview was conducted with a certified nursing assistant (CNA/staff #133) on (MONTH) 25, (YEAR) at 10:23 a.m. She stated that the resident was alert and oriented and could tell staff what she wanted. An interview was conducted with the Administrator (staff #253) on (MONTH) 25, (YEAR) at 1:25 p.m. She stated that the information regarding the change of Advance Directive had occurred in August, and was probably due to the resident's decline. She stated that the resident's family was very involved in the decision-making process. In an interview with the Director of Nursing (staff #45) on (MONTH) 26, (YEAR) at 2:54 p.m., she stated that when there is a change in a resident's Advance Directive, the nurse will contact the physician, the care plan is updated, and all staff will be notified of the change. She stated that she has known the resident for a long time and the family member had always seemed to be the decision maker. Staff #45 could not say whether the family member was the resident's PO[NAME] She said the resident was alert and oriented and could tell staff what she wanted. She further stated that if the resident could not make a decision regarding Advance Directive, it is understood that the resident would be a full code. An interview was conducted with a Licensed Practical Nurse (LPN/staff #88) at 1:35 p.m. on [DATE]. She said the process regarding Advance Directive is that the nurse will go over the paperwork with the resident or the family depending on the resident's cognition. She stated that alert and oriented residents can determine their own Advance directive. She said that even if an alert resident has a POA or a direct family member involved, the resident will be able to make their own decisions regarding Advance Directives. She said that she knew this resident and that she was alert and able to make her own decisions. She said that she knows if a resident is a full code or DNR, based on the facesheet and the orders in the electronic computer system. An interview with the unit manager (staff #12) was conducted at 1:50 p.m. on [DATE]. She said that as the unit manager, she is involved with the Advance Directive paperwork. She said that in general, a resident who is alert and oriented and able to make their own decisions will determine their code status, even if they have a POA or other responsible party. She said that this resident really wasn't alert and oriented, and that is why the family member signed the DNR paperwork. She said that she had noticed a decline over several months and that she called the family member and said that it was time to reconsider her code status and if aggressive measures were desired. She said the family member agreed, but wanted to discuss the option with the resident first. She stated that a few days later, the resident's family member told her that she had discussed the code status with the resident, and the resident wanted to be a DNR. She further stated that there was no documentation in the clinical record indicating that the resident was spoken to about the Advance Directive change. She said the paperwork by the family was accepted, because the family member had said that the resident was involved in the decision. She stated that she did not have any direct conversations with the resident about the code status change. She said that since the the resident was a DNR, no CPR was started. Another interview was conducted with staff #45 at 2:15 p.m. on [DATE]. She said that she was familiar with the resident and the fact that her Advance Directives were changed to DNR in (MONTH) (YEAR). She said that the resident had a steep decline over the last few months of her life and that they had discussed hospice with the resident and family. She said they declined it, but wanted to change the code status to DNR. She said the family member was involved in the resident's care. In an interview with a Nurse Practitioner (staff #254) at 3:10 p.m. on [DATE], she stated that she has been caring for the resident for some time. She said that as the resident was declining, she called the family member and said that it was time to have a conversation regarding hospice care or comfort care and that they should discuss if a full code was still desired. She said when she discussed this with the family member, the family member wanted to discuss this with the resident. She said later, the family member said it was discussed with the resident and the decision was made for a DNR status. She stated that she could see how the resident not signing the most recent Advance Directives because of her vision looks odd, but the resident struggled physically and even signing a paper would be difficult for her. Review of the facility's Advance Directive policy revealed the resident has the right to self-determination regarding their medical care. This includes the right of an individual to direct his or her own medical treatment, including withholding or withdrawing treatment. An Advance Directive is defined as a written instruction regarding care and treatment, and recognized under state law in relation to the provision of such care when the resident is incapacitated.",2020-09-01
836,LIFE CARE CENTER OF NORTH GLENDALE,35126,13620 NORTH 55TH AVENUE,GLENDALE,AZ,85304,2018-10-31,600,G,0,1,SCA611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documentation and policies and procedures, the facility failed to ensure one resident (#99) was free from neglect. Findings include: Resident #99 was admitted to the facility on (MONTH) 21, (YEAR) and readmitted on (MONTH) 29, (YEAR). [DIAGNOSES REDACTED]. A Fall Risk assessment dated (MONTH) 15, (YEAR) revealed the resident was at risk for falls. A quarterly Minimum Data Set (MDS) assessment dated (MONTH) 4, (YEAR) revealed a Brief Interview for Mental Status score of 3, which indicated the resident had severe cognitive impairment. The MDS included the resident had sustained a fall with injury since the previous assessment. The MDS also included the resident required extensive assistance with bed mobility, transfers, toilet use and was frequently incontinent of bowel and bladder. Review of a care plan revealed the resident was at risk for injury related to falls. A goal included that the resident would not sustain a serious injury requiring hospitalization . Interventions included call light in reach, toilet after meals, and do not leave resident unattended while toileting. Review of the CNA (Certified Nursing Assistant) Care Guide revealed toileting directives which included to assist the resident with toileting as needed and do not leave resident unattended on the toilet. Review of the nursing progress note dated (MONTH) 4, (YEAR) at 6:37 p.m., revealed the nurse was told by another resident that resident #99 was on the floor. The resident complained of pain in her legs and right hip and the right leg was slightly rotated inward. The on call nurse practitioner was notified and orders were received for a right hip x-ray. Per the note, the x-ray was done, which revealed a [MEDICAL CONDITION] hip. Orders were received to send the resident to the emergency room for evaluation and treatment. The resident left the facility via gurney at 9:15 p.m. A nursing progress note dated (MONTH) 5, (YEAR) revealed the resident was admitted to the hospital. Review of the hospital History and Physical report dated (MONTH) 5, (YEAR) revealed the resident was brought to the emergency room for further evaluation for hip pain, which happened after a fall. The x-ray showed an acute comminuted, displaced right femoral neck and intertrochanteric femur fracture. The plan included to admit the resident to the medical floor and for an orthopedic evaluation in the morning. Review of the facility's investigative report revealed the resident sustained [REDACTED]. A CNA (staff #118) reported that the resident needed to use the restroom, so she assisted the resident to the bathroom. She said that she told the resident to turn on the call light when she was done, because she was going to grab some towels for her shower. The report further included that the resident was left unattended in the bathroom while a CNA (staff #118) stepped out of the room to gather towels and the resident fell landing on her right side, resulting in a [MEDICAL CONDITION] hip. The report also included that staff #118 was educated on (MONTH) 4, (YEAR) by the RN regarding strict adherence to Kardex directives, which included that the resident is not to be left unattended while toileting. In an interview with the Director of Nursing (DON/staff #45) on (MONTH) 26, (YEAR) at 11:30 a.m., the DON stated that she and the nursing supervisor investigated this accident and completed a Quality Assurance Improvement Plan for this issue. She stated that it was one CNA who left the resident unattended on the toilet, when she stepped just outside the door to get some linens, in preparation for the resident's shower. She further stated that it was clearly noted on the Care Guide that the resident was not to be left unattended in the bathroom. The DON stated that the CNA was educated on the spot and that all of the CNA's were in-serviced, and that follow up observations of care were done. Review of the facility's Quality Assurance Performance Improvement Plan revealed that after the incident, staff #118 and all nursing staff were educated regarding following resident's care plans and supervision of residents. The documentation also included monitoring of CNA practices by the licensed nurses and nursing administration over several weeks. A telephone interview was conducted on (MONTH) 26, (YEAR) at 12:07 p.m., with a Licensed Practical Nurse (LPN/staff #77), who was on duty at the time of the resident's fall. Staff #77 stated that she thought resident #99 told her that she was trying to get up from the toilet and fell . Staff #77 stated that she notified the nursing supervisor of the fall. A telephone interview was attempted with staff #118 however, the CNA was on leave and did not return any calls. Review of the facility policy titled, Protection of Residents: Reducing the Threat of Abuse and Neglect revised (MONTH) (YEAR), revealed that each resident has the right to be free from abuse and neglect. The policy included that neglect means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Neglect may be the result of a pattern of failures or may be the result of one or more failures involving one resident and one staff person. The policy further included that all residents will be protected from all types of abuse and neglect. The facility will have structures and processes in place to provide the needed care and services to all residents.",2020-09-01
837,LIFE CARE CENTER OF NORTH GLENDALE,35126,13620 NORTH 55TH AVENUE,GLENDALE,AZ,85304,2018-10-31,609,D,0,1,SCA611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documentation and policies and procedures, the facility failed to ensure that a violation involving neglect for one resident (#99) was reported to the State Survey Agency. Findings include: Resident #99 was admitted to the facility on (MONTH) 21, (YEAR) and readmitted on (MONTH) 29, (YEAR). [DIAGNOSES REDACTED]. A Fall Risk assessment dated (MONTH) 15, (YEAR) revealed the resident was at risk for falls. A quarterly Minimum Data Set (MDS) assessment dated (MONTH) 4, (YEAR) revealed a Brief Interview for Mental Status score of 3, which indicated the resident had severe cognitive impairment. The MDS included the resident had sustained a fall with injury since the previous assessment. The MDS also included the resident required extensive assistance with bed mobility, transfers, toilet use and was frequently incontinent of bowel and bladder. Review of a care plan revealed the resident was at risk for injury related to falls. A goal included that the resident would not sustain a serious injury requiring hospitalization . Interventions included call light in reach, toilet after meals, and do not leave unattended while toileting. A review of the CNA (Certified Nursing Assistant) Care Guide revealed toileting directives which included to assist the resident with toileting as needed and do not leave resident unattended on the toilet. Review of the nursing progress note dated (MONTH) 4, (YEAR) at 6:37 p.m. revealed the nurse was told by another resident that resident #99 was on the floor. The resident complained of pain in her legs and right hip and the right leg was slightly rotated inward. The on call nurse practitioner was notified and orders were received for a right hip x-ray. Per the note, the x-ray was done, which revealed a [MEDICAL CONDITION] hip. Orders were received to send the resident to the emergency room for evaluation and treatment. The resident left the facility via gurney at 9:15 p.m. Review of the hospital History and Physical report dated (MONTH) 5, (YEAR) revealed the resident was brought to the emergency room for further evaluation for hip pain, which happened after a fall. The x-ray showed an acute comminuted, displaced right femoral neck and intertrochanteric femur fracture. The plan included to admit the resident to the medical floor and for an orthopedic evaluation in the morning. Review of the facility's investigative report revealed the resident sustained [REDACTED]. A CNA (staff #118) reported that the resident needed to use the restroom, so she assisted the resident to the bathroom. She said that she told the resident to turn on the call light when she was done, because she was going to grab some towels for her shower. The report further included that the resident was left unattended in the bathroom while a CNA (staff #118) stepped out of the room to gather towels and the resident fell landing on her right side, resulting in a [MEDICAL CONDITION] hip. The report also included that staff #118 was educated on (MONTH) 4, (YEAR) by the RN regarding strict adherence to Kardex directives, which included that the resident is not to be left unattended while toileting. In a telephone interview conducted on (MONTH) 26, (YEAR) at 12:07 p.m. with a Licensed Practical Nurse (LPN/staff #77), staff #77 stated that it did not cross her mind that this might have been neglect. In a telephone interview conducted on (MONTH) 26, (YEAR) at 12:28 p.m. with a Registered Nurse (RN/staff #36), staff #36 stated that not providing care in accordance with the care plan could be considered neglect. An interview with the Executive Director (staff #253) and the Director of Nursing (DON/staff #45) was conducted on (MONTH) 29, (YEAR) at 1:13 p.m. Staff #45 stated that the incident was not reported to the State Agency, because it did not cross their minds that this incident was neglect. Review of the facility policy titled, Protection of Residents: Reducing the Threat of Abuse and Neglect revised (MONTH) (YEAR), revealed that each resident has the right to be free from abuse and neglect. Neglect means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Neglect may be the result of a pattern of failures or may be the result of one or more failures involving one resident and one staff person. The policy further included that all violations involving abuse and neglect are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serous bodily injury, to the Administrator of the facility and to the State Survey Agency, in accordance with State law through established procedures. The policy also dictated that the results of the investigation must be reported to the State Survey Agency, within 5 working days from the date of the incident. Failure to do so will mean that the facility is not in compliance with the Federal regulations.",2020-09-01
838,LIFE CARE CENTER OF NORTH GLENDALE,35126,13620 NORTH 55TH AVENUE,GLENDALE,AZ,85304,2018-10-31,641,D,0,1,SCA611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure MDS (Minimum Data Set) assessments for two residents (#29 and #61) were accurate. Findings include: -Resident #29 was admitted (MONTH) 6, (YEAR), with a [DIAGNOSES REDACTED]. A quarterly MDS assessment dated (MONTH) 26, (YEAR), revealed the resident received a hypnotic medication during the 7 day look-back period. However, review of the recapitulation of physician's orders [REDACTED]. An interview was conducted on (MONTH) 30, (YEAR) at 11:07 a.m. with the MDS nurse (staff #39). After reviewing the physician's orders [REDACTED]. Staff #39 stated the resident was administered an antianxiety medication and not a hypnotic medication. The MDS nurse stated the MDS assessment should have been coded for the antianxiety. The RAI manual instructs to review the resident's medical record for documentation that any of these medications (antipsychotic, antianxiety, antidepressant, hypnotic, anticoagulant, antibiotic, diuretic, and opioid) were received by the resident during the 7 day look-back period and record the number of days the resident received the medications. -Resident #61 was admitted (MONTH) 11, (YEAR), with [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed a physician's orders [REDACTED]. A Significant Change of Condition MDS assessment dated (MONTH) 14, (YEAR), revealed the resident had not received any Restorative Nursing Assistant (RNA) services during the 7 day look-back period. Review of the RNA documentation for (MONTH) (YEAR) revealed the resident received RNA services twice during the 7 day look-back period. An interview was conducted with staff #39 on (MONTH) 29, (YEAR) at 11:38 a.m. After reviewing the physician's orders [REDACTED].#39 stated that the resident did received RNA services during the 7 day look-back period and that the MDS assessment should have been coded for RNA services. She further stated that she did not review the documentation from RNA services when she was coding the MDS assessment. The RAI manual instructs to review the restorative nursing program notes and/or flow sheets in the medical record and record the number of days the restorative nursing program was performed during the 7 day look-back period. Review of the RAI manual for the MDS assessment also revealed the importance of accurately completing and submitting the MDS assessment cannot be over emphasized. The MDS assessment is the basis for the development of an individualized care plan.",2020-09-01
839,LIFE CARE CENTER OF NORTH GLENDALE,35126,13620 NORTH 55TH AVENUE,GLENDALE,AZ,85304,2018-10-31,658,D,0,1,SCA611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, staff interviews, and review of policies and procedures, the facility failed to ensure one resident (#54) was free from a medication error. Findings include: Resident #54 was admitted to the facility on (MONTH) 29, (YEAR), with [DIAGNOSES REDACTED]. The most recent recapitulation of physician's orders [REDACTED]. During an observation of medication administration conducted on (MONTH) 25, (YEAR) at 7:27 a.m., a Licensed Practical Nurse (LPN/staff #3) was observed to administer one multivitamin with minerals tablet to resident #54. The resident was then observed to put the tablet in her mouth and swallow the medication. Staff #3 was not observed to administer the [MEDICATION NAME] medication. During a review of the current physician's orders [REDACTED]. A review of the Medication Administration Record [REDACTED]. An interview was conducted with staff #3 on (MONTH) 25, (YEAR) at 3:20 p.m. Staff #3 stated that she realized she had made an error earlier today, when she administered resident #54 medications. She stated that she administered the multivitamin with minerals instead of the [MEDICATION NAME]. The LPN stated that after she realized the error, she immediately notified the physician of the error which is standard nursing practice. Staff #3 further stated that she had initialed the (MONTH) (YEAR) MAR indicated [REDACTED]. An interview was conducted with the Director of Nursing (staff #45) on (MONTH) 31, (YEAR) at 4:35 p.m. She stated it is the expectation that all nurses follow physician orders [REDACTED]. The facility's policy regarding physician orders [REDACTED]. Review of the facility's policy regarding medications revealed a physician order [REDACTED].",2020-09-01
840,LIFE CARE CENTER OF NORTH GLENDALE,35126,13620 NORTH 55TH AVENUE,GLENDALE,AZ,85304,2018-10-31,676,D,0,1,SCA611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and policy and procedures, the facility failed to provide the appropriate care and services for one resident (#146), in order to maintain or improve the resident's abilities during dining. Findings include: Resident #146 was admitted on (MONTH) 11, 2012, with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated (MONTH) 3, (YEAR), revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact. The MDS assessment also included the resident required limited assistance of one person with eating. Review of the care plan dated (MONTH) 9, (YEAR), revealed the resident was at nutritional risk and that the goal would be no significant weight change. Interventions included placing the resident's food in bowls to promote self-dining, informing the resident where the food is located (related to [MEDICAL CONDITION]), and providing the resident the amount of assistance/supervision as needed. A nursing progress note dated (MONTH) 10, (YEAR) revealed the resident needs assistance with eating and eats with assistance in the dining room. A lunch dining observation was conducted on (MONTH) 23, (YEAR) at 11:55 AM. Resident #146 was observed bent over the table with the top of her head touching the edge of the table and her left hand resting on the top of her head. The resident was observed to use her right hand to open one of the bowls of food and attempt to feed herself. During this observation the other bowls of food remained covered and untouched and no staff was observed to assist the resident with her meal or reposition her. During a breakfast dining observation conducted in the assisted dining room on (MONTH) 25, (YEAR) at 7:52 AM, resident #146 was observed bent over to the left with her chin nearly touching her abdomen. A certified nursing assistant was observed to serve the resident her meal which consisted of a bowl of cream of wheat, a bowl of yogurt, a bowl with a fried egg, two glasses of juice, and a carton of milk. The CNA opened the carton of milk and inserted a straw and left. The resident was observed to locate her spoon and bowl of cream of wheat after several attempts. The resident was observed having difficulty feeding herself, getting a half of spoonful of the cream of wheat in her mouth and dropping the other half in her lap. At 8:10 AM, one of the CNAs assisted the resident with two bits of yogurt and then left to assist another resident. The resident continued to attempt to feed herself. At 8:28 AM the resident was wheeled out of the dining room by a CN[NAME] The bowl of cream of wheat was still 3/4 full and the bowl of yogurt was almost full. The bowl with the fried egg and the 2 glasses of juice were still covered and untouched. No staff was observed to reposition the resident and no other staff was observed to assist the resident with eating. During an interview conducted with a CNA (staff #133) on (MONTH) 25, (YEAR) at 10:23 AM., the CNA stated that the resident is able to verbalize her needs and that she wants to be independent with eating. She stated that the resident requires supervision, cueing, and assistance with meals and that it takes the resident a long time to feed herself. The CNA stated that the resident does not always allow her to assist her with her meals. She also stated that other than the leg rest, the resident does not have any other positioning devices in place. An interview was conducted on (MONTH) 25, (YEAR) at 12:28 PM with the Director of Rehabilitation (staff #255). She stated that a therapy screening is conducted quarterly and as needed for all residents. Staff #255 stated that if a resident has postural issues, such as leaning to one side or forward, the resident would be screened for supportive/adaptive devices that could be put in place, such as wedge cushions, trunk support and arm support to maintain and improve the resident's quality of life. She stated that if the resident is leaning forward because of a kyphotic condition, the resident would be assessed for possible interventions (i.e., adaptive equipment that could be used, such as the use of a tilt wheelchair). Staff #255 stated a forward lean is one of the hardest to deal with but that there is a lot of potential for improvement of quality of life. She stated that if the resident refused the screening or supportive/adaptive devices, it would be care planned. An interview was conducted with the resident on (MONTH) 25, (YEAR) at 1:05 PM. The resident stated that she has trouble eating and has asked the nurse to provide her with a lower table so that she can reach her food better. The resident stated that the nurses stated that they would assist her with eating. She stated that she needs assistance but that the staff does not always assist her. The resident stated that therapy did not recommend the use of any positioning device like wedge cushions or a pillow to assist her in an upright position and that the devices would probably help her and that she would not refuse them. On (MONTH) 25, (YEAR) at 1:25 PM, an interview was conducted with the administrator (staff #253). She stated that therapy offered to screen the resident, but that the resident and family declined on (MONTH) 24, (YEAR). The administrator was unable to state whether the resident and family had declined therapy or the therapy recommendation. The facility's policy titled Nutrition Intervention Program Overview revealed that to encourage food and beverage intake, special attention is directed towards creating a positive and fulfilling dining experience. The policy included that dining skills are also evaluated in order to provide a dining experience that enhances quality of life and is supportive of each resident's individual needs. The policy also included the resident's interdisciplinary care plan addresses dining skill levels and interventions based on an interdisciplinary evaluation.",2020-09-01
841,LIFE CARE CENTER OF NORTH GLENDALE,35126,13620 NORTH 55TH AVENUE,GLENDALE,AZ,85304,2018-10-31,692,E,0,1,SCA611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, resident and staff interviews, facility documentation and policy review, the facility failed to ensure that nutritional care and services were provided to two residents (#127 and #146). Findings include: -Resident #127 was admitted to the facility on (MONTH) 1, 2010 and readmitted on (MONTH) 23, (YEAR), with [DIAGNOSES REDACTED]. According to a significant change Minimum Data Set (MDS) assessment dated (MONTH) 21, (YEAR), the resident had moderate cognitive impairment and required total assistance with transfers and supervision with eating. The MDS also included the resident did not have any weight loss of 5% or more in the last month or a loss of 10% or more in the last 6 months. Review of the NP (nurse practitioner) progress note dated (MONTH) 10, (YEAR) revealed the resident had weight loss which was not expected and had a 25% weight loss in the past year. The plan included monthly weight monitoring and continued dietary follow-up. According to the clinical record, the resident went out to the hospital on (MONTH) 19, (YEAR) and was readmitted to the facility on (MONTH) 23, (YEAR). Review of the nutrition care plan dated (MONTH) 23, (YEAR) revealed the resident was at nutritional risk and was on a mechanical soft diet with nectar thick liquids. The goal was for resident to have no significant weight changes. Approaches included diet as ordered, large protein portions at all meals, multivitamins with minerals, 30 ml (milliliter) of Pro-Source Plus (supplement) twice daily and 4 oz of House supplement daily. The Aspiration Risk care plan dated (MONTH) 23, (YEAR) included the resident had a [DIAGNOSES REDACTED]. Approaches included diet as ordered, monitor intake and weights and provide supervision with eating. Review of the weight record revealed the resident weighed 206 lbs on (MONTH) 24, (YEAR). A NP note dated (MONTH) 24, (YEAR) revealed the resident was negative for weight loss. The documentation included the resident had dysphagia which was described as currently worse. Per the note, the diet was down-graded to pureed diet with thickened liquids. The nutrition data collection/assessment dated (MONTH) 26, (YEAR) included for large protein portions three times daily. Per the documentation, there were no supplements ordered. A nutrition note dated (MONTH) 26, (YEAR) included the resident required limited assistance with meals and that meal intake was 88%. The note included that the diet was changed to regular puree, honey thick liquids, double egg portions at breakfast and large meat portions with lunch and dinner. A physician's order dated (MONTH) 1, (YEAR) also included for 1 package of Juven (nutritional supplement) in 6 oz of sugar free beverage by mouth twice daily. The order for the Juven was transcribed into the MAR (medication administration record) for (MONTH) (YEAR) and was administered as ordered. Review of the weight record revealed that on (MONTH) 8, (YEAR), the resident weighed 196 lbs. This was a 10 lb weight loss (4.85% weight loss) in 14 days. A nutrition note dated (MONTH) 9, (YEAR) included the resident had a 10 lb weight loss in 2 weeks since readmission. The note also included the resident received a multivitamin with minerals daily, 4 oz of NSA (no sugar added) House supplement daily and 30 ml of Pro-Source Plus twice daily. The plan was to discuss the resident's condition at the weekly NAR (Nutrition at Risk) meeting and monitor meal intake percentages for trends. Review of Section III of the Nutrition Data Collection/assessment dated (MONTH) 12, (YEAR) revealed the resident required increased protein needs and had a gradual weight loss. The diet was regular puree and honey thick liquids. Nutrition interventions included multivitamin with minerals, 4 oz NSA House supplement daily and 30 ml Pro-Source Plus twice daily. However, review of the clinical record revealed there were no orders for the resident to receive a multivitamin with minerals, NSA House supplement or for Pro-Source Plus in (MONTH) (YEAR). There was also no documentation that the resident received a multivitamin with minerals, NSA House supplement or for Pro-Source Plus in (MONTH) (YEAR). Review of a dietary note dated (MONTH) 12, (YEAR) revealed the following interventions: multivitamins with minerals, 4 oz NSA House supplement and for 30 ml Pro-Source Plus twice daily. Per the note, the resident had additional nutritional needs related to wound healing. It also noted that high calorie and protein supplements were in place. The quarterly nutrition data collection/assessment dated (MONTH) 19, (YEAR) also included the resident was receiving 4 oz of House supplement daily and 30 ml of Pro-Source Plus twice daily. A nutritional progress note dated (MONTH) 24, (YEAR) included the resident continued to have gradual weight loss. Per the documentation, the resident received nutritional support with extra calories, protein and multivitamin with minerals. Interventions included multivitamin with minerals, 4 oz House Supplement and ProSource Plus twice daily. Review of the recapitulation of physician orders for (MONTH) (YEAR) revealed the following order: may follow dietary recommendations regarding diet. Despite documentation that the resident was supposed to be receiving a multivitamin with minerals, 4 oz House Supplement and ProSource Plus twice daily, there were no physician orders for these dietary recommendations for (MONTH) and (MONTH) (YEAR). In addition, these dietary recommendations were not transcribed onto the MAR/TAR (Medication and Treatment Administration Records) for (MONTH) and (MONTH) (YEAR). There was no clinical record documentation that the resident received the multivitamin with minerals, 4 oz House Supplement and ProSource Plus twice daily. During an interview with a CNA (certified nursing assistant/staff #133) conducted on (MONTH) 25, (YEAR) at 10:23 a.m., she stated that weights are taken by the RNA's (restorative nursing assistant) on a weekly basis. She stated if there is weight loss she or the RNA will report it to the nurse, who will then instruct them on new interventions to address the resident's weight loss. An interview with the Director of Nursing (DON/staff #45) was conducted on (MONTH) 26, (YEAR) at 2:54 p.m. She stated that when a resident has weight loss, the nurse will notify the physician and will look for the reason for the weight loss. She said if no reason is found, then it would be brought to the NAR meeting and supplements would be put in place as interventions. Staff #45 said if supplements are recommended, the dietary technician writes the recommendation and gives it to the nurse, who will then call the NP or the physician. She stated that if there's a recommendation that was not carried out, there must be documentation of the reason in the clinical record. She said that if an order is written for the recommendation, it should be transcribed onto the MAR or TAR and should be administered as ordered. Further, she said that if the MAR and TAR does not show evidence that dietary recommendations were administered, then the recommendations and/or orders for supplements must not have been carried out. -Resident #146 was admitted at the facility on (MONTH) 12, 2012, with [DIAGNOSES REDACTED]. Review of a nutrition review summary dated (MONTH) 22, (YEAR), revealed the resident was at nutritional risk and needed 1425-1710 cal per day as evidenced by 65-78% of meal intake. The note included the resident was on a mechanical soft diet and meal intake was 90%. The note also included the resident was legally blind, required food in bowls and that staff were to identify food location. A nutrition care plan updated on (MONTH) 8, (YEAR) included the resident was at nutritional risk as evidenced by [MEDICAL CONDITION], impaired vision and a mechanically altered diet with thin liquids related to chewing deficits. A goal was for the resident to have no significant weight change 5% x 30 days or 7.5% x 90 days. Approaches included the resident eats in the dining room and for food to be in bowls to promote self dining related to poor vision, and to inform resident where foods are located. Review of the weight record revealed that on (MONTH) 4, (YEAR) the resident weighed 131 lbs. Record of resident's meal intake percentages for (MONTH) (YEAR) revealed the resident required supervision defined as oversight, encouragement and cueing with set-up help only with eating. It also included the resident consumed an average of 76-100% of each meal. However, towards the end of the of the month it showed a decline to 51-75% of each meal especially for dinner. According to a Significant Change in Status MDS assessment dated (MONTH) 4, (YEAR), the resident had a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. The MDS included the resident was independent with one person physical assistance with eating, was on a mechanically altered diet and did not have any oral/dental issues. Review of the weight record revealed that on (MONTH) 4, (YEAR), the resident weighed 125 lbs. The documentation included that this was a 3% weight loss from (MONTH) 4. A care plan for the potential for alteration in comfort due to a [DIAGNOSES REDACTED]. Interventions were to provide comfort measures which included repositioning. Review of an activities of daily living (ADL's) care plan with a target date of (MONTH) 9, (YEAR), revealed the resident has a [DIAGNOSES REDACTED]. The goal was the resident would participate as able with ADL's. Interventions were to provide the amount of supervision needed, staff to assist with ADL's and food in bowls so resident can more easily retrieve the food. A vision care plan with an updated date of (MONTH) 9, (YEAR), included the resident had impaired vision and was legally blind. Approaches included to place items within easy reach and orient to placement, provide adaptations to maintain resident involvement, and to identify the type/location of food on plate as needed. An Activity Evaluation dated (MONTH) 12, (YEAR) revealed the resident needed assistance with meal set up and eating and required cueing. Review of the resident's meal intake percentages for (MONTH) (YEAR) revealed the resident continued to require supervision with set-up help only with eating. It also included that the resident continued to consume an average of 51-75% of each meal. Despite documentation that the resident's meal intake percentages had declined, and that the resident sustained [REDACTED]. Review of the weight record revealed the resident weighed 125 pounds on (MONTH) 8, (YEAR). Review of the resident's meal intake percentages for (MONTH) (YEAR) revealed the resident continued to require supervision with set-up help only with eating most of the time. It also included that the resident's meal intake percentage varied and averaged between 25-50%, which was a decrease from July. Review of the weight record revealed the resident weighed 116 lbs on (MONTH) 6, (YEAR). Per the documentation, this was a weight loss of 10% (from a comparison weight taken on (MONTH) 2, (YEAR)), and a weight loss of 3% from the weight taken on (MONTH) 8. A dietary note dated (MONTH) 6, (YEAR) included the resident had a 5 lb (3.85%) weight loss in 3 months. It also included the resident was legally blind and required food in bowls and for staff to identify the location of the food. The plan included discussing the resident's condition at the weekly NAR (Nutrition At Risk) meeting and monitoring labs, weight reports and meal intake percentages for trends. The Resident At Risk Meeting documentation dated (MONTH) 6, (YEAR) revealed a handwritten note under the section titled Concern/Issue, Team Recommendation included to see dietary progress note from (MONTH) 6, (YEAR). A physician's order dated (MONTH) 6, (YEAR) included for 8 oz of Ensure (nutritional supplement) two times a day and to document percentage taken. This order was transcribed onto the MAR for (MONTH) (YEAR). The Nutrition Report revealed the resident's average meal intake percentage changed from 63% (week ending (MONTH) 31) to 52% for week ending (MONTH) 7, (YEAR). Per the report, there was a weight loss of 9 lbs. A dietary note dated (MONTH) 10, (YEAR) included the resident sustained [REDACTED]. Recommendations included for Ensure twice daily and that the supplement will provide 700 calories/40 grams protein. The plan included to continue to monitor labs, weight reports and meal intake percentages for trends. A dietary note dated (MONTH) 13, (YEAR) revealed the resident was alert and oriented x 3 and was able to make needs known. The resident had a poor appetite and required assistance and cueing with eating. According to the (MONTH) (YEAR) MAR, the resident was administered the Ensure as ordered. A physician's order dated (MONTH) 24, (YEAR) included to discontinue the Ensure and administer 8 oz of House Shake two times a day and to document percentage taken. Record of the resident's meal intake percentages for (MONTH) (YEAR) revealed they ranged between 25-50%. The Nutrition Data note completed by the clinical manager dated (MONTH) 2, (YEAR) included the resident had a significant weight change of 9 lbs, which was a decrease in 1 month. Average daily percentage consumption of meals was documented as 75-100% for breakfast, lunch and dinner. Current diet included mechanical soft with 8 ounces of Ensure twice daily as a supplement. Per the note, the resident did not have a problem with chewing or swallowing and was independent with dining. Review of the weight record revealed that on (MONTH) 7, (YEAR), the resident's weight was 111 lbs, which was a weight loss of 10% from a comparison weight taken on (MONTH) 2, and a weight loss of 3% from the weight taken on (MONTH) 6. A dietary note dated (MONTH) 10, (YEAR) included the resident had a significant weight loss of 5 lbs (4.3%) in 1 month and was re-weighed, and the weight was confirmed. It also included the following meal intake percentages: 55% for the week of (MONTH) 19; 74% for the week of (MONTH) 26; 59% for the week of (MONTH) 3; and 55% for the week of (MONTH) 10. The note included the resident was on a mechanical soft diet with thin liquids and whole milk three times daily, and received 8 oz of Ensure twice daily. Another dietary note written by a nurse dated (MONTH) 10, (YEAR) included the resident was blind, continued with a gradual decline, had poor oral intake and had a weight loss of 5 lbs in 1 month. Per the note, the resident eats in the assisted dining room and requires assistance with eating. The Nutritional Data Collection/assessment dated (MONTH) 11, (YEAR) revealed the resident's weight was down by 14 lbs (11%) in 60 days, with the resident eating more than 50% of meals and increased calorie supplement and a multivitamin with minerals. The documentation included the resident required a mechanical soft diet and had chewing deficits. Interventions included for 8 oz of Ensure, 8 oz of House Shake twice daily, fortified cream of wheat and fortified foods with lunch and dinner. During an interview conducted on (MONTH) 23, (YEAR) at 9:39 a.m., resident #146 stated that she had some weight loss which was good at first, but she does not want to continue to loose weight. She stated that she eats in the dining room and does not receive assistance. An observation was conducted on (MONTH) 23, (YEAR) from 11:55 a.m. to 12:15 p.m., of the resident in the assisted dining room sitting in her wheelchair at a table. The resident was bent over with her head toward her abdomen and her head was almost touching the edge of the table. This dining room table was approximately 2 inches lower than the other tables in the dining room. During the observation, the resident was served three bowls of food. The resident then attempted to feed herself with her head bent over and her forehead almost touching the edge of the table, while she put the spoon in her mouth. The resident ate from the same bowl of food and the other two bowls of food remained covered and untouched. During the observation, there were staff in the assisted dining room, however, no staff were observed to cue the resident, repositioned the resident or assist the resident with her meal. Another observation was conducted on (MONTH) 25, (YEAR) at 7:29 a.m., of resident #146 sitting in her wheelchair in the assisted dining room. Her upper body was hunched over toward her left hip, and her chin was nearly touching her abdomen. Her head was bent so far forward that the top of her head almost reached the height of the table. At this time, a CNA (Certified Nursing Assistant) served the resident three bowls of food which contained cream of wheat, yogurt and a fried egg, and two 8 oz glasses of juice and a carton of milk. The CNA removed the items from the tray and placed them in front of the resident, but did not remove the lids from the bowls. The CNA opened the carton of milk and put a straw in it and then walked away. The CNA did not reposition the resident or tell the resident the location of the food items. The resident was then observed trying to find the bowls of food and the spoon. At 8:01 a.m., a CNA removed the lids from the bowls, however, the CNA did not reposition the resident, as the resident continued to be hunched over, nor did the CNA assist the resident with her meal. The resident was observed trying to find the spoon and the bowls of food. After several attempts, the resident managed to get a half of a spoonful of cream of wheat into her mouth and the other half fell in her lap. At 8:10 a.m., a CNA started to assist the resident with her meal. The CNA and was going back and forth between resident #146 and another resident. When the CNA was assisting the other resident, resident #146 tried feeding herself with her head bent way forward. At 8:23 a.m., the resident was observed to be eating from the same bowl of food. At 8:28 a.m., another CNA entered the dining room and told the resident that she needed to be cleaned. The CNA did not ask the resident if she was done with her meal. The bowl of food that the resident was eating from was still 3/4 full, and the other three bowls of food and the two 8-oz glasses of juice remained untouched. The CNA then removed the resident from the dining room. During an interview with a CNA (staff #133) conducted on (MONTH) 25, (YEAR) at 10:23 a.m., she stated that resident #146 is alert and oriented and can tell staff what she needs. She stated the resident requires supervision, cueing and assistance with meals, because it takes her a long time to eat. An interview with the medical records director (staff #231) was conducted on (MONTH) 25, (YEAR) at 11:10 a.m. She stated there was no nutritional assessment found for resident #146 from (MONTH) through (MONTH) (YEAR), because the dietician was on vacation and there was no one who covered in their absence. Another interview was conducted on (MONTH) 25, (YEAR) at 1:05 p.m., with resident #146. She stated that she was having trouble with eating so she asked the nurses to provide her with a lower table, so she could reach her food better. She said that she wants and needs assistance with eating, but staff do not always provide her assistance with eating. She stated that she could probably eat more than she does, if she had assistance with her meals.The resident further stated that therapy did not recommend any positioning device to be used to help keep her in an upright position, and that she did not refuse a positioning device. She stated that one would probably help her. In an interview with the dietician (staff #251) dated (MONTH) 26, (YEAR) at 8:35 a.m., she stated that she comes to the facility every week and reviews identified high risks residents, which include residents who are underweight, eating poorly, receiving tube feedings and those with wounds. She stated that the following percentages of weight loss will have interventions put into place: 3% in a week, 5% in 30 days, 7.5% in 90 days and 10% in 6 months. She also stated interventions will initially include an assessment of food preferences, use of supplements, and assistance with dining which includes cueing residents during meals. She stated that she relies on the dietary techs who are very good at documenting weights and reporting weight loss and informing her whether interventions in place are working or not. She further stated that if the resident's weight loss is not 5% or more, she will not necessarily put interventions into place, but she will assess other factors that may be contributing to the resident's weight loss. Review of a policy regarding the Nutrition Intervention Program revealed the facility is committed in ensuring that each resident maintains acceptable parameters of nutritional status as indicated by clinical measures, such as body weight and ensuring that residents receive a therapeutic diet when there is a nutritional problem. The policy included that residents are provided nutritional care and services consistent with their comprehensive assessment and that their needs are addressed with appropriate interventions which are consistent with the resident's assessed needs. The policy further included that interventions are implemented or clinical justification is provided if not done.",2020-09-01
842,LIFE CARE CENTER OF NORTH GLENDALE,35126,13620 NORTH 55TH AVENUE,GLENDALE,AZ,85304,2018-10-31,812,D,0,1,SCA611,"Based on observations, staff interview and policy review, the facility failed to ensure that food was served in a sanitary manner. Findings include: A dining observation was conducted on (MONTH) 25, (YEAR) at 8:00 a.m. A resident was being assisted with their breakfast, by a Registered Nurse (RN/staff #14). The RN picked up the resident's toast with her bare hand and offered it to the resident. The resident took bites of the toast, while the RN continued to hold the toast with her bare hand. During this same dining observation, staff #14 was observed to assist another resident with their breakfast meal. The RN picked up a sweet roll with her bare hand and offered it to the resident. The resident took bites of the sweet roll, while the RN continued to hold the sweet roll with her bare hand. After the observations, an interview was conducted with the RN. The RN stated that she was not assigned to feed residents, but that she enjoys helping out with meals. She stated that she did use her bare hand on the toast and the sweet roll and that she was unaware that she needed a glove. A review of a policy titled, Safe Food Handling revealed that all food purchased, stored, and distributed is handled with accepted food-handling practices and per federal, state and local requirements.",2020-09-01
843,PRESCOTT NURSING AND REHABILITATION CENTER,35127,864 DOUGHERTY STREET,PRESCOTT,AZ,86305,2018-03-29,600,D,1,1,I2MB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, facility documentation and polices and procedures, the facility failed to ensure that one resident (#2) was free from physical abuse by another resident (#99). Findings include: Resident #99 was admitted on (MONTH) 1, 2010, with [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment dated (MONTH) 12, (YEAR), included the resident had severe cognitive impairment. The MDS assessment also included the resident had physical and verbal behavioral symptoms directed at others, and was unable to communicate verbally. Review of a care plan for nutrition risk included a goal that the resident would not aspirate. An intervention included to seat the resident away from other residents during dining if the resident was trying to swipe at others. A care plan for altered thought process related to organic brain damage and [MEDICAL CONDITION] included that resident #99 had combative behaviors such as scratching, pinching and grabbing other residents. A goal was that the resident would not injure herself or others. Interventions included to wear gloves to both hands to prevent pinching, and that staff were to intervene as necessary to protect the rights and safety of others, including removing the resident from situations and take her to an alternate location as necessary. A care plan conference note dated (MONTH) 3, (YEAR), included that resident #99 had intermittent behaviors of hitting, scratching and grabbing. Review of a behavioral monitoring flow sheet for (MONTH) (YEAR), revealed that resident #99 was monitored daily on each shift, for physical aggression, yelling and agitation. -Resident #2 was admitted on (MONTH) 8, 2013, with [DIAGNOSES REDACTED]. An annual MDS assessment dated (MONTH) 22, (YEAR), included the resident had a BIMS (Brief Interview for Mental Status) score of 8, which indicated the resident had moderate cognitive impairment. The MDS assessment also included the resident required supervision of one staff member for locomotion on the unit, and used a wheelchair. A care plan for impaired cognition and behaviors revealed that resident #2 had a history of [REDACTED]. Interventions included that staff were to redirect the resident away from other residents for safety, and to remove the resident from a situation if his behavior interferes with others, or if the environment is determined to be a trigger behavior. A nursing progress note dated (MONTH) 1, (YEAR) included that resident #2 had sustained a scratch to the left wrist, and the resident stated to the nurse that another resident had scratched him. An unusual occurrence report dated (MONTH) 1, (YEAR), included that resident #2 had sustained a 0.3 cm open area from another resident (staff #99) in the activity room. The injury was described as a skin tear, with discoloration to the left forearm antecubital area. The report included that resident #2 was in his wheelchair going past another resident (#99), who reached out and grabbed his arm. Review of a reportable event record dated (MONTH) 6, (YEAR) revealed that a resident to resident incident occurred on (MONTH) 1, (YEAR) at 4:20 p.m., in the activity room on the behavioral care unit. When resident #2 passed by a female peer (resident #99) in the activity room, resident #99 reached out and grabbed resident #2. A CNA (Certified Nursing Assistant) was present in the activity room and immediately separated the residents. Resident #2 sustained a 0.3 cm skin tear to the left forearm, and first aide was provided. An interview was conducted on (MONTH) 27, (YEAR) at 1:00 p.m., with an LPN (licensed practical nurse/staff #73). During the interview, staff #73 stated that resident #99 attempts to grab at people if they get close to her especially males, and that she is fearful of people in general especially men. Staff #73 stated that staff are [MEDICAL CONDITION] of where she is at all times, and that she wears gloves due to scratching behaviors. Staff #73 said that resident #99 was wearing gloves at the time she grabbed resident #2. Staff #73 further stated that resident #99 has long standing behaviors of grabbing at other people. An interview was conducted on (MONTH) 27, (YEAR) at 1:15 p.m. with a Registered Nurse (staff #17). Staff #17 stated that resident #99 sits alone at her own table in the common areas and in the dining room where she cannot grab others and that staff keep other residents away from her personal space. An observation was conducted on (MONTH) 27, (YEAR) at 1:16 p.m. of resident #99 seated alone at a table in the dining room. When approached, resident #99 began to reach out and kicked her feet. An interview was conducted on (MONTH) 28, (YEAR) at 1:00 p.m., with a CNA (Certified Nursing Assistant/staff #40). Staff #40 stated that on (MONTH) 1, (YEAR) at the time of the incident, she was in the hallway near the door to the common room on the behavioral unit to monitor the room. She said that resident #2 entered the common room in his wheelchair, because he was headed out onto a patio area, and the door to the patio was located in the common room. She said resident #99 was seated in an area in the common room where others needed to pass by on their way to the patio. She stated that while heading to the door to the patio, resident #2 wandered close to resident #99, and she had looked into the hallway and when she looked back into the common room, resident #99 was releasing the left arm of resident #2. She also said that resident #99 was being monitored, because she frequently grabs at others. Review of a policy and procedure for escalated behavioral management revealed the facility shall take a cautionary and safe approach to treating and caring for individuals who exhibit behaviors that may pose a threat to the health and safety of the resident or other individuals in the facility. Review of a policy titled, Abuse Prevention revealed it is their policy to take appropriate steps to prevent the occurrence of abuse. The policy included that Abuse is the willful infliction of injury and includes hitting, slapping, pinching and kicking.",2020-09-01
844,PRESCOTT NURSING AND REHABILITATION CENTER,35127,864 DOUGHERTY STREET,PRESCOTT,AZ,86305,2018-03-29,609,D,0,1,I2MB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documentation, review of a police report and policies and procedures, the facility failed to ensure that an allegation of abuse was immediately reported to the Administrator and to the State agency for one resident (#11) as required. Findings include: Resident #11 was admitted to the facility on (MONTH) 1, 2010, with [DIAGNOSES REDACTED]. Review of a police report revealed an incident was called in on (MONTH) 10, (YEAR) at 10:24 p.m. The report included that the incident had occurred on (MONTH) 8, (YEAR) at 5 a.m. Per the report, an officer arrived at the facility on (MONTH) 11, (YEAR) at approximately 10:30 p.m. for a delayed assault. The report included that the reporting party (registered nurse/staff #48) advised the officer that excessive force was used by (registered nurse/staff #15). Staff #48 reported that a blood draw was being done on the resident and the resident became actively resistant and that staff #15 used excessive force to keep the resident's right arm pinned down. The report included that staff wanted the police contacted due to severe bruising on the resident's right arm. The report further included that the officer attempted to talk with the resident, however, the resident was unable to communicate and that bruising was observed on the resident's right arm. Review of the facility's investigative documentation revealed that the Director of Nursing (staff #21) was notified on (MONTH) 11, (YEAR) at 8:25 a.m. that the police had been notified that staff #15 may have used excessive force during a blood draw, causing bruising to the resident's right arm. The report included that on (MONTH) 8, (YEAR), a registered nurse (staff #48), a lab tech and another registered nurse (staff #15) were present during a lab draw. During the procedure, staff #48 held the resident's left arm and staff #15 held down the resident's right arm, as the resident was moving her arms and trying to grab at things. Per the documentation, a licensed practical nurse (LPN/staff #102) observed the bruising on the resident's arm and told registered nurse (RN/staff #9). Staff #9 stated that she observed the bruising and felt it was serious and needed to be investigated. However, the documentation did not include the date that staff #102 told staff #9, nor did it include the date that staff #9 observed the bruising on the resident's arm. Further review of the investigative documentation revealed that facility staff had not immediately notified the Administrator of the allegation of abuse, nor was the State agency notified within 2 hrs after the allegation was made. Per the facility's report, the Administrator was notified on (MONTH) 11, (YEAR) at 8:30 a.m., and the State agency was notified on (MONTH) 11, (YEAR) at 10:15 a.m. An interview was conducted with a LPN (staff #102) on (MONTH) 28, (YEAR) at 9:12 a.m. She stated that the bruises on the arm of resident #11 looked like finger marks. She stated that she called the police around 11 p.m. on (MONTH) 9, (YEAR) and sent a message to the Director of Nursing (DON). However, the police report included that the report was not received until (MONTH) 10, (YEAR) at 10:24 p.m. An interview was conducted with a RN (staff #9) on (MONTH) 28, (YEAR) at 10:37 a.m. She stated that on (MONTH) 9, (YEAR) she was notified of a concern about bruising on the arm of resident #11 from the LPN (staff #102) who was caring for the resident. Staff #9 stated that she told the oncoming RN (staff #48) in report about the concern and staff #48 told her that she thought the bruising was from staff #15 who held down the resident's arm during a blood draw. Staff #9 stated that she looked at the resident's bruises on her next shift on (MONTH) 10. She stated that she observed thumb marks. She said that she sent a text to the Director of Nursing to notify him that they needed to report the bruises and when he did not call back, they called the police. She stated that she never called the Administrator, because she did not know that she was supposed to report suspicions of abuse to the Administrator. An interview was conducted with the Director of Nursing (DON/staff #21) on (MONTH) 28, (YEAR) at 1:14 p.m. He stated that if he receives an allegation of abuse from staff, he would report it immediately to the appropriate agencies including the State agency. He stated that he was not notified by staff that the police had been called. He stated that he was not aware of any suspicion of abuse regarding this resident, until he came to the facility on (MONTH) 11, (YEAR) and found a note under his door notifying him of the police involvement. An interview was conducted with the Administrator (staff #53) on (MONTH) 28, (YEAR) at 1:37 p.m. She stated that the nurse called the police and did not communicate her suspicions to the Administrator. She said that she was aware of the bruising on the resident's arm, but there had been no allegation or suspicion of abuse. She said staff should have called the Administrator immediately, with any suspicion of abuse. Review of a facility policy regarding Abuse Prevention revealed that it is the responsibility of all employees to immediately report any suspected or alleged violation of abuse to the Administrator. The policy further included that all suspected or alleged violations involving abuse are reported immediately, but not later than 2 hrs after the allegation is made to the Administrator and the State agency.",2020-09-01
845,PRESCOTT NURSING AND REHABILITATION CENTER,35127,864 DOUGHERTY STREET,PRESCOTT,AZ,86305,2018-03-29,636,D,0,1,I2MB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, review of the Resident Assessment Instrument (RAI) manual and policy and procedures, the facility failed to ensure that comprehensive assessments were completed in the required timeframes for two residents (#4 and #6). Findings include: -Resident #4 was admitted to the facility on (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record on (MONTH) 29, (YEAR), revealed an annual MDS assessment with an assessment reference date (ARD) of (MONTH) 22, (YEAR). However, the MDS assessment had not been completed and was in progress. In addition in the MDS section was the following warning: ARD: 2/22/2018, Complete by: 3/8/2018 - 21 days overdue. During an interview conducted at 9:50 a.m. on (MONTH) 29, (YEAR), the MDS Coordinator (staff #50) stated that she had not finalized the annual assessment and needed to complete the Care Area Assessment before having a Registered Nurse sign the assessment as completed. Another interview was conducted at 10:10 a.m. on (MONTH) 29, (YEAR) with staff #50, who stated that MDS assessments were required to be signed within 14 days of the ARD date. She stated that the resident's annual MDS assessment should have been signed by (MONTH) 8, (YEAR), and had not completed the assessment within the required time. During an interview conducted at 10:35 a.m. on (MONTH) 29, (YEAR) with the Director of Nursing (staff #21), he stated that he was responsible for ensuring the MDS assessments were completed in the required timeframes. Staff #21 stated he was not aware that the MDS assessments were not being completed, within the required timeframes. -Resident #6 was admitted on (MONTH) 13, 2013, with [DIAGNOSES REDACTED]. Review of the electronic record revealed an annual MDS assessment with an ARD of (MONTH) 1, (YEAR), which included a notation that the assessment was in progress. It was further noted in red that the assessment was 12 days overdue. An interview was conducted with staff #50 on (MONTH) 29, (YEAR) at 11:07 a.m. She stated that all residents in the long term care unit require quarterly assessments. She stated the annual MDS assessment must be done yearly, every 365 days. She stated that she uses the Resident Assessment Instrument (RAI) manual for direction on completing the MDS assessments. She further stated that the MDS for resident #6 was not done on time and she is late in completing the assessment. She stated that she is responsible to ensure that MDS's are completed on time. An interview was conducted with the Director of Nursing (staff #21) on (MONTH) 29, (YEAR) at 12:00 p.m. He stated that his expectation is that the MDS nurse follow the state and federal guidelines for the timing and accuracy of the MDS assessment. He stated that he was not very familiar with the MDS guidelines regarding the MDS completion requirements and that he would defer to the MDS Coordinator. He stated that he and the Administrator are the ones who usually sign the MDS, and that the MDS nurse notifies them when the MDS is ready to be signed. Review of the facility's policy and procedure regarding MDS 3.0 revealed that the MDS assessments will be completed by the Interdisciplinary Team in a timely manner in accordance with the guidelines and requirements in the MDS RAI version 3.0 manual. The policy included that the annual assessment must be completed on an annual basis (at least 366 days) and that the completion date must be no later than 14 days after the ARD. According to the RAI manual, the annual comprehensive assessment completion date must be no later than 14 days after the ARD (ARD + 14 calendar days).",2020-09-01
846,PRESCOTT NURSING AND REHABILITATION CENTER,35127,864 DOUGHERTY STREET,PRESCOTT,AZ,86305,2018-03-29,658,E,0,1,I2MB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews and policy review, the facility failed to ensure services met professional standards of quality, by failing to ensure that one resident (#31) who fell , received ongoing assessments and monitoring. Findings include: Resident #31 was admitted to the facility on (MONTH) 5, (YEAR), with [DIAGNOSES REDACTED]. A care plan included the resident was at risk for falls, due to weakness, debility and multiple medication use. The care plan included that the resident required extensive assistance with transfers and toileting. The care plan also included that the resident sustained [REDACTED]. Interventions were to provide verbal reminders to request assistance with transfers and mobility, call light within reach and encourage to use, encourage resident to wear well fitting non slip footwear for all transfers and ambulation, and ensure proper body alignment when repositioning to prevent falls, as resident attempts to reposition self. A quarterly Minimum Data Set assessment dated (MONTH) 17, (YEAR) revealed a Brief Interview for Mental Status score of 13, which indicated the resident was cognitively intact. The MDS assessed the resident to require extensive assistance with bed mobility and limited assistance with transfers. The MDS also included that the resident had sustained two or more falls since admission. During an interview conducted on (MONTH) 28, (YEAR) at 11:30 a.m., resident #31 stated that about one month ago (February (YEAR)) he fell in his room using his walker and bruised both knees. However, review of the clinical record, inclusive of the interdisciplinary progress notes revealed there was no documented evidence that the resident had sustained a fall in (MONTH) (YEAR). An interview was conducted with a Certified Nursing Assistant (CNA/staff #85) on (MONTH) 27, (YEAR) at 2:32 p.m. She stated that in (MONTH) (YEAR) (unsure of exact date) she entered the resident's room and found him on the floor. Staff #85 stated the resident tried to transfer from the chair to the bed and fell . She stated she then informed her charge nurse of the incident. An interview was conducted with a Registered Nurse (staff #9) on (MONTH) 28, (YEAR) at 10:23 a.m. She stated sometime in (MONTH) (YEAR), the CNA caring for the resident informed her that resident #31 was found on the floor. She stated she quickly went to the resident's room and assessed him for pain and injuries. She stated the resident had no apparent injuries and had denied hitting his head. She further stated that she did not document anything in the clinical record but absolutely should have, as that is the standard of practice, as well as their facility policy. She stated that following a fall, a 24 hour report form is started so the resident can be continually monitored. Further review of the clinical record revealed there was no documentation that the resident was assessed after the fall, nor any documentation that the resident was assessed and monitored following the fall. An interview was conducted with a Registered Nurse (staff #10) on (MONTH) 28, (YEAR) at 1:16 p.m. She stated that if a resident is found on the floor, an immediate head to toe assessment is completed and a 24 hour occurrence report started. Staff #10 said the resident is then monitored for the next three shifts for any unusual symptoms. She further stated that all information regarding the fall is to be documented in the clinical record, as this is the nursing standard of practice, as well as facility policy. A facility policy regarding Fall Documentation included that complete, accurate, and timely documentation shall be documented for a resident who has sustained a fall. Nursing staff is responsible for documenting the circumstance of the fall, as well as the care delivered to a resident who has a fall on the 24 Hour Unusual Occurrence Nursing Follow-up form. The policy further included that the initial assessment following a fall on the 24 hour unusual occurrence form shall include the following (whether the resident was injured or not): a) vital signs and neurological assessment if appropriate. b) where resident was found and time of day. c) full name of first on the scene who found the resident or witnessed the fall. d) describe resident's location, appearance, and mental state. e) if visible injury, describe. f) identify any assessment that was performed. g) document notification of physician and family/representative. h) document immediate interventions implemented to prevent another fall. The policy also included that Follow-up documentation must: a) occur every shift x 24 hours. b) be specific to both event and initial assessment c) be specific and document only relevant information and assessments. d) document absence of findings/symptoms/injury. e) document report of changes in condition to the medical practitioner.",2020-09-01
847,PRESCOTT NURSING AND REHABILITATION CENTER,35127,864 DOUGHERTY STREET,PRESCOTT,AZ,86305,2018-03-29,842,D,0,1,I2MB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy review, the facility failed to ensure that a medication order was transcribed correctly into the electronic record for one resident (#34). Findings include: Resident #34 was admitted to the facility on (MONTH) 23, 2011, with [DIAGNOSES REDACTED]. A nurse practitioner order was hand written on (MONTH) 2, (YEAR) for [MEDICATION NAME] (narcotic pain medication) 10 mg three times a day. However, review of the MAR (Medication Administration Record) for (MONTH) through (MONTH) (YEAR), revealed the order was transcribed as [MEDICATION NAME] 10 mg three time a day for a pain scale of 6-10. In an interview with a registered nurse (staff #17) on (MONTH) 29, (YEAR) at 11:51 a.m., she stated that scheduled pain medications typically do not have pain parameters included. During an interview with the Director of Nursing (staff #21) on (MONTH) 29, (YEAR) at 1:02 p.m., he reviewed the order in the electronic record and stated that a pain scale would typically only be included for a PRN (as needed) medication. A short time later, staff #21 provided the original hand written order for the [MEDICATION NAME] 10 mg and the order did not include a pain scale. Staff #21 stated that it was a transcription error when it was put into the electronic record. Review of a facility policy titled, Physician order [REDACTED].",2020-09-01
848,PRESCOTT NURSING AND REHABILITATION CENTER,35127,864 DOUGHERTY STREET,PRESCOTT,AZ,86305,2018-03-29,880,D,0,1,I2MB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and review of the Catheter Care Protocol, the facility failed to ensure one resident's (#4) urinary catheter tubing was not touching and dragging on the floor. Findings include: Resident #4 was admitted to the facility on (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. A review of the annual Minimum Data Set assessment dated (MONTH) 22, (YEAR), revealed the resident had an indwelling catheter. During a random observation conducted at 9:17 a.m. on (MONTH) 28, (YEAR), the resident was observed in her room sitting in a wheelchair. The resident's catheter bag was in a privacy bag hanging under her wheelchair and the catheter tubing was observed touching the floor. At 9:50 a.m. on (MONTH) 28, (YEAR), a certified nursing assistant was observed pushing the resident in the wheelchair down the hallway to the dining room. Approximately 2 inches of the urinary catheter tubing was observed dragging on the floor. At 10:40 a.m. on (MONTH) 28, (YEAR), the resident was observed participating in an activity in the dining room and the catheter tubing was touching the floor. At 12:53 p.m. on (MONTH) 28, (YEAR), the resident was observed in the dining room at a table eating lunch. The catheter tubing was again observed resting on the floor under the wheelchair. During an interview conducted at 1:00 p.m. on (MONTH) 28, (YEAR), a certified nursing assistant (CNA/ staff #83) stated that after a resident's catheter bag is emptied, the catheter bag should be placed back into the privacy bag and the tubing positioned to ensure it is not touching the floor. She stated if the catheter tubing was dragging on the floor, it would be an infection control problem. At 1:05 p.m. on (MONTH) 28, (YEAR), a CNA (staff #40) was observed pushing the resident in the wheelchair down the hall from the dining room to the resident's room. The resident's catheter tubing (approximately 2 - 4 inches) was dragging on the floor. During an interview conducted at 1:10 p.m. on (MONTH) 28, (YEAR), staff #40 stated that she did not see the resident's catheter tubing dragging on the floor. She stated that the tubing should be positioned so it does not touch the floor. An interview was conducted at 1:15 p.m. on (MONTH) 28, 2019 with a Licensed Practical Nurse (staff #103), who stated that she was in the dining room, but had not noticed that the resident's catheter tubing was touching the floor. She stated that if she had seen the tubing touching the floor, she would have ensured that the tubing was repositioned off the floor. She stated allowing the catheter tubing to touch or drag on the floor was an infection control problem, as germs on the floor could get on the tubing and infect the resident. According to the Catheter Care Protocol, Direct care staff is responsible for ensuring that a resident with an indwelling urinary catheter receives appropriate infection prevention and control practices at all times. The protocol also included Do not allow the drainage bag or the tubing to drag and pull on the catheter.",2020-09-01
849,PRESCOTT NURSING AND REHABILITATION CENTER,35127,864 DOUGHERTY STREET,PRESCOTT,AZ,86305,2019-06-13,761,D,0,1,J89111,"Based on observations, staff interviews, and policy review, the facility failed to ensure that expired blood Vacutainer tubes and Pneumococcal vaccines were not available for use in 2 of 2 medication storage areas. The deficient practice could result in inaccurate laboratory results and the risk of ineffective vaccines. Findings include: An observation of the main medication storage area was conducted on (MONTH) 12, 2019 at 9:53 a.m., with the Assistant Director of Nursing (ADON/staff #60). At this time, there were 20 expired blood Vacutainer tubes with expiration dates that varied from (MONTH) 31, (YEAR) to (MONTH) 31, 2019. An observation of the secured unit medication storage refrigerator was conducted on (MONTH) 12, 2019 at 11:01 a.m., with a LPN (staff #117). Inside of the refrigerator there were two expired vials of pneumococcal vaccine, one had expired on (MONTH) 16, 2019 and the other had expired on (MONTH) 11, 2019. An interview was conducted with a Licensed Practical Nurse (LPN/staff #97) on (MONTH) 12, 2019 at 10:47 a.m. She stated that when she does a blood draw, she obtains a blood draw tube out of the main medication room drawer, checks the expiration date of the tube and if expired, it would be disposed. She stated that it is not the facility practice to have expired tubes available for blood draws, as there is a risk of an expired tube being used for a laboratory test. An interview was conducted with the ADON (staff #60) on (MONTH) 12, 2019 at 10:53 a.m. She stated there should not be any expired blood draw tubes available for use, and that she would expect all nurses to check the expiration date of the tube before using. She stated there is a risk of inaccurate laboratory results if an expired tube is used. An interview with a LPN (staff #117) was conducted on (MONTH) 12, 2019 at 11:12 a.m. She stated that expired medications/Pneumococcal vaccines should not be available for use. Staff #117 said that if a vaccine was administered it could pose the risk of being ineffective for the resident. On (MONTH) 12, 2019 at 3:00 p.m., the Administrator (staff #67) stated that the facility did not have a policy which addressed blood draw/lab supplies. An interview was conducted with the Director of Nursing (DON/staff #6) and the Administrator (staff #67) on (MONTH) 13, 2019 at 8:42 a.m. Staff #6 stated they would not want to have expired medications or biologicals available for use. Staff #6 said they have several checks and balances in place such as; pharmacy visits and checks for expired items, the nurses observe for expired items when in the medication cart, and the night shift nurses do a more formal check for outdated items. Staff #6 stated that the final check is done by the staff member using the item as they are expected to check the date. Staff #6 stated that the risk of a medication/biological being available for use would depend on the specific item, but as a standard of practice they would not want to use an expired product. Review of the facility policy regarding Medication Management revealed that in order to promote and maintain each resident's physical and mental well-being relative to his/her medication regimen, medication management shall be provided in accordance with professional standards and pursuant to the policies and procedures established by the pharmacy. The policy further noted that expired medications shall be disposed of in accordance with Safety Drug Pharmacy policies and procedures.",2020-09-01
850,ARCHSTONE CARE CENTER,35130,1980 WEST PECOS ROAD,CHANDLER,AZ,85224,2019-02-07,578,D,0,1,IXRE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy, the facility failed to ensure one resident (#126) advanced directive was accurately documented in the clinical record. Findings include: Resident #126 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the [DATE] admission face sheet indicated the resident was identified as his responsible party. A physician order [REDACTED].>Review of a document titled Advanced Directive Decisions dated [DATE] revealed the resident's decision was Do Not Resuscitate and Do Not Hospitalize. The section to be completed by the physician was blank. Review of the Social History assessment dated [DATE] completed by social services revealed the resident was his own responsible party. The assessment revealed the section Do Not Resuscitate Order (see DNR form) was marked CPR and the Advance Directive section was marked yes. The admission Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Further review of the clinical record did not reveal a Prehospital Medical Care Directive or that an Advanced Directive had been completed. An interview was conducted on [DATE] at 12:53 PM with the Admissions Manager (staff #115), who that stated the Advanced Directive Decisions form is completed at the time of admission Staff #115 stated that the form is put into a binder at the nurse's station and that the physician will sign it. Staff #115 further stated that if the resident is a Do Not Resuscitate (DNR) status, the orange Prehospital Medical Care Directive form is completed, the physician will sign it, and the status is updated in the clinical record. However, the Admission Manager was unable to locate the form for this resident in the binder at the nurse's station. On [DATE] at 01:23 PM, the resident declined an interview regarding his Advanced Directive status. An interview was conducted on [DATE] at 01:45 PM with the Director of Nursing (DON/staff #110), who stated the Advanced Directives processes are started during the admission process as part of the admission paperwork. The DON stated that if the resident wishes to be a DNR status, the orange Prehospital Medical Care Directive form is to be completed along with the required signatures. Staff #110 also stated that the Social Worker completed the Social History Assessment for this resident and that for the choices of CPR (Cardiopulmonary resuscitation) and no CPR under the DNR section, the Social Worker selected CPR and selected Yes under the Advanced Directive section. During an interview conducted on [DATE] at 01:10 PM with the Social Worker (SW/staff #114), the SW stated that when she completed the Social History Assessment form this resident, the resident chose CPR, but also wanted the Power of Attorney (POA) to make the decision. Staff #114 stated that by marking the CPR selection under Do Not Resuscitate it applied to the performance of CPR only and that the Advanced Directive section meant the resident or the resident's POA would initiate Advanced Directives. The Social Worker stated that she had spoken with the resident's POA on a previous date and then again on [DATE] and that it was clarified that the resident was a Full Code status. However she did not have any documentation of the communications with the resident's PO[NAME] The facility's policy titled Advanced Directives included the policy statement that, Advanced Directives will be respected in accordance with state law and facility policy. The policy revealed that Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he if she chooses to do so .If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative . The policy included that information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. The policy also included the Director of Nursing or designee will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident's clinical record and plan of care.",2020-09-01
851,ARCHSTONE CARE CENTER,35130,1980 WEST PECOS ROAD,CHANDLER,AZ,85224,2019-02-07,637,D,0,1,IXRE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that a significant change in status Minimum Data Set (MDS) assessment was completed within the required timeframe for one resident (#75). Findings include: Resident #75 was admitted on (MONTH) 7, (YEAR) with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of the care plan revealed the resident was admitted to hospice services on (MONTH) 5, (YEAR). A physician's progress note dated (MONTH) 5, (YEAR) included the resident's admission to hospice services. However, review of clinical record revealed no significant change in status MDS assessment was completed in (MONTH) (YEAR). An interview was conducted on (MONTH) 6, 2019 at 12:18 p.m. with the MDS Registered Nurse (RN/staff #28) who stated that when a resident is admitted to hospice services, it is considered a significant change of condition and a significant change in status MDS assessment is required to be completed. Staff #28 also stated that they follow the RAI manual for MDS assessment requirements and schedules. An interview was conducted on (MONTH) 7, 2019 at 10:59 a.m. with the Director of Nursing (DON/staff #110) who stated that her expectation is for staff to complete the MDS assessments accurately and in a timely manner. Staff #110 stated that if a resident is admitted to hospice services, that would be a significant change of condition and completion of a significant change in status MDS assessment would be required. The DON stated the MDS assessment policy is to follow the RAI manual. The RAI manual instructs a Significant Change in Status Assessment (SCSA) is required to be performed when a terminally ill resident enrolls in a hospice program. The manual included the Assessment Reference Date (ARD) must be within 14 days from the effective date of the hospice election. The manual also instructs that a SCSA must be performed regardless of whether an assessment was recently conducted for the resident.",2020-09-01
852,ARCHSTONE CARE CENTER,35130,1980 WEST PECOS ROAD,CHANDLER,AZ,85224,2019-02-07,695,D,0,1,IXRE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, and policy review, the facility failed to ensure that oxygen was administered per physician's order for one resident (#229). Findings include: Resident #229 was admitted on (MONTH) 24, 2019 with [DIAGNOSES REDACTED]. The physician's orders dated (MONTH) 29, 2019 included for oxygen at 2 liters per minute (LPM) via nasal cannula to maintain oxygen saturation at 90% every 8 hours as needed (PRN) for shortness of breath. The admission Minimum Data Set assessment dated (MONTH) 31, 2019 revealed a Brief Interview of Mental Status score of 15, indicating the resident was cognitively intact. The assessment also included the resident was provided oxygen therapy. During an observation conducted of the resident on (MONTH) 4, 2019 at 10:51 a.m., the resident was observed with oxygen via nasal cannula at 3.5 LPM. An observation was conducted of the resident on (MONTH) 6, 2019 at 11:18 a.m. The resident was observed receiving oxygen via nasal cannula at 3.5 LPM. An interview was conducted on (MONTH) 6, 2019 at 11:25 a.m. with a Licensed Practical Nurse (LPN/staff #76) who stated that some oxygen orders will have a LPM range, so adjusting the oxygen flow would be following the physician order. Staff #76 stated that if a physician order is specific for LPM, then the expectation is that order should be followed for that resident. During an observation conducted of the resident #229 on (MONTH) 7, 2019 at 10:35 a.m., the resident was observed with oxygen via nasal cannula at 3.5 LPM. Immediately following this observation, an interview was conducted with a Registered Nurse (RN/staff #61), who stated that the resident has been using oxygen daily since admission. Staff #61 stated that the physician's order is for the resident to have oxygen at 2 LMP prn and that the order should be followed. After observing the resident was receiving oxygen at 3.5 LPM, the RN stated that the oxygen should be at 2 LPM and not 2 LPM. Staff #61 immediately decreased the oxygen to 2 LPM. An interview was conducted on (MONTH) 7, 2019 at 10:59 a.m. with the Director of Nursing (DON/staff #110). The DON stated that the expectation is that the nurses follow physician orders. The facility's policy titled Oxygen Administration revealed the purpose is to provide guidelines for safe oxygen administration. The policy included to verify that there is a physician's order for oxygen and to review the order for oxygen administration. The policy also included to adjust the oxygen delivery device so that the proper flow of oxygen is being administered.",2020-09-01
853,ARCHSTONE CARE CENTER,35130,1980 WEST PECOS ROAD,CHANDLER,AZ,85224,2019-02-07,757,D,0,1,IXRE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy and procedures, the facility failed to ensure one resident's (#231) drug regimen was free of unnecessary drugs, by failing to ensure that pain medication was administered within the pain parameters per the physician's orders [REDACTED].>Findings include: Resident #231 was admitted on (MONTH) 31, 2019 with [DIAGNOSES REDACTED]. A review of physician's orders [REDACTED]., and [MEDICATION NAME] (narcotic) HCI tablet 10 mg by mouth every 4 hours as needed for pain 9-10. Review of the Mediation Administration Record (MAR) for (MONTH) 2019 revealed [MEDICATION NAME] 10 mg was administered for a pain level of 2 on (MONTH) 3, 2019 at 1:01 a.m. and 9:32 p.m. An interview was conducted on (MONTH) 6, 2019 at 11:25 a.m. with a Licensed Practical Nurse (LPN/staff #76) who stated that as needed (PRN) pain medication will have a specific pain scale attached to the order. The LPN stated that the resident's pain level will determine which PRN medication is to be administered to the resident. Staff #76 stated that the expectation is that nurses follow the physician's orders [REDACTED].>During an interview conducted on (MONTH) 7, 2019 at 10:59 a.m. with the Director of Nursing (DON/staff #110) the DON stated that the expectation is that staff follow the physician's orders [REDACTED]. The facility's policy titled Pain-Clinical Protocol revealed the staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. The policy included the physician will order appropriate medication interventions to address the resident's pain. The policy also included pain medications should be selected based on pertinent treatment guidelines.",2020-09-01
854,ARCHSTONE CARE CENTER,35130,1980 WEST PECOS ROAD,CHANDLER,AZ,85224,2019-02-07,761,E,0,1,IXRE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of clinical records, staff interviews, and policy review, the facility failed to ensure that expired medications were not available for use for two residents (#17 and #14) and failed to ensure that the expired medications were not administered to one resident (#14). Findings include: -Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE]. During a medication storage observation conducted on 02/05/19 at 2:15 PM of a medication cart on Station 2 the following medications for resident #17 were observed: -One bubble pack of Calcium antacid chewable tablets 500 milligram (mg) (packaged as two tablets per bubble) with 26 doses remaining with an expiration date of 10/06/18. -Two bubble packs of [MEDICATION NAME] (antidiarrheal) 2 mg tablets with one pack containing 30 remaining doses with an expiration date of 10/06/18 and one pack containing 10 remaining doses with an expiration date of 09/09/18. -One bubble pack of [MEDICATION NAME] ([MEDICATION NAME]) 325 mg tablets (packaged as two tablets per bubble) with 24 doses remaining with an expiration date of 10/06/18. -Two bubble packs of [MEDICATION NAME][MEDICATION NAME] ([MEDICATION NAME]) 25 mg tablets with one pack containing 2 remaining doses with an expiration date of 09/19/18 and one pack with 28 remaining doses with an expiration date of 10/06/18. Review of the resident's Medication Administration Records (MAR) revealed the resident last received the medications prior to (MONTH) (YEAR). -Resident #14 was admitted to the facility on [DATE]. During a medication storage observation conducted on 02/06/19 at 02:03 PM of a medication cart on Station 1, one bubble pack of [MEDICATION NAME] 500 mg tablets with 62 tablets remaining was observed with an expiration date of 11/08/18. Review of the physician orders [REDACTED]. Review of the MARs for (MONTH) and (MONTH) 2019 revealed documentation that the resident was administered the medication as ordered. During an interview conducted on 02/06/19 at 02:03 PM with a Licensed Practical Nurse (LPN/staff #76), the LPN stated that she had administered Tylenol from that pack to the resident that morning. An interview was conducted on 02/07/19 at 09:32 AM with the Director of Nursing (DON/staff #110). The DON stated that the night shift nurse is responsible for checking the carts every night for any expired medications and to ensure that opened medications are dated when opened. The facility's policy titled Storage of Medications revealed Medication and biologicals are stored safety, securely, and properly following manufacturer's recommendations or those of the supplier. The policy included Outdated, contaminated or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal .and reordered from the pharmacy .if a current order exists.",2020-09-01
855,ARCHSTONE CARE CENTER,35130,1980 WEST PECOS ROAD,CHANDLER,AZ,85224,2016-10-06,225,D,0,1,8CES11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews and policy and procedures, the facility failed to investigate and report an allegation of abuse to the State agency regarding one resident (#128). Finding include: Resident #128 was admitted to the facility on (MONTH) 7, (YEAR), with [DIAGNOSES REDACTED]. A review of the admission MDS (Minimum Data Set) assessment dated (MONTH) 14, (YEAR) revealed a Brief Interview for Mental Status score of 14, which indicated that the resident was cognitively intact. Review of a Physical Therapy Note dated (MONTH) 29, (YEAR) revealed Pt. (patient) stated she wasn't feeling up to therapy due to an altercation with another resident at the facility, nursing was notified. During an interview conducted at 3:42 p.m. on (MONTH) 3, (YEAR), resident #128 stated that she was trying to get out of her room and another resident was blocking her doorway. She stated that she asked this resident to move out of the way several times, but the other resident became agitated and began to shake. She further stated that this resident kicked her in the leg and then threw her chair at her, hitting her legs. Resident #128 said that she had reported the altercation to a staff member, but did not recall who she told. During an interview conducted at 1:55 p.m. on (MONTH) 4, (YEAR), the Social Worker (staff #86) stated she was not aware of any resident to resident altercations involving resident #128. She stated if she had been aware of an altercation, she would have coordinated with the Director of Nursing (DON) and an investigation would have been initiated. During an interview conducted at 2:00 p.m. on (MONTH) 4, (YEAR), the Director of Nursing (DON/staff #74) stated that she was not aware of any altercation involving resident #128 and that no investigation was conducted. The DON stated that when an allegation of abuse is reported she and the Social Worker (staff #86) will coordinate the investigation. An interview was conducted at 2:05 p.m. on (MONTH) 4, (YEAR), with the Assistant Director of Nursing (ADON/staff #73), who stated that she had read the therapy note and asked the nurse caring for resident #128 about the altercation. Staff #73 stated the nurse who was caring for resident #128 told her that she had seen another resident by resident #128's doorway, however; there was no contact between the residents, therefore no further action was taken. Staff #73 stated that she did not interview resident #128 regarding this. An interview was conducted at 2:20 p.m. on (MONTH) 4, (YEAR), with resident #128 and the Licensed Practical Nurse (LPN/staff #26) who was caring for resident #128 this day. Resident #128 stated that a resident kicked her and threw a chair at her. Resident #128 then identified the resident who had kicked her and threw a chair at her. Resident #128 identified a different resident than who was identified by the LPN in the above interview with the ADON. During the interview, the LPN stated that the resident (who allegedly threw the chair at resident #128) was very feisty and wanders around the facility. She also stated that she had not been made aware of any altercation between these two residents. An interview was conducted at 2:34 p.m. on (MONTH) 5, (YEAR) with a Physical Therapist (staff #124) who stated that a week earlier (between (MONTH) 27 and 29) resident #128 told her that another resident had thrown her wheelchair at her and hit her legs. The PT further stated that she reported the allegation the following morning during the morning meeting, which had been attended by several department heads. Review of the ACTS (Aspen Complaint/Incident Tracking System) revealed no evidence that the facility reported the allegation of abuse to the State agency, prior to surveyor intervention on (MONTH) 4, (YEAR). The facility was unable to provide any documentation that the allegation of abuse had been investigated or reported to the State agency, prior to (MONTH) 4, (YEAR). Review of the Abuse Reporting policy and procedure revealed All personnel must promptly report any incidents or suspected incidents of resident abuse, including injuries of an unknown source. The policy also included Our facility will not condone resident abuse by anyone, including staff members, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, sponsors, friends, or other individuals. The policy further noted that When an alleged or suspected case of mistreatment, neglect, or abuse is reported, the facility administrator or his/her designee, will notify the following persons or agencies of such incident: a. State Licensing and Certification Agency; b. Ombudsman; c. Resident Representative; d. Adult Protective Services; e. Law Enforcement Officials . Review of the Abuse Investigation policy and procedure revealed All reports of resident abuse, neglect and injuries of unknown source shall be thoroughly and promptly investigated by the facility management.",2020-09-01
856,ARCHSTONE CARE CENTER,35130,1980 WEST PECOS ROAD,CHANDLER,AZ,85224,2016-10-06,226,D,0,1,8CES11,"Based on a clinical record review, resident and staff interviews and policy and procedures, the facility failed to implement their Abuse policy regarding an allegation of abuse for one resident (#128). Findings include: Review of a Physical Therapy Note dated (MONTH) 29, (YEAR) revealed Pt. (patient) stated she wasn't feeling up to therapy due to an altercation with another resident at the facility, nursing was notified. During an interview conducted at 3:42 p.m. on (MONTH) 3, (YEAR), resident #128 stated that she was trying to get out of her room and another resident was blocking her doorway. She stated that she asked this resident to move out of the way several times, but the other resident became agitated and began to shake. She further stated that this resident kicked her in the leg and then threw her chair at her, hitting her legs. Resident #128 said that she had reported the altercation to a staff member, but did not recall who she told. During an interview conducted at 1:55 p.m. on (MONTH) 4, (YEAR), the Social Worker (staff #86) stated she was not aware of any resident to resident altercations involving resident #128. She stated if she had been made aware of a resident to resident altercation, per the facility's procedures, she would have coordinated with the Director of Nursing (DON) and an investigation would have been completed that included interviewing the residents, staff members and other possible witnesses. During an interview conducted at 2:00 p.m. on (MONTH) 4, (YEAR), the Director of Nursing (DON/staff #74) stated that she was not aware of any altercation involving resident #128 and that no investigation was conducted. The DON stated that when an allegation of abuse is reported she and the Social Worker (staff #86) will coordinate the investigation. An interview was conducted at 2:05 p.m. on (MONTH) 4, (YEAR), with the Assistant Director of Nursing (ADON/staff #73), who stated that she had read the therapy note and asked the nurse caring for resident #128 about the altercation. Staff #73 stated the nurse who was caring for resident #128 told her that she had seen another resident by resident #128's doorway, however; there was no contact between the residents, therefore no further action was taken. Staff #73 stated that she did not interview resident #128 regarding this. An interview was conducted at 2:20 p.m. on (MONTH) 4, (YEAR), with resident #128 and the Licensed Practical Nurse (LPN/staff #26) who was caring for resident #128 this day. Resident #128 stated that a resident kicked her and threw a chair at her. Resident #128 then identified the resident who had kicked her and threw a chair at her. Resident #128 identified a different resident than the one who was identified by the LPN in the above interview with the ADON. During the interview, the LPN stated that the resident (who allegedly threw the chair at resident #128) was very feisty and wanders around the facility. She also stated that she had not been made aware of any altercation between these two residents. An interview was conducted at 2:34 p.m. on (MONTH) 5, (YEAR) with a Physical Therapist (staff #124) who stated that a week earlier (between (MONTH) 27 and 29) resident #128 told her that another resident had thrown her wheelchair at her and hit her legs. The PT further stated that she reported the allegation the following morning during the morning meeting, which had been attended by several department heads. Review of the ACTS (Aspen Complaint/Incident Tracking System) revealed no evidence that the facility reported the allegation of abuse to the State agency, prior to surveyor intervention on (MONTH) 4, (YEAR). The facility was unable to provide any documentation that the allegation of abuse had been investigated or reported to the State agency, prior to (MONTH) 4, (YEAR). Review of the Abuse Reporting policy and procedure revealed All personnel must promptly report any incidents or suspected incidents of resident abuse, including injuries of an unknown source. The policy also included Our facility will not condone resident abuse by anyone, including staff members, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, sponsors, friends, or other individuals. The policy further noted that When an alleged or suspected case of mistreatment, neglect, or abuse is reported, the facility administrator or his/her designee, will notify the following persons or agencies of such incident: a. State Licensing and Certification Agency; b. Ombudsman; c. Resident Representative; d. Adult Protective Services; e. Law Enforcement Officials . Review of the Abuse Investigation policy and procedure revealed All reports of resident abuse, neglect and injuries of unknown source shall be thoroughly and promptly investigated by the facility management.",2020-09-01
857,ARCHSTONE CARE CENTER,35130,1980 WEST PECOS ROAD,CHANDLER,AZ,85224,2016-10-06,323,K,0,1,8CES11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, staff interviews, and review of policy and procedures, the facility failed to ensure the residents' environment was free of accident hazards, by failing to ensure safe water temperatures were maintained in multiple residents' bathrooms and in two shower rooms. As a result, the Condition of Immediate Jeopardy and Substandard Quality of Care were identified. Findings include: At 2:30 p.m. on (MONTH) 3, (YEAR), the Condition of Immediate Jeopardy and Substandard Quality of Care were identified. The Director of Nursing (DON/staff #74) and the Assistant Director of Nursing (ADON/staff #73) were informed of the facility's failure to maintain safe water temperatures in multiple residents' bathrooms and in two shower rooms. Observations revealed the water temperatures in ten resident bathrooms (in which 15 residents resided) and two shower room sinks were found to have hot water temperatures between 120.3 and 135 degrees Fahrenheit (F.) The Director of Nursing presented a plan of correction at 4:20 p.m. on (MONTH) 3, (YEAR). The Director of Nursing was informed at 4:45 p.m. that the plan of correction needed additional information regarding the monitoring of the hot water temperatures, and a plan for in-servicing staff regarding the risks of hot water temperatures and how and when to report hot water temperatures. A revised plan of correction was received at 5:45 p.m. on (MONTH) 3, (YEAR). The plan of correction included that a plumber was immediately contacted and the mixing value was dialed down to decrease the water temperature, and that the dial thermometer and the mixing valve gauge were replaced. The Director of Nursing was notified that the plan of correction was accepted at 6:00 p.m. on (MONTH) 3, (YEAR). Multiple observations were conducted on (MONTH) 3 and 4, (YEAR), of the facility implementing their plan of correction, which included staff in-services, the facility's monitoring and documentation of water temperatures in resident rooms and shower rooms. and the use of new thermometers by maintenance staff. Surveyors also retested the water temperatures and were found to be within acceptable ranges. As a result of the facility implementing their plan of correction, the Condition of Immediate Jeopardy was abated at 9:45 a.m. on (MONTH) 4, (YEAR). -During random observations conducted at 10:15 a.m. on (MONTH) 3, (YEAR), the hot water temperature in resident room #129 was 130 degrees F. and in room #130 the water temperature was 129 degrees F. Due to the elevated temperatures, 10 additional resident rooms were checked on multiple hallways and revealed the following: Room #'s Temperatures #105 134 degrees F #106 134 degrees F #150 124 degrees F #151 123 degrees F #153 127 degrees F #160 126 degrees F The water temperatures in 4 other rooms were checked and ranged from 115 to 120 degrees F. Review of the facility's Water Temperature Weekly Logs for (MONTH) 3, (YEAR) revealed the water temperatures in two resident bathrooms and two shower rooms were documented at 119 degrees F. The log also included that on (MONTH) 3, the water temperature of the hot water heaters (#'s 1, 2, and 3) all read 143 degrees F. During an interview conducted at 11:40 a.m. on (MONTH) 3, (YEAR), the Maintenance Supervisor (staff #117) stated that a maintenance staff member (staff #118) checked the water temperatures the morning of (MONTH) 3, and no problems were identified. When asked when the last time the thermometer was calibrated, staff #117 stated that he was unsure. He stated that he did not know how to calibrate the thermometer, therefore; he takes the thermometer to the Dietary Manager to have the thermometer calibrated. He further stated that he believed he had the thermometer calibrated approximately a month ago by the Dietary Manager. Following this interview, the Maintenance Supervisor was observed in the kitchen with the dietary manager (staff #103) calibrating the thermometer used by maintenance staff. The thermometer calibrated at 32 degrees F., by using a cup of ice with a small amount of water. No adjustment was needed to this thermometer. The surveyor's digital thermometer was also checked and registered at 32 degrees F. An interview was conducted at 11:55 a.m. on (MONTH) 3, 2106 with staff #118, with staff #117 present. Staff #118 stated the rooms he had checked and recorded on the Water Temperature Weekly Logs on the morning of (MONTH) 3, were rooms #106 and #163. At this time, along with staff #117 and #118, the water temperatures were checked using the surveyor's digital thermometer and the maintenance staff's thermometer in two resident bathrooms and two shower room sinks and revealed the following: Room Maintenance Thermometer Digital Thermometer #106 120 degrees F. 134 degrees F. Station 1 shower room 119 degrees F. 132 degrees F. #163 115 degrees F. 127 degrees F. Station 2 shower room 113 degrees F. 120 degrees F. During an interview conducted at 12:30 p.m. on (MONTH) 3, (YEAR), staff #117 stated that he obtained a second thermometer from the kitchen which was also calibrated to 32 degree F. He said they rechecked the same two resident bathrooms (#s 106 and 163) and found that the temperatures read the same as those found on the digital thermometer. He stated that the thermometer used by the maintenance staff member was not working properly. -Resident #44 was admitted to the facility on (MONTH) 1, 2009, with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 25, (YEAR), revealed a Brief Interview for Mental Status score of 3, which indicated that the resident had severe cognitive impairment. Observations on (MONTH) 3, (YEAR) revealed that this resident resided in one of the rooms with the elevated water temperatures. During an interview conducted with a Licensed Practical Nurse (LPN/staff #26) at 2:20 p.m. on (MONTH) 4, (YEAR), the LPN stated that resident #44 was confused and wanders around the facility. -Resident #41 was readmitted on (MONTH) 1, 2013, with [DIAGNOSES REDACTED]. The MDS assessment dated (MONTH) 9, (YEAR) included that the resident required limited assistance of one person with locomotion on and off the unit and that the resident utilized a wheelchair. According to a care plan, the resident required limited assistance of one staff with personal hygiene and oral care. The care plan further included that the resident had impaired cognitive function, due to dementia. Multiple observations were made during the survey of the resident self propelling herself throughout the facility. An observation on (MONTH) 3, (YEAR) at 10 a.m., revealed that this resident resided in one of the rooms with the elevated water temperatures. An interview was conducted with staff a LPN (staff #26) on (MONTH) 4, (YEAR) at 11:12 a.m. Staff #26 stated that the resident had the ability to self propel in her wheelchair and could wash her hands by herself. She also stated that the resident was usually confused. -Resident #100 was admitted to the facility on (MONTH) 14, 2014, with [DIAGNOSES REDACTED]. A MDS quarterly assessment dated (MONTH) 9, (YEAR) identified that the resident had a BIMS score of 9, which indicated the resident had moderate cognitive impairment. An observation on (MONTH) 3, (YEAR) revealed that this resident resided in one of the rooms with the elevated water temperatures. In an interview with resident #100 on (MONTH) 3, (YEAR) at 11:37 a.m., the resident stated that she uses the sink in her bathroom. At this time, the resident was observed sitting in a wheelchair and she was able to move around in her room. Review of the policy regarding the Safety of Water Temperatures revealed Tap water in the facility shall be kept within a temperature range to prevent scalding of residents. The policy also included Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120 degrees F ., or the maximum allowable temperatures per state regulation. According to the Federal regulation under F323, Table 1., the time required for a 3rd degree burn to occur is 1 min at 127 degrees F; 15 seconds at 133 degrees F; 5 seconds at 140 degrees F. and 2 seconds at 147 degrees F. The regulation also included that a safe water temperature was 100 degrees F. and that burns can occur even at temperatures below those identified in the table, depending on an individuals condition and the length of exposure.",2020-09-01
858,ARCHSTONE CARE CENTER,35130,1980 WEST PECOS ROAD,CHANDLER,AZ,85224,2017-10-26,224,E,1,1,EWWK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews, facility documentation, and policies and procedures, the facility failed to ensure that three residents (#4, #15 and #33) were free from physical abuse by one resident (#114), who had a known history of abusive behaviors. Findings include: -Resident #33 was admitted on (MONTH) 14, (YEAR) and readmitted on (MONTH) 4, (YEAR), with [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed a quarterly MDS (Minimum Data Set) assessment dated (MONTH) 4, (YEAR), which included that the resident had moderate cognitive impairment. A quarterly MDS assessment dated (MONTH) 1, (YEAR) included the resident had a BIMS (Brief Interview for Mental Status) score of 4, which indicated the resident had severe cognitive impairment. A review of the care plans for resident #33 revealed the resident was dependent on staff for emotional, intellectual, and physical needs and was able to propel self in a wheelchair. -Resident #4 was admitted on (MONTH) 5, 2011, with [DIAGNOSES REDACTED]. A quarterly MDS assessment dated (MONTH) 19, (YEAR) included the resident had severe cognitive impairment. The resident's care plans revealed the resident was dependent on staff for meeting emotional, intellectual, physical and social needs, due to dementia. The care plans further included the resident used a wheelchair for mobility and required assistance from staff for locomotion in the wheel chair. -Resident #15 was admitted on (MONTH) 6, (YEAR) and readmitted on (MONTH) 28, (YEAR). [DIAGNOSES REDACTED]. A quarterly MDS assessment dated (MONTH) 1, (YEAR) included the resident had severe cognitive impairment. A review of the care plans for resident #15 revealed the resident had impaired cognitive function and impaired thought processes related to dementia, had limited physical mobility and required extensive assistance of staff for locomotion. The care plans further included the resident was verbally aggressive towards staff and other residents on occasion, becomes agitated quickly and was not easily re-directed. -Resident #114 was admitted on (MONTH) 26, (YEAR), with [DIAGNOSES REDACTED]. A behavior care plan dated (MONTH) 6, (YEAR) included the resident displayed aggressive behaviors toward staff during cares. An intervention included to monitor the resident for behaviors. Review of a facility's investigative report revealed that on (MONTH) 22, (YEAR) at 6:45 p.m., resident #114 walked up to resident #33 who was in a wheelchair, and attempted to push resident #33 down the hallway. A Certified Nursing Assistant (staff #124) then observed resident #114 holding resident #33's arms down and punching the resident in the arms. The residents were separated and resident #33 was checked by a LPN (licensed practical nurse/staff #20) and no injuries were noted. Neither resident was able to verbalize an account of the incident. The report also included that the interventions implemented after the incident consisted of separating and monitoring the residents. Review of a facility's investigative report revealed that an activity aide (staff #78) had observed resident #114 and resident #4 in the activity room on (MONTH) 23, (YEAR) at approximately 10:15 a.m. At this time, staff #78 witnessed resident #114 slap resident #4 numerous times on the arm and then told resident #4, You better shut up before I punch you in the face. As staff approached the residents, resident #114 put both hands around the throat of resident #4 and attempted to choke her. Staff #78 reported that when she tried to move resident #4 away from resident #114, resident #114 tried to reach for resident #4 and choke her again. Staff #78 was able to separate the residents with the assistance of two therapy staff (staff #116 and #117). Resident #4 was assessed to have no injuries and was unable to recall the incident. Resident #114 was interviewed regarding what happened and replied, Because look how she (resident #4) sitting looking, she's a [***] . The documentation included that resident #114 was recently diagnosed with [REDACTED]. The investigative report further included that prior to the (MONTH) 23 incident, resident #114 had care plans in place addressing physical aggression and cognitive deficits. Interventions implemented after the incident included immediately separating the residents and monitoring. Review of a psych note dated (MONTH) 23, (YEAR) revealed the resident tried to choke another resident in the dining room. The plan was to increase the resident's [MEDICATION NAME] dose (used for mood stabilizer), suggest [MEDICATION NAME] as needed, and adjust medications accordingly. A quarterly MDS assessment dated (MONTH) 3, (YEAR) included the resident had a BIMS score of 6, which indicated the resident had severe cognitive impairment. The MDS also included the resident was resistive to cares, used a wheelchair or walker for mobility, and required extensive assistance of one person with locomotion on and off the unit. Per the MDS, the resident had physical and verbal behavior symptoms directed towards other. The behavioral care plan was updated on (MONTH) 5, (YEAR) and now included that the resident was physically aggressive with staff and other residents. Behaviors documented were hitting and scratching staff and other residents. Interventions included analyzing the times of day, places, circumstances, triggers, and what de-escalates behaviors and to document; assess for contributing sensory deficits; administer medications (anti-anxiety and mood stabilizer) per orders; give the resident as many choices as possible about cares and activities; and monitor and document behaviors and interventions in the behavior log. Although the resident was being followed by psych and had medication changes, there was no documentation that resident #114 was provided increased supervision or that any other interventions were implemented to prevent further occurrences. An interview was conducted on (MONTH) 25, (YEAR) at 12:17 p.m., with a LPN (staff #34), who was working at the time of the incident on (MONTH) 23. Staff #34 stated that she did not witness the incident between resident #4 and resident #114, but staff had reported the incident to her and she assessed the residents and both had no injuries. Staff #34 stated that resident #114 had previous incidents of aggression towards other residents, but this was the first incident with resident #4. An interview was conducted on (MONTH) 25, (YEAR) at 12:36 p.m., with the activity aide (staff #78), who had witnessed the incident on (MONTH) 23 between resident #4 and resident #114. Staff #78 stated that resident #4 was being very loud and resident #114 had become annoyed and hit resident #4. Staff #78 stated the therapy staff assisted in separating the residents. An interview was conducted on (MONTH) 25, (YEAR) at 12:53 p.m., with therapy staff (staff #116). Staff #116 stated she was leaving the therapy area to go get another resident when she witnessed resident #114 hitting resident #4, however, she did not see resident #114 attempt to choke resident #4. An interview was conducted on (MONTH) 25, (YEAR) at 1:00 p.m., with therapy staff (staff #117). Staff #117 stated she observed resident #4 and resident #114 sitting next to one another in the activity room. Staff #117 stated she did not see resident #114 hit or attempt to choke resident #4. Staff #117 stated she assisted staff #78 and staff #116 with separating and moving the residents to opposite sides of the room. Staff #117 stated she told staff #78 that resident #114 had been aggressive with therapy staff, but had not previously shown aggression towards other residents. Review of a facility's investigative report revealed that on (MONTH) 11, (YEAR) at approximately 3:15 p.m., a CNA (staff #66) observed resident #114 standing behind resident #33 who was in her wheelchair, and was pulling resident #33 by the wheelchair handles. At this time, resident #114 started hitting resident #33 at least three times on her back. The report included that resident #33 was attempting to go into another resident's room. Staff #66 and staff #125 (LPN) immediately separated the residents. Resident #33 was assessed with [REDACTED].#33 was moved to a different unit to minimize the potential for further negative interactions. The report further included that resident #114 had care plan interventions in place which addressed physical aggression, and that the resident was being followed by a psychiatric provider for behavioral symptoms and psychopharmacological medication management. Interventions implemented after the (MONTH) 11 incident included immediately separating resident #33 and #114. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. However, there was no documentation that resident #114 was provided any increased supervision, nor were there any specific interventions which were implemented to prevent further occurrences, despite resident #114 being the aggressor in three altercations with other residents. An interview was conducted on (MONTH) 26, (YEAR) at 8:55 a.m., with staff #66 who had witnessed the (MONTH) 11 incident between resident #114 and resident #33. Staff #66 stated resident #114 got up from her wheelchair and walked towards resident #33, told her to shut up and hit resident #33 on the shoulder with a half closed hand. Review of a facility's investigative report revealed that on (MONTH) 17, (YEAR) at approximately 3:40 p.m., an LPN (staff #125) witnessed resident #114 take a white cloth out of the hands of resident #33. At this time, staff #125 did not witness any further interactions between the residents. However, a CNA (staff #43) then witnessed resident #114 hit resident #33 on the top of her head, with the white cloth. Resident #33 was assessed and had no injuries. Per the report, the residents were unable to recall the situation, however, since there had been multiple altercations between resident #114 and resident #33, resident #114 was moved to the opposite side of the facility. The report also included resident #114 had a care plan in place prior to the (MONTH) 17 incident, which addressed behaviors of physical aggression and cognitive deficits, and that a psychiatric provider was continuing to follow resident #114 for increased behavioral symptoms and psychopharmacological medication management. The interventions implemented following the incident included the residents were immediately separated with no further altercations, staff would continue to monitor the residents and resident #114 was moved to the opposite side of the facility. Review of a social services note dated (MONTH) 18, (YEAR) included the psych provider was called regarding the resident's increase in behavioral symptoms and incidents with other residents. The note further included that psych was to be out to re-evaluate the resident on (MONTH) 19. Review of the Psychiatric note dated (MONTH) 19, (YEAR) revealed the resident continues to be agitated and has assaulted two more residents in the dining room. The note included the resident has a history of [MEDICAL CONDITION] and worsening of dementia with behavioral disturbances. The plan included to continue the [MEDICATION NAME] and start [MEDICATION NAME] (antipsychotic) for dementia with behavioral disturbances, as evidenced by aggression and agitation. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Although the resident was continuing to be followed by psych with medications changes and the resident was moved to another area, there was no evidence that resident #114 was provided increased supervision or that any other interventions were implemented to prevent further occurrences, despite resident #114 being the aggressor in four altercations with residents. Review of a facility's investigative report revealed that on (MONTH) 5, (YEAR) at approximately 1:15 p.m., a CNA (staff #41) heard a call for help and stepped out into the hallway and witnessed resident #114 pushing resident #15 in a wheelchair. Resident #15 said something to resident #114 and staff #41 witnessed resident #114 slap resident #15, three times on the left side of her face near the left eye, with an open hand. The residents were separated. Resident #15 was assessed to have no injuries. When questioned regarding the incident, resident #15 stated she didn't count how many times she was hit and resident #114 stated she didn't hit anyone. The investigative report further included that resident #14 had care plans addressing cognitive deficits and verbal and physical aggression, prior to the (MONTH) 5 incident. The report stated that the care plans included resident #114 continues to be followed by a psychiatric provider for increased behavioral symptoms and psychopharmacological medication management. Interventions implemented after the incident included the residents were immediately separated and taken to their rooms, with no further interactions. Neither resident was able to recall the incident or identify each other after the incident. Staff were to continue to monitor. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. During an interview conducted on (MONTH) 26, (YEAR) at 10:45 a.m., with the Social Services Director (staff #81) and the Administrator (staff #1), staff #81 stated that the incidents involving resident #114 hitting resident #4, #15, and #33 were not abuse, as all of the residents were cognitively impaired and could not remember the incidents or why they occurred. Staff #81 stated that resident #114 could not form willful intent to harm, due to her cognitive impairment. Staff #81 stated the facility had moved resident #114 and had a psychiatrist providing medication management to address the resident's behaviors. Staff #1 stated that resident #114 was cognitively impaired and could not form intent to cause willful harm. A review of the Abuse policy revealed the residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes, but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, and physical abuse. The policy also included that staff will investigate occurrences of abuse to clarify what happened and identify causes. The policy further stated that administration will protect the resident's from abuse by anyone including, but not limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. According to the policy regarding Resident to Resident Altercations, staff will monitor residents for aggressive behavior towards other residents. If two residents are involved in an altercation, staff will identify what happened, including what might have led to the aggressive conduct of those involved, make any necessary changes in the care plan approaches, and to document in the resident's clinical record all interventions and their effectiveness.",2020-09-01
859,GRANITE CREEK HEALTH & REHABILITATION CENTER,35131,1045 SCOTT DRIVE,PRESCOTT,AZ,86301,2017-01-26,371,E,0,1,QCE011,"Based on observations, staff interviews and review of policy and procedures, the facility failed to ensure that stored, ready to use pans and dishes were dry and free of food particles. Findings include: Observations were conducted in the kitchen at 1:50 p.m. on (MONTH) 25, (YEAR). There were three, two inch full size steam table pans which were stacked and ready to use. The top two pans had water that dripped when tipped, on the interior surfaces and both had food particles adhering to the interior surfaces. Also, there were two of four stacked, ready to use four inch quarter steam table pans, which had particles adhering to the interior surfaces. One of the pans had water adhering to the interior surface and dripped when tipped. Additional observations in the kitchen revealed there was a large covered container, which contained plastic tulip cups that were stored ready to use. One of the tulip cups had a purple, dry substance in the interior surface of the cup. In a second container, there was a stack of six plastic tulip bowls, which had approximately 1/4 to 1/2 teaspoon of water in each bowl. During an interview at the time of the observations, a dietary aid (staff #14) stated the tulip bowls had not been used and were washed today. She also stated that she should have checked the dishes and pans after they were washed to ensure they were clean and free of food particles. During an interview conducted at 2:29 p.m. on (MONTH) 25, (YEAR), the dietary manager (staff #9) stated the dishes are suppose to be air dried, before being stacked on the rack where the ready to be used pans are stored. He also stated that the tulip bowls were washed the day before (January 24) and that allowing the wet dishes to sit with pooled water could lead to the growth of bacteria and mold. A review of the Dry Storage Dishes and Utensils policy and procedure revealed, Dishes must be stored to promote air drying i.e. use dish racks or trays with plastic mesh that allow air to circulate and air dry dishes. A review of the Pots and Pans - Hot water policy and procedure revealed When items are dry, store in proper storage area.",2020-09-01
860,GRANITE CREEK HEALTH & REHABILITATION CENTER,35131,1045 SCOTT DRIVE,PRESCOTT,AZ,86301,2017-01-26,441,D,0,1,QCE011,"Based on observation, staff interviews and policy review, the facility failed to ensure infection control procedures were followed during medication administration. Findings include: During a resident interview conducted on (MONTH) 24, (YEAR), a LPN (Licensed Practical Nurse/staff #87) was observed to enter the resident's room and prepare to administer medications to the resident. Staff #87 had a plastic medicine cup with applesauce in it, and a paper cup with several medications inside. Staff #87 placed applesauce on a teaspoon and then, with her bare fingers, she picked up two medications from the paper medication cup and placed them on the teaspoon of applesauce. Staff #87 then repeated this same process two more times. An interview was conducted on (MONTH) 25, (YEAR) at 8:15 a.m., with the Director of Nursing (staff #129). Staff #129 stated that the LPN should never have touched the resident's pills with her bare hands, because hands are never clean. She stated the LPN should have used the spoon to scoop up the pills and then put them into the applesauce. A facility policy titled, General Dose Preparation and Medication Administration included the following: 3.4 Facility staff should not touch the medication when opening a bottle or unit dose package.",2020-09-01
861,GRANITE CREEK HEALTH & REHABILITATION CENTER,35131,1045 SCOTT DRIVE,PRESCOTT,AZ,86301,2019-05-23,684,D,0,1,49RX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy review, the facility failed to ensure that 1 of 21 sampled residents (#81) received treatments as ordered by the physician. Failure to implement physician orders [REDACTED]. Findings include: Resident #81 was admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set) assessment dated [DATE] included the resident had a BIMS (Brief Interview for Mental Status) score of 15, which indicated the resident was cognitively intact. A physician's orders [REDACTED]. On (MONTH) 24, 2019, a physician's orders [REDACTED]. Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. According to the (MONTH) 2019 MAR, there was no documentation that the O2 liter flow and O2 sats were checked on (MONTH) 2. Regarding the physician orders [REDACTED].>A physician's orders [REDACTED]. Review of the (MONTH) 2019 MAR indicated [REDACTED]. Further review revealed that on (MONTH) 5, the resident's weight was 180.4 pounds. A nursing progress note dated (MONTH) 5, 2019 stated the resident was alert, oriented x 4 and was anxious/agitated. The note stated the resident had an episode of anxiety today due to his breathing, feeling like he was not oxygenating well. Sats were checked and he was 90% on 2 liters of oxygen. A Small Volume Nebulizer (SVN) treatment was administered and he felt a little better. This note did not address the resident's weight gain or that the physician was notified of the weight gain. Review of the clinical record revealed there was no documentation that the physician had been notified of the resident's weight gain at this time as ordered. An interview was conducted on (MONTH) 22, 2019 at 12:09 p.m., with a Licensed Practical Nurse (LPN/staff #68). She stated the nurses work three shifts; days, evenings and night shift. She acknowledged there was missing documentation on the (MONTH) and (MONTH) MAR's for O2 monitoring. She also stated the resident's 6.4 lb weight gain on (MONTH) 5 should have been immediately reported to the physician. She said her process would be to follow the physician's orders [REDACTED].>An interview was conducted on (MONTH) 22, 2019 at 8:31 a.m., with the Director of Nursing (DON/staff #142). He stated his expectation is for the nurses to follow the physician's orders [REDACTED]. The facility policy on Physician order [REDACTED].in accordance with the resident's plan of care.",2020-09-01
862,GRANITE CREEK HEALTH & REHABILITATION CENTER,35131,1045 SCOTT DRIVE,PRESCOTT,AZ,86301,2019-05-23,686,D,0,1,49RX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy review, the facility failed to thoroughly assess a newly identified stage 2 pressure ulcer and notify the physician for treatment orders for one resident (#14). The deficient practice resulted in a delay in treatment, which could cause wound deterioration and complications. Findings include: Resident #14 was admitted to the facility on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated (MONTH) 4, (YEAR) revealed the resident scored an 8 on the brief interview for mental status, which indicated the resident had moderate cognitive impairment. The MDS included the resident was at high risk for pressure ulcer development and did not have a current pressure ulcer. Per the MDS, the resident required extensive assistance with two staff for bed positioning. A care plan dated (MONTH) 2019 documented a focus area of a potential for pressure ulcer development, due to immobility in bed and a history of pressure ulcer development. A goal was the resident would have no complications. Interventions included the following: -Notify the nurse immediately of any new areas of skin breakdown such as redness, blisters, bruises or discoloration. -Monitor/document/report to MD as necessary any changes in skin status such as appearance, color, wound healing, signs and symptoms of infection, wound size and stage. -Assess/record/monitor for wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the physician. -Follow facility policies and protocols for the prevention/treatment of [REDACTED]. A weekly licensed nurse skin evaluation dated (MONTH) 3, 2019 documented the identification of a wound on the right inner heel. The documentation included that treatment had been administered and documented on the Treatment Administration Record (TAR). However, there was no evidence of any measurements, a description of the wound, physician notification or the type of treatment that had been administered. Review of the clinical record including the physician orders, nursing progress notes, TARs and care plans revealed no evidence of the right inner heel wound until (MONTH) 7, 2019. A weekly pressure ulcer form dated (MONTH) 7, 2019 now revealed the resident had a fluid filled blister on the right medial heel, which was identified as a stage 2 pressure ulcer. Further review of the clinical record revealed no evidence of physician notification or any treatment orders, and there was no documentation of any treatments that had been administered on the (MONTH) 2019 TAR. An interview was conducted with a Licensed Practical Nurse (staff #36) on (MONTH) 22, 2019 at 12:47 p.m. Staff #36 stated she completed a clinical record review and a skin problem had been identified on (MONTH) 3, 2019. Staff #36 stated there was no documentation of physician notification or wound descriptors. Staff #36 stated the usual protocol is for the nurse to notify the wound nurse and or the physician. Staff stated for resident #14, a skin problem had been identified however; no further action was taken until 4 days later on (MONTH) 7, 2019. An interview was conducted with the Director of Nursing (staff #142) on (MONTH) 22, 2019 at 1:53 p.m. Staff #142 stated the facility protocol had not been put into place for this resident, because the physician had not been notified when a wound had been identified. Staff #142 stated the protocol was the same as outlined in the policy which includes that once a wound has been identified, assessed and documented, nursing shall administer treatment to the affected area as per the physician's orders [REDACTED].#142 said that wound and skin treatments should be documented in the clinical record at the time they are administered. According to a facility policy regarding wound management the following was included: A resident who enters the facility without pressure ulcers does not develop pressure ulcers .and a resident having pressure ulcers receives necessary treatment and services to promote healing. Once a wound has been identified, assessed, and documented nursing shall administer treatment to the affected area as per the physician's orders [REDACTED].",2020-09-01
863,GRANITE CREEK HEALTH & REHABILITATION CENTER,35131,1045 SCOTT DRIVE,PRESCOTT,AZ,86301,2019-05-23,696,E,0,1,49RX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff and resident interviews and policy and procedures, the facility failed to ensure that care and assistance were provided to one resident (#30) with a prosthesis, which did not fit properly. The deficient practice could result in a decline in mobility and level of functioning, requiring more assistance and being more dependent. Findings include: Resident #30 was admitted on (MONTH) 13, (YEAR), with [DIAGNOSES REDACTED]. Review of a physician's progress note dated 10/5/18 revealed the following: Evaluated and measured patient for new prosthesis. Current socket and foot no longer fit or function well. Will follow up for casting/scanning for new prosthesis. However, there was no clinical record documentation that the new prosthesis was obtained for the resident or the rational as to why this was not done from (MONTH) (YEAR) through (MONTH) 2019. A nursing progress note dated (MONTH) 19, 2019 included a call was placed to the Nurse Practitioner (NP) to report a [MEDICAL CONDITION] was discovered via venous Doppler in the resident's right lower extremity (RLE). A quarterly MDS assessment (MONTH) 23, 2019 revealed the resident scored 10 on the Brief Interview for Mental Status, indicating moderate cognitive impairment. The MDS also noted that the resident used a wheelchair. An Activities of Daily Living (ADL) care plan dated (MONTH) 2, 2019, revealed the resident required assistance with ADL's related to decreased mobility, deconditioning and weakness. The goal was for the resident to gradually increase to an independent level in all ADL's including bed mobility, transfers, dressing, grooming, toilet use and personal hygiene through the next review. An intervention included for the Restorative Nurse Assistant (RNA) program: lower extremity strengthening exercises three times per week. Review of a Physical Therapy (PT) Evaluation and Plan of Treatment dated (MONTH) 1, 2019, revealed the following goals: the resident will safely perform bed mobility tasks with modified independence and functional transfers with stand by assistance. The approaches included for therapeutic exercises and activities, manual therapy and neuromuscular reeducation. The resident's goal was to get better at transfers and eventually walk again. Per the evaluation, the resident demonstrates good rehab potential as evidence by active participation in skilled treatment, able to make needs known and motivated to participate. The PT evaluation also included the resident has had a significant decline over the past several months, due to a [DIAGNOSES REDACTED]. He previously required 1 person assist with mobility and has had a prosthesis for his left lower extremity, but it does not fit properly. He has been non-ambulatory greater than 6 months and in bed the majority of time in the past few months. Resident is starting to feel better and is willing to participate with skilled PT. The evaluation did not include any plan to address the resident's prosthesis, which did not fit properly. An interview was conducted on (MONTH) 20, 2019 at 10:03 a.m., with resident #30. He stated the prosthesis for his left lower leg is too small for his stump. He stated that staff are aware and is doing nothing about it. He said he used to wear his prosthesis before he got a blood clot in his other leg, but since he got the blood clot he has been laying in bed, and it no longer fits. The resident stated that with the prosthesis it made it easier to do the PT exercises and that he would like to get a new one that fits. An interview was conducted on (MONTH) 22, 2019 at 8:16 a.m., with a Certified Nursing Assistant (CNA/staff #65). She stated the resident does have a prosthetic, but it doesn't fit him any more. She said she had not passed on the information that the prosthesis may be too small, because she doesn't always work the same hall and she hasn't remembered to tell anyone. An interview was conducted on (MONTH) 22, 2019 at 8:25 a.m., with a Licensed Practical Nurse (LPN/staff #22). She stated the resident does have a prosthesis and that he was currently receiving restorative nursing to build up strength in the leg, which had the [MEDICAL CONDITION]. She said she knows of no other reason for him not to wear it. She said once he gets his strength back, he has no reason for not wearing it. She stated the prosthesis fit a few months back and was unaware of whether or not it fit now. An interview was conducted on (MONTH) 22, 2019 at 8:31 a.m., with the Director of Nursing (DON/staff #142). He stated the resident receives PT and that they would have therapy evaluate him, get the NP and/or doctor involved and have someone in to re-measure the resident's stump. He stated they could certainly get him fitted and could get a referral ordered. On (MONTH) 22, 2019 at 8:48 a.m., an interview was conducted with a Physical Therapist (staff #16). She said that PT picked him up to reassess for transfers and strengthening exercises (in May). She said the resident gained a lot of weight and that his prosthetic leg didn't fit any more. She stated the resident comes to PT to do exercises and practices using the standing frame, and sometimes he tries to use the sliding board for transfers. She said that resident #30 seems to participate less in PT lately, and if he didn't participate they may have to drop him. She further stated that if the resident's prosthesis fit, it would definitely assist him in accomplishing his goals. Review of the facility policy on Prosthesis revised (MONTH) 2007 revealed that assisting the resident to use all needed prostheses on a daily basis is part of standard care and shall be encouraged. Direct care staff, in recognition of functional ability and dignity issues, are responsible for seeing that all residents with artificial limbs are wearing these devices unless the resident refuses. Referrals to outside services or in-house therapy departments for repair, maintenance, or replacement are to be made through the nurse and/or Social Services Department and/or resident and/or a family member.",2020-09-01
864,CORONADO HEALTHCARE CENTER,35132,11411 NORTH 19TH AVE,PHOENIX,AZ,85029,2020-01-22,609,D,1,0,FHS811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interviews and review of policies and procedures, the facility failed to ensure that an allegation of suspected neglect was reported to the State Agency for one resident (#1) who sustained additional injuries to a fall related fracture. The deficient practice may result in additional allegations of neglect not being reported to the State Survey Agency. Findings include: Resident #1 was admitted on (MONTH) 15, 2019 with [DIAGNOSES REDACTED]. An initial Admission Record dated (MONTH) 16, 2019 included that the resident was self-mobile in a wheelchair and used a walker, was alert and orientated at times to place, person and time and able to follow simple directions, and had adequate hearing and vision. The record included that the resident had functional limitation of her range of motion on one side and no [MEDICAL CONDITION], had a contracture of the left ankle and had a weight bearing limitation due to a [MEDICAL CONDITION] ankle. A Fall Risk Assessment with an effective date of (MONTH) 15, 2019 at 10:06 p.m. included that the resident had a fall risk score of 10, which indicated that the resident was at medium risk for falling. A Therapy note dated (MONTH) 18, 2019 included that the resident had a (recent) history of having blood glucose levels in the 600's and was to have surgery on the left ankle when her [MEDICAL CONDITION] was under control. The note included that the resident was supposed to be NWB (Non-Weight Bearing) on the left lower extremity, and has been non-compliant. A Daily Skilled Note dated (MONTH) 18, 2019 included that resident #1 was alert and oriented x 3, had pain in the left ankle which was fractured, was NWB and non-compliant. A physician progress notes [REDACTED].#1 had been sent from the hospital for rehab, had a left ankle fracture which was chronic, and that the resident was advised that she was non-weight bearing but seems to be non-compliant. A nursing note dated (MONTH) 19, 2019 at 5:30 p.m. included that the resident had been observed in an upright position on the floor next to a wheelchair, was disoriented and complaining to increased pain in the right foot. The note included that the right foot had swelling, the resident was combative and refused vital signs, and her blood glucose was 65. The note included that the physician had given orders to send the resident to the emergency department for evaluation. A nursing note dated (MONTH) 20, 2019 at 12:32 a.m. included that there resident had been admitted to the hospital for surgery related to a ground level fall, and dislocated/broken right ankle. A Trauma Surgeon's report dated (MONTH) 20, 2019 at 6:03 p.m. included that the resident, who had a history of [REDACTED]. The report included that the resident had chronic numbness in her feet related to diabetic [MEDICAL CONDITION], and had reported numbness in bilateral lower extremities for the prior few weeks. The note included that the resident's medical history included Charcot's arthroscopy, and the resident was alert and oriented x 3. Continued review of hospital records dated (MONTH) 20, 2019 revealed that resident #1 had an ORIF (Open Reduction Internal Fixation) performed on the right ankle, and that a cast had been placed on the right ankle following surgery. Surgical discharge instructions dated (MONTH) 24, 2019 and completed by an orthopedic specialist included instructions to notify the orthopedic surgeon's office if the resident had severe uncontrollable pain, redness, tenderness or signs of infection. The instructions included an activity restriction for the resident to be touch down weight bearing on the right lower extremity until follow-up with the orthopedic surgeon. A nurses note dated (MONTH) 25, 2019 included that resident #1 had returned to the facility at 6:30 p.m. with a [DIAGNOSES REDACTED]. An additional documentation note also dated (MONTH) 25, 2019 included that education and teaching had been provided to the resident on weight bearing statues due to observations of the resident ambulating without assistance. An Occupational Therapy Evaluation and Plan of Treatment dated (MONTH) 26, 2019 included that the resident had an ORIF of the right ankle, was touch down weight bearing on the right lower extremity, and was weight bearing as tolerated on the left lower extremity, and was a fall risk. The evaluation included that resident #1 had impairments in balance, gross motor coordination, mobility and strength. A physician progress notes [REDACTED].#1 had been sent from the hospital for rehab, had a left ankle fracture which was chronic, and that the resident was advised that she was non-weight bearing but seems to be non-compliant. An Admission MDS assessment dated (MONTH) 2, 2019 included that the resident had clear comprehension of others and a BIMS (Brief Mental Status) score of 14, which indicated that the resident was cognitively intact. The assessment included that resident #1 required extensive physical assistance for transferring, and bed mobility from one person and assistance from one person for walking. The assessment included that the resident did not have steady balance when moving from a sitting to standing position or when walking, and was only able to stabilize balance with assistance. The assessment included that the resident used a walker or a wheelchair, had a surgical wound and had pain almost constantly on a level of 4 (on a scale of 0-10, with 10 being the worst pain). A nursing note dated (MONTH) 8, 2019 at 7:49 a.m. included that at 4:15 a.m. the resident was found sitting on the floor, and stated she was having a bed dream. The note included that the resident denied pain. The note included that no musculoskeletal changes were observed. Review of the clinical record did not reveal any additional information regarding the resident being found sitting on the floor, or if the incident had been investigated as a possible fall, or if the resident's right ankle ORIF site had been assessed for injury. A Daily Skilled note dated (MONTH) 12, 2019 at 3:45 p.m. included that the resident had pain at a level 7, which originated from chronic and surgical (sites) on both ankles and was described as aching. The note included that the resident had a non-removable splint cast to the right lower extremity, and that there as no numbing, tingling or swelling. An incident note dated (MONTH) 13, 2019 at 6:54 a.m. included that resident #1 was found again sitting in an upright position on her buttocks in front of her bedroom chair at 5:19 a.m. The note included that there was water on the floor, and that the resident stated she was attempting to go to the bathroom, and her wheelchair was too far away. The note included that there were no apparent injuries, she had range of motion to all extremities without difficulty and denied pain. The note included that a message was left for her attending physician. A Pain Management Review dated (MONTH) 13, 2019 included that the reason for the review was a change in condition, and that the resident had pain per the checked boxes on the form daily or several times a day in the last 5 days. Located in an incision, which was specified as ankle pain, and the checked boxes included that the pain was worsened in the early morning, mid-morning, afternoon, late evening and at night. The review included that the pain was aching, stabbing, and throbbing, and affected the resident's emotions. The review included that the pain was worsened with physical activity, and turning and repositioning, also the pain was managed moderately with [MEDICATION NAME]. The review listed staff observations of possible indicators for pain including negative verbalizations, and facial expressions, and a recommendation to continue with the current plan of care. A Change of Condition Note dated (MONTH) 21, 2019 at 11:21 a.m. included that the resident was found on the floor by her bed, an assessment was completed, and the resident was assisted to her bed by staff. The note included that the resident denied pain, and was not in distress. The note included that the (attending) physician was notified. A fall risk evaluation dated (MONTH) 21, 2019 at 11:14 p.m. included that the resident had decreased muscular coordination and a fall risk score of 10, which indicated the resident was at medium risk for falling. A nursing note dated (MONTH) 23, 2019 at 1:18 p.m. included that resident #1 had gone to a scheduled appointment at 8:14 a.m. and that a call had been received from the emergency department that the resident was being admitted (to the hospital) for an open dislocation. Emergency Department reports dated (MONTH) 23, 2019 included that resident #1 had been sent to the the Emergency Department from an orthopedic clinic due to right ankle pain and concern over a right ankle wound which had been examined and found to have a deformity with hardware protruding out her right foot. The reports included that an X-Ray was performed and showed a [MEDICAL CONDITION] plate and dislocation of the right ankle, and that the resident was able to move her toes and sensation (in the toes of the right foot) was intact. The report included that the resident was wheelchair bound, but stated that she had been walking on the (right) extremity, and included that (the [MEDICAL CONDITION] and dislocation of the right ankle) was not a new injury, but was due to the patient walking/ambulating, and that a tentative plan was to amputate (the right lower extremity). During an interview conducted on (MONTH) 21, 2020 at 10:10 a.m. with the Director of Nursing/staff #206, she stated that the after the resident was discharged to the hospital, the resident's attending physician/Medical Director was notified by the orthopedic specialist that something had happened to the resident's right ankle at the facility, and the resident was having her right leg amputated. The Director stated that she did not have any specific information about what had happened to the resident's ankle, and the physician had asked questions about the care that had been provided to the resident. The Director stated that she knew that the resident had fallen, but she did not know how she had injured her ankle and stated Looking back on it, yes we should have reported it. During an interview conducted on (MONTH) 21, 2020 at 1:45 p.m. with the resident's attending physician/Medical Director (staff #219) he stated that was aware that the resident had a fractured right ankle, that the resident had a cast on the right ankle and stated that you cannot visualize what is under a cast. The physician stated that the re-injury to the right ankle was due to the resident's non-compliance with non-weight bearing status, and that the injury could have happened from any one of her falls. A policy and procedure titled Abuse: Prevention of and Prohibition Against included that each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The policy included a definition of neglect which is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain. mental anguish or emotional distress. The policy included that all allegations of neglect are reported outside the facility and to the appropriate State or Federal agencies in the applicable time frames, as per this policy and applicable regulations.",2020-09-01
865,CORONADO HEALTHCARE CENTER,35132,11411 NORTH 19TH AVE,PHOENIX,AZ,85029,2020-01-22,657,D,1,0,FHS811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interviews and review of policies and procedures, the facility failed to ensure that a comprehensive care plan for one resident (#1) was developed, reviewed and revised for services provided for a [MEDICAL CONDITION] ankle. The deficient practice may result in care and services not being provided to additional residents with bone fractures. Findings include: Resident #1 was admitted on (MONTH) 15, 2019 with [DIAGNOSES REDACTED]. An initial Admission Record dated (MONTH) 16, 2019 included that the resident was self-mobile in a wheelchair and used a walker, was alert and orientated at times to place, person and time and able to follow simple directions, and had adequate hearing and vision. The record included that the resident had functional limitation of her range of motion on one side no [MEDICAL CONDITION], had a contracture of the left ankle and had a weight bearing limitation due to a [MEDICAL CONDITION] ankle. An Initial Care Plan dated (MONTH) 15, 2019 included that resident #1 was at risk for falls, a goal that the resident would not sustain serious injury, and listed multiple interventions including to ensure that the resident is wearing appropriate footwear when ambulating or wheeling in her wheelchair. A nursing note dated (MONTH) 19, 2019 at 5:30 p.m. included that the resident had been observed in an upright position on the floor next to a wheelchair, was disoriented and complaining to increased pain in the right foot. The note included that the right foot had swelling, the resident was combative and refused vital signs, and her blood glucose was 65. The note included that the physician had given orders to send the resident to the emergency department for evaluation. A fall risk evaluation dated (MONTH) 19, 2019 at 5:30 p.m. included that the resident had a balance problem while standing and walking, and a fall risk score of 13, which indicated the resident was at high risk for falling. A nursing note dated (MONTH) 20, 2019 at 12:32 a.m. included that the resident had been admitted to the hospital for surgery related to a ground level fall, and dislocated/broken right ankle. Review of hospital records dated (MONTH) 20, 2019 revealed that resident #1 had an ORIF (Open Reduction Internal Fixation) performed on the right ankle, and that a cast had been placed on the right ankle following surgery. Surgical discharge instructions dated (MONTH) 24, 2019 instructions to notify the orthopedic surgeon's office if the resident had severe uncontrollable pain, redness, tenderness or signs of infection. The instructions also included an activity restriction for the resident to be touch down weight bearing on the right lower extremity until follow-up with the orthopedic surgeon. A nurses note dated (MONTH) 25, 2019 included that resident #1 had returned to the facility at 6:30 p.m. with a [DIAGNOSES REDACTED]. An additional documentation note also dated (MONTH) 25, 2019 included that education and teaching had been provided to the resident on weight bearing statues due to observations of the resident ambulating without assistance. A physician's orders [REDACTED]. 0 = No pain. 1-3 = Mild pain. 4-6 = Moderate pain. 7-10 = Severe pain. Review of the MAR (Medication Administration Record) revealed a pain monitoring record that included on (MONTH) 25, 2019 on the night shift, the resident had severe pain at a level 9. An Occupational Therapy Evaluation and Plan of Treatment dated (MONTH) 26, 2019 included that the resident had an ORIF of the right ankle, was touch down weight bearing on the right lower extremity, and was weight bearing as tolerated on the left lower extremity, and was a fall risk. The evaluation included that resident #1 had impairments in balance, gross motor coordination, mobility and strength. Review of a comprehensive plan of care initiated on (MONTH) 26, 2019 included the following: -A care plan for acute and chronic pain related to [MEDICAL CONDITION] ankle had a goal that the resident was to voice a level of comfort by the review date. The care plan listed multiple interventions listed including to monitor and record pain characteristics including quality, severity (using a 1-10 scale), anatomical location, aggravating factors and relieving factors. -A care plan for risk for falls related to diabetes, [MEDICAL CONDITION] medication, and left and right ankle fractures. The care plan included a goal that the resident would not sustain serious injury, and listed multiple interventions including that the resident was non-weight bearing on the left ankle, and continued to be non-compliant. -A care plan for impairment to skin integrity related to ORIF of the right ankle, history of impaired mobility, related to left and right ankle fracture, generalized weakness and Charcot's arthroscopy. The care plan included that the resident had a right lower extremity splint cast, and a goal that the resident would not sustain serious injury. The care plan listed multiple interventions including to follow facility protocols for treatment of [REDACTED]. Continued review of the comprehensive care plan revealed that there were no interventions for pain in the right ankle, and there were no interventions regarding touch down bearing for the right lower extremity until evaluation by orthopedics. Also, the care plan did not include any additional interventions for the residents non-compliance with weight bearing restrictions including non-weight bearing on the left side, and touch down bearing for the right lower extremity Review of the MAR/narcotic pain assessments dated (MONTH) 26, and (MONTH) 27, 2019 revealed the following: -November 26, 2019 severe pain level 8, at 4:54 p.m. and severe pain level 7 at 4:50 p.m. -November 27, 2019 severe pain level 7 at 9:00 a.m. A physician progress notes [REDACTED].#1 had been advised that she was non-weight bearing but seems to be non-compliant. Review of MAR/narcotic pain assessments dated (MONTH) 28, and (MONTH) 29, 2019 revealed the following: -On (MONTH) 28, 2019 the resident had severe pain level 8 at 7:39 a.m. -On (MONTH) 29, 2019 the resident had severe pain level 8 at 1:33 p.m. A MAR/pain monitoring record revealed that on (MONTH) 30, 2019 on the night shift, the resident had severe pain at a level 8. Review of the MAR/narcotic pain assessments dated (MONTH) 1, and (MONTH) 2, 2019 revealed the following: -December 1, 2019 severe pain level 7, at 3:54 a.m., severe pain level 7 at 11:30 a.m. and severe pain level 9 at 8:03 p.m. -December 2, 2019 severe pain level 8 at 1:59 a.m. and severe pain level 7 at 7:11 a.m. An Admission MDS assessment dated (MONTH) 2, 2019 included that the resident had clear comprehension of others and a BIMS (Brief Mental Status) score of 14, which indicated that the resident was cognitively intact. The assessment included that resident #1 required extensive physical assistance for transferring, and bed mobility from one person and assistance from one person for walking. The assessment included that the resident did not have steady balance when moving from a sitting to standing position or when walking, and was only able to stabilize balance with assistance. The assessment included that the resident used a walker or a wheelchair, had a surgical wound and had pain almost constantly on a level of 4 (on a scale of 0-10). Review of the MAR/narcotic pain assessments dated (MONTH) 3, and (MONTH) 4, 2019 revealed the following: -December 3, 2019 severe pain level 8 at 2:14 a.m., severe pain level 7 at 8:53 a.m. and severe pain level 8 at 2:20 p.m. -December 4, 2019 severe pain level 8 at 7:35 a.m. and severe pain level 8 at 1:35 p.m. A physician progress notes [REDACTED]. Review of the MAR/narcotic pain assessments dated (MONTH) 5, and (MONTH) 7, 2019 revealed the following: -December 5, 2019 severe pain level 8, at 7:11 a.m., severe pain level 9 at 4:38 p.m. -December 7, 2019 severe pain level 8 at 4:54 p.m. A nursing note dated (MONTH) 8, 2019 at 7:49 a.m. included that at 4:15 a.m. the resident was found sitting on the floor, and stated she was having a bed dream. The note included that the resident denied pain. The note included that no musculoskeletal changes were observed. A MAR/narcotic pain assessment dated (MONTH) 8, 2019 revealed that on (MONTH) 8, 2019 the resident had severe pain level 7, at 8:14 a.m., and severe pain level 8 at 2:40 p.m. A physician progress notes [REDACTED].#1 had been advised that she was non-weight bearing but seems to be non-compliant. Review of the MAR/narcotic pain assessments dated (MONTH) 9, through (MONTH) 11, 2019 revealed the following: -December 9, 2019 severe pain level 8, at 8:48 a.m. -December 10, 2019 severe pain level 8 at 8:54 a.m. and severe pain level 8 at 4:19 p.m. -December 11, 2019 severe pain level 7 at 4:35 a.m., severe pain level 8 at 11:56 a.m. A Daily Skilled note dated (MONTH) 12, 2019 at 3:45 p.m. included that there resident had pain at a level 7, which originated from chronic and surgical (sites) on both ankles and was described as aching. The note included that the resident had a non-removable splint cast to the right lower extremity, and that there as no numbing, tingling or swelling. A MAR/narcotic pain assessment dated (MONTH) 12, 2019 included that the resident had severe pain level 7, at 7:39 a.m. An incident note dated (MONTH) 13, 2019 at 6:54 a.m. included that resident #1 was found sitting in an upright position on her buttocks in front of her bedroom chair at 5:19 a.m. The note included that there was water on the floor, and that the resident stated she was attempting to go to the bathroom, and her wheelchair was too far away. The note included that there were no apparent injuries, she had range of motion to all extremities without difficulty and denied pain. The note included that a message was left for her attending physician. A MAR/narcotic pain assessment dated (MONTH) 13, 2019 revealed that the resident had severe pain level 10, at 5:30 p.m. A Pain Management Review dated (MONTH) 13, 2019 included that the reason for the review was a change in condition, and that the resident had pain daily or several times a day in the last 5 days. It was located in an incision, which was specified as ankle pain, and when she had pain it was worse in the early morning, mid-morning, afternoon, late evening and at night (all boxes of times were checked). The review included that the pain was aching, stabbing, and throbbing, and affected the resident's emotions. The review included that the pain was worsened with physical activity, and turning and repositioning, also the pain was managed moderately with [MEDICATION NAME]. The review listed staff observations of possible indicators for pain including negative verbalizations, and facial expressions, and a recommendation to continue with the current plan of care. Review of the plan of care revealed that there continued to be no care plan interventions for pain in the right ankle. A MAR/pain monitoring record included an entry dated (MONTH) 13, 2019 on the night shift, that included the resident had severe pain at a level 10. physician progress notes [REDACTED].#1 had been advised that she was non-weight bearing but seems to be non-compliant. Review of Daily Skilled notes revealed the following: -A note dated (MONTH) 16, 2019 at 2:36 p.m. included that the resident had pain at a level 8, which originated from a surgical (site) at the right lower extremity described as an ache/sharp and that non-pharmacological interventions were not effective. -A note dated (MONTH) 17, 2019 at 3:07 p.m. included that the resident had pain at a level 8, which originated from a surgical (site) at the right lower extremity described as an ache/sharp and that non-pharmacological interventions were not effective. -A note dated (MONTH) 18, 2019 at 9:12 a.m. included that the resident had pain at a level 8, which originated from a surgical (site) at the right lower extremity described as an ache/Sharpe and that non-pharmacological interventions were not effective. -A note dated (MONTH) 19, 2019 at 12:40 p.m. included that the resident had pain at a level 8, which originated from a surgical (site) at the right lower extremity described as an ache/sharp and that non-pharmacological interventions were not effective. Review of the MAR/narcotic pain assessments dated (MONTH) 14, through (MONTH) 19, 2019 revealed the following: -December 16, 2019 severe pain level 8, at 2:36 p.m. -December 17, 2019 severe pain level 8 at 8:58 a.m. -December 18, 2019 severe pain level 8 at 9:12 a.m. -December 19, 2019 severe pain level 8 at 2:49 p.m. and severe pain level 8 at 11:13 p.m. physician progress notes [REDACTED].#1 had been advised that she was non-weight bearing but seems to be non-compliant. A MAR/narcotic pain assessment dated (MONTH) 20, 2019 revealed that the resident had severe pain level 8, at 5:57 a.m. A nursing Note dated (MONTH) 21, 2019 at 6:09 a.m. included that the resident had urinated in her bed, was confused, and refused to speak or answer questions. The note included that the resident was asking what was on her foot and where am I? A Change of Condition Note dated (MONTH) 21, 2019 at 11:21 a.m. included that the resident was found on the floor by her bed, an assessment was completed, and the resident was assisted to her bed by staff. The note included that the resident denied pain, and included that the physician was notified. A Daily Skilled note dated (MONTH) 22, 2019 at 10:00 a.m. included that the resident had pain at a level 2, which originated from chronic and surgical (sites) on both ankles and was described as aching, and the resident was alert and oriented x 4. The note included that no musculoskeletal changes were observed. Review of MAR/narcotic pain assessments revealed the following: -On (MONTH) 22, 2019 at 3:10 a.m. the resident had severe pain level 7, and severe pain level 8 at 11:25 p.m. -On (MONTH) 23, 2019 at 7:34 a.m. the resident had severe pain level 8. A nursing note dated (MONTH) 23, 2019 at 1:18 p.m. included that resident #1 had gone to a scheduled appointment at 8:14 a.m. and that a call had been received from the emergency department that the resident was being admitted (to the hospital) for open dislocation. Continued review of care plans (MONTH) 25, through (MONTH) 23, 2019 revealed that there were no interventions added to the plan of care for pain in the right ankle, and there were no additional interventions added to the plan of care for the resident's non-compliance with weight bearing restrictions including non-weight bearing on the left side, and touch down bearing for the right lower extremity. Emergency Department reports dated (MONTH) 23, 2019 included that resident 31 had been sent the the Emergency Department from an orthopedic clinic due to right ankle pain and concern over a right ankle wound which had been examined and found to have a deformity with hardware protruding out her right foot. The report included that the resident had been walking on the (right) extremity, that (the [MEDICAL CONDITION] and dislocation of the right ankle) was not a new injury, but was due to the patient walking/ambulating. The note included a tentative plan to amputate (the right lower extremity). During an interview conducted on (MONTH) 21, 2020 at 10:10 a.m. with the Director of Nursing/staff #206, she reviewed the resident's comprehensive plan of care and stated she was unable to find a care plan for pain located in the resident's right ankle. The Director stated that all of the nurses can update the care plans, and that the IDT (Inter-Disciplinary Team) reviews falls and will adjust the care plan if an issue that needed to be included wasn't in the care plan. During an interview conducted on (MONTH) 21, 2020 at 12:00 with an RN (Registered Nurse/staff #21) she stated that any of the RN's are able to update care plans if it is needed. A policy and procedure titled Pain Management included that it is the policy of the facility to provide an environment and programs that assist each resident to attain or maintain the resident's highest practicable physical, mental and psychosocial well being. The policy included that residents are provided and receive the care and services needed according to established practice guidelines, and that resident pain is assessed and managed by an interdisciplinary team who work together to achieve the highest practicable outcome. The policy included to document on the Care Plan any preventative or care interventions for any resident admitted with pain. A policy and procedure titled Fall Management System included that each resident is assisted in attaining or maintaining their highest practicable level of functioning through providing the resident adequate supervision, assistive devices, and functional programs as appropriate to prevent accidents. The policy included that residents with Fall Risk evaluation scores of 11 or above are considered high risk and will have an individualized care plan developed that includes measurable objectives and timeframes. A policy and procedure titled Change of Condition Reporting included that it is the policy of the facility that all changes in resident condition will be communicated to the physician, and the Comprehensive Care Plan will be revised accordingly.",2020-09-01
866,CORONADO HEALTHCARE CENTER,35132,11411 NORTH 19TH AVE,PHOENIX,AZ,85029,2020-01-22,675,E,1,0,FHS811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interviews and review of policies and procedures, the facility failed to ensure that one resident (#1) was provided care and services necessary to maintain the highest practicable physical well being of the resident's right ankle surgical site. The deficient practice may result resulted in additional residents who have had surgery sustaining injuries the go undetected. Findings include: Resident #1 was admitted on (MONTH) 15, 2019 with [DIAGNOSES REDACTED]. A hospital History and Physical report dated (MONTH) 14, 2019 (prior to admission) included that resident #1 had pending surgery for [REDACTED]. The report included that the resident was advised to be non-weight bearing, however she was non-compliant. An initial Admission Record dated (MONTH) 16, 2019 included that the resident was self-mobile in a wheelchair and used a walker, was alert and orientated at times to place, person and time and able to follow simple directions, and had adequate hearing and vision. The record included that the resident had functional limitation of her range of motion on one side no [MEDICAL CONDITION], had a contracture of the left ankle and had a weight bearing limitation due to a [MEDICAL CONDITION] ankle. A Fall Risk Assessment with an effective date of (MONTH) 15, 2019 at 10:06 p.m. included that the resident was alert and oriented X 3 (to time, Place , person), had a history of [REDACTED]. The risk assessment included that the resident scored a 10, and indicated that the resident was at medium risk for falling. An Initial Care Plan dated (MONTH) 15, 2019 included that resident #1 was at risk for falls, a goal that the resident would not sustain serious injury, and listed multiple interventions including to ensure that the resident is wearing appropriate footwear when ambulating or wheeling in her wheelchair. A Fall Risk Assessment with an effective date of (MONTH) 16, 2019 at 10:00 p.m. was not indicated for the resident having a balance problem while standing and walking, and included a fall risk score of 7, and indicated that the resident remained at medium risk for falling. A Therapy note dated (MONTH) 18, 2019 included that the resident had a (recent) history of having blood glucose levels in the 600's and was to have surgery on the left ankle when her [MEDICAL CONDITION] was under control. The note included that the resident was supposed to be NWB (Non-Weight Bearing) on the left lower extremity, and has been non-compliant. A Daily Skilled Note dated (MONTH) 18, 2019 included that resident #1 was alert and oriented x 3, had pain in the left ankle which was fractured, was NWB and non-compliant. A physician progress notes [REDACTED].#1 had been sent from the hospital for rehab, had a left ankle fracture which was chronic, and that the resident was advised that she was non-weight bearing but seems to be non-compliant. A nursing note dated (MONTH) 19, 2019 at 5:30 p.m. included that the resident had been observed in an upright position on the floor next to a wheelchair, was disoriented and complaining to increased pain in the right foot. The note included that the right foot had swelling, the resident was combative and refused vital signs, and her blood glucose was 65. The note included that the physician had given orders to send the resident to the emergency department for evaluation. A fall risk evaluation dated (MONTH) 19, 2019 at 5:30 p.m. included that the resident had a a balance problem while standing and walking, and a fall risk score of 13, which indicated the resident was at high risk for falling. A nursing note dated (MONTH) 20, 2019 at 12:32 a.m. included that there resident had been admitted to the hospital for surgery related to a ground level fall, and dislocated/broken right ankle. A Trauma Surgeon's report dated (MONTH) 20, 2019 at 6:03 p.m. included that the resident, who had a history of [REDACTED]. The report included that the resident had chronic numbness in her feet related to diabetic [MEDICAL CONDITION], and had reported numbness in bilateral lower extremities for the prior few weeks. The note included that the resident's medical history included Charcot's arthroscopy, and the resident was alert and oriented x 3. Continued review of hospital records dated (MONTH) 20, 2019 revealed that resident #1 had an ORIF (Open Reduction Internal Fixation) performed on the right ankle, and that a cast had been placed on the right ankle following surgery. Surgical discharge instructions dated (MONTH) 24, 2019 and completed by an orthopedic specialist included instructions to notify the orthopedic surgeon's office if the resident had severe uncontrollable pain, redness, tenderness or signs of infection. The instructions included an activity restriction for the resident to be touch down weight bearing on the right lower extremity until follow-up with the orthopedic surgeon. A nurses note dated (MONTH) 25, 2019 included that resident #1 had returned to the facility at 6:30 p.m. with a [DIAGNOSES REDACTED]. An additional documentation note also dated (MONTH) 25, 2019 included that education and teaching had been provided to the resident on weight bearing statues due to observations of the resident ambulating without assistance. A physician's order dated (MONTH) 25, 2019 included to monitor the resident's level of pain every shift using the following scale: 0 = No pain. 1-3 = Mild pain. 4-6 = Moderate pain. 7-10 = Severe pain. Review of the MAR (Medication Administration Record) revealed a pain monitoring record that included on (MONTH) 25, 2019 on the night shift, the resident had severe pain at a level 9. A physician's order dated (MONTH) 26, 2019 included to perform CMS (Circulation An Occupational Therapy Evaluation and Plan of Treatment dated (MONTH) 26, 2019 included that the resident had an ORIF of the right ankle, was touch down weight bearing on the right lower extremity, and was weight bearing as tolerated on the left lower extremity, and was a fall risk. The evaluation included that resident #1 had impairments in balance, gross motor coordination, mobility and strength. Review of a comprehensive plan of care initiated on (MONTH) 26, 2019 included the following: -A care plan for acute and chronic pain related to [MEDICAL CONDITION] ankle had a goal that the resident was to voice a level of comfort the the review date. The care plan listed multiple interventions listed including to monitor and record pain characteristics including quality, severity (using a 1-10 scale), anatomical location, aggravating factors and relieving factors. -A care plan for risk for falls related to diabetes, [MEDICAL CONDITION] medication, and left and right ankle fractures. The care plan included a goal that the resident would not sustain serious injury, and listed multiple interventions including that the resident was non-weight bearing on the left ankle, and continued to be non-compliant. -A care plan for impairment to skin integrity related to ORIF of the right ankle, history of impaired mobility, related to left and right ankle fracture, generalized weakness and Charcot's arthroscopy. The care plan included that the resident had a right lower extremity splint cast, and a goal that the resident would not sustain serious injury. The care plan listed multiple interventions including to follow facility protocols for treatment of [REDACTED]. Review of the MAR/narcotic pain assessments dated (MONTH) 26, and (MONTH) 27, 2019 revealed the following: -November 26, 2019 severe pain level 8, at 4:54 p.m. and severe pain level 7 at 4:50 p.m. -November 27, 2019 severe pain level 7 at 9:00 a.m. A physician progress notes [REDACTED].#1 had been sent from the hospital for rehab, had a left ankle fracture which was chronic, and that the resident was advised that she was non-weight bearing but seems to be non-compliant. The note did not include that the resident had returned from the hospital with a [MEDICAL CONDITION] ankle and ORIF, and did not include any additional information that the physician had examined the right ankle. Review of MAR/narcotic pain assessments dated (MONTH) 28, and (MONTH) 29, 2019 revealed the following: -On (MONTH) 28, 2019 the resident had severe pain level 8 at 7:39 a.m. -On (MONTH) 29, 2019 the resident had severe pain level 8 at 1:33 p.m. A MAR/pain monitoring record revealed that on (MONTH) 30, 2019 on the night shift, the resident had severe pain at a level 8. Review of the MAR/narcotic pain assessments dated (MONTH) 1, and (MONTH) 2, 2019 revealed the following: -December 1, 2019 severe pain level 7, at 3:54 a.m., severe pain level 7 at 11:30 a.m. and severe pain level 9 at 8:03 p.m. -December 2, 2019 severe pain level 8 at 1:59 a.m. and severe pain level 7 at 7:11 a.m. An Admission MDS assessment dated (MONTH) 2, 2019 included that the resident had clear comprehension of others and a BIMS (Brief Mental Status) score of 14, which indicated that the resident was cognitively intact. The assessment included that resident #1 required extensive physical assistance for transferring, and bed mobility from one person and assistance from one person for walking. The assessment included that the resident did not have steady balance when moving from a sitting to standing position or when walking, and was only able to stabilize balance with assistance. The assessment included that the resident used a walker or a wheelchair, had a surgical wound and had pain almost constantly on a level of 4 (on a scale of 0-10). Review of the MAR/narcotic pain assessments dated (MONTH) 3, and (MONTH) 4, 2019 revealed the following: -December 3, 2019 severe pain level 8 at 2:14 a.m., severe pain level 7 at 8:53 a.m. and severe pain level 8 at 2:20 p.m. -December 4, 2019 severe pain level 8 at 7:35 a.m. and severe pain level 8 at 1:35 p.m. A physician progress notes [REDACTED].#1 had been sent from the hospital for rehab, had a left ankle fracture which was chronic, and that the resident was advised that she was non-weight bearing but seems to be non-compliant. The note did not include any information regarding the right ankle fracture, or that the physician had examined the right ankle. Review of the MAR/narcotic pain assessments dated (MONTH) 5, and (MONTH) 7, 2019 revealed the following: -December 5, 2019 severe pain level 8, at 7:11 a.m., severe pain level 9 at 4:38 p.m. -December 7, 2019 severe pain level 8 at 4:54 p.m. A nursing note dated (MONTH) 8, 2019 at 7:49 a.m. included that at 4:15 a.m. the resident was found sitting on the floor, and stated she was having a bed dream. The note included that the resident denied pain. The note included that no musculoskeletal changes were observed. Review of the clinical record did not reveal any additional information regarding the resident being found sitting on the floor, or if the incident had been investigated as a possible fall, or if the resident's right ankle ORIF site had been assessed for injury. A MAR/narcotic pain assessment dated (MONTH) 8, 2019 revealed that on (MONTH) 8, 2019 the resident had severe pain level 7, at 8:14 a.m., and severe pain level 8 at 2:40 p.m. A physician progress notes [REDACTED].#1 had been sent from the hospital for rehab, had a left ankle fracture which was chronic, and that the resident was advised that she was non-weight bearing but seems to be non-compliant. The note did not include any information regarding the right ankle fracture, or that the physician had examined the right ankle. Review of the MAR/narcotic pain assessments dated (MONTH) 9, through (MONTH) 11, 2019 revealed the following: -December 9, 2019 severe pain level 8, at 8:48 a.m. -December 10, 2019 severe pain level 8 at 8:54 a.m. and severe pain level 8 at 4:19 p.m. -December 11, 2019 severe pain level 7 at 4:35 a.m., severe pain level 8 at 11:56 a.m. A Daily Skilled note dated (MONTH) 12, 2019 at 3:45 p.m. included that there resident had pain at a level 7, which originated from chronic and surgical (sites) on both ankles and was described as aching. The note included that the resident had a non-removable splint cast to the right lower extremity, and that there as no numbing, tingling or swelling. A MAR/narcotic pain assessment dated (MONTH) 12, 2019 included that the resident had severe pain level 7, at 7:39 a.m. An incident note dated (MONTH) 13, 2019 at 6:54 a.m. included that resident #1 was found sitting in an upright position on her buttocks in front of her bedroom chair at 5:19 a.m. The note included that there was water on the floor, and that the resident stated she was attempting to go to the bathroom, and her wheelchair was too far away. The note included that there were no apparent injuries, she had range of motion to all extremities without difficulty and denied pain. The note included that a message was left for her attending physician. A MAR/narcotic pain assessment dated (MONTH) 13, 2019 revealed that the resident had severe pain level 10, at 5:30 p.m. A Pain Management Review dated (MONTH) 13, 2019 included that the reason for the review was a change in condition, and that the resident had pain daily or several times a day in the last 5 days, located in an incision, which was specified as ankle pain, and when she had pain it was worse in the early morning, mid-morning, afternoon, late evening and at night. The review included that the pain was aching, stabbing, and throbbing, and affected the resident's emotions. The review included that the pain was worsened with physical activity, and turning and repositioning, also the pain was managed moderately with [MEDICATION NAME]. The review listed staff observations of possible indicators for pain including negative verbalizations, and facial expressions, and a recommendation to continue with the current plan of care. However, there were no care plan interventions for pain in the right ankle. A MAR/pain monitoring record included an entry dated (MONTH) 13, 2019 on the night shift, that included the resident had severe pain at a level 10. physician progress notes [REDACTED].#1 had been sent from the hospital for rehab, had a left ankle fracture which was chronic, and that the resident was advised that she was non-weight bearing but seems to be non-compliant. The note did not include any information regarding the right ankle fracture, or that the physician had examined the right ankle. Review of Daily Skilled notes revealed the following: -A note dated (MONTH) 16, 2019 at 2:36 p.m. included that the resident had pain at a level 8, which originated from a surgical (site) at the right lower extremity described as an ache/sharp and that non-pharmacological interventions were not effective. -A note dated (MONTH) 17, 2019 at 3:07 p.m. included that the resident had pain at a level 8, which originated from a surgical (site) at the right lower extremity described as an ache/sharp and that non-pharmacological interventions were not effective. -A note dated (MONTH) 18, 2019 at 9:12 a.m. included that the resident had pain at a level 8, which originated from a surgical (site) at the right lower extremity described as an ache/Sharpe and that non-pharmacological interventions were not effective. -A note dated (MONTH) 19, 2019 at 12:40 p.m. included that the resident had pain at a level 8, which originated from a surgical (site) at the right lower extremity described as an ache/sharp and that non-pharmacological interventions were not effective. Review of the MAR/narcotic pain assessments dated (MONTH) 14, through (MONTH) 19, 2019 revealed the following: -December 16, 2019 severe pain level 8, at 2:36 p.m. -December 17, 2019 severe pain level 8 at 8:58 a.m. -December 18, 2019 severe pain level 8 at 9:12 a.m. -December 19, 2019 severe pain level 8 at 2:49 p.m. and severe pain level 8 at 11:13 p.m. physician progress notes [REDACTED].#1 had been sent from the hospital for rehab, had a left ankle fracture which was chronic, and that the resident was advised that she was non-weight bearing but seems to be non-compliant. The note did not include any information regarding the right ankle fracture, or that the physician had examined the right ankle. A MAR/narcotic pain assessment dated (MONTH) 20, 2019 revealed that the resident had severe pain level 8, at 5:57 a.m. A nursing Note dated (MONTH) 21, 2019 at 6:09 a.m. included that the resident had urinated in her bed, was confused, and refused to speak or answer questions. The note included that the resident was asking what was on her foot and where am I? A Change of Condition Note dated (MONTH) 21, 2019 at 11:21 a.m. included that the resident was found on the floor by her bed, an assessment was completed, and the resident was assisted to her bed by staff. The note included that the resident denied pain, and was not in distress. Then note included that the (attending) physician was notified. A fall risk evaluation dated (MONTH) 21, 2019 at 11:14 p.m. included that the resident had decreased muscular coordination and a fall risk score of 10, which indicated the resident was at medium risk for falling. A Daily Skilled note dated (MONTH) 22, 2019 at 10:00 a.m. included that the resident had pain at a level 2, which originated from chronic and surgical (sites) on both ankles and was described as aching, and the resident was alert and oriented x 4. The note included that no musculoskeletal changes were observed. Review of MAR/narcotic pain assessments revealed the following: -On (MONTH) 22, 2019 at 3:10 a.m. the resident had severe pain level 7, and severe pain level 8 at 11:25 p.m. -On (MONTH) 23, 2019 at 7:34 a.m. the resident had severe pain level 8. A nursing note dated (MONTH) 23, 2019 at 1:18 p.m. included that resident #1 had gone to a scheduled appointment at 8:14 a.m. and that a call had been received from the emergency department that the resident was being admitted (to the hospital) for open dislocation. Continued review of the clinical record for (MONTH) 25, through (MONTH) 23, 2019 revealed the following: -Although the resident's level of pain was recorded daily, sometimes multiple times each day, corresponding documentation that described the location and characteristics of the pain was not consistently documented. -There was no documented evidence that the resident's physician/Medical Director examined the resident's right foot or ankle after the resident had been found on the floor in (MONTH) 8, and fell on (MONTH) 13, and 21, 2019. -Despite the resident's daily complaints of pain, which were frequently expressed to be severe pain on level 7-10, the orthopedic surgeon was not contacted. -Additional medical services (i.e. X-Ray) that may have shown evidence of continued injury to the right ankle early in the resident's stay were not provided despite the resident's ongoing non-compliance with weight bearing restrictions, frequent ongoing complaints of pain, and falls. -Physician's orders did not include an order to contact the orthopedic surgeon if the resident experienced severe uncontrolled pain. Emergency Department reports dated (MONTH) 23, 2019 included that resident #1 had been sent the the Emergency Department from an orthopedic clinic due to right ankle pain and concern over a right ankle wound which had been examined and found to have a deformity with hardware protruding out her right foot. The reports included that an X-Ray was performed and showed a [MEDICAL CONDITION] plate and dislocation of the right ankle, and that the resident was able to move her toes and sensation (in the toes of the right foot) was intact. The report included that the resident was wheelchair bound, but stated that she had been walking on the (right) extremity, and included that (the [MEDICAL CONDITION] and dislocation of the right ankle) was not a new injury, but was due to the patient walking/ambulating, and that a tentative plan was to amputate (the right lower extremity). During an interview conducted on (MONTH) 21, 2020 at 10:10 a.m. with the Director of Nursing/staff #206, she stated that the resident had a non-removable cast on the right ankle, and was unable to explain why the orthopedic specialist was not contacted per her instructions when the resident had severe pain, and pain which was at level 10, after she fell on (MONTH) 13, 2019. During an interview conducted on (MONTH) 21, 2020 at 12:00 with an RN (Registered Nurse/staff #21) she stated that when pain is assessed prior to giving a pain medication, the nurse assesses the location of the pain and characteristics of the pain, is it throbbing, aching, or sharp and documents the information in a progress note in the clinical record. The RN stated that if a resident who had bone surgery, including an ORIF was to fall, and the fractured limb was involved in the fall, she would ask the physician for an X-ray of the limb to ensure it was not re-injured. During an interview conducted on (MONTH) 21, 2020 at 1:45 p.m. with the resident's attending physician/Medical Director (staff #219) he stated that although he did not document on the resident's right ankle, he was aware that the resident had a fractured right ankle. The physician stated that the reason there was no X-Rays of the right ankle was that the resident had a cast, and the purpose of a cast is to immobilize the bone. The physician stated that you cannot visualize what is under a cast, and that there was never uncontrolled pain under the cast and there was nothing to signify doing imaging (X-ray) underneath the cast. The physician stated that the re-injury to the right ankle was due to the resident's non-compliance with non-weight bearing status, and that the injury could have happened from any one of her falls. During an interview conducted on (MONTH) 22, 2020 at 10:50 a.m. with the physician/Medical Director (staff #219) the physician stated that the resident's right ankle wound as presented in the hospital was a progression of the original injury and that the resident may have had decreased pain sensation in her lower extremities due to the effects of prolonged uncontrolled diabetes, which also could have affected her ability for bone to heal, and bone density. The physician repeated his previous statement that he did not observe any changes or swelling in the right foot , the resident did not complain of increased pain, and there was no reason to order an X-ray of the right ankle. A policy and procedure titled Pain Management included that it is the policy of the facility tom provide an environment and programs that assist each resident to attain or maintain the resident's highest practicable physical, mental and psychosocial well being. The policy included that residents are provided and receive the care and services needed according to established practice guidelines, and that resident pain is assessed and managed by an interdisciplinary team who work together to achieve the highest practicable outcome. The policy included that the facility assists each resident with pain by screening to determine if the resident has been or is experiencing pain, comprehensively assessing the pain, developing and implementing a plan, and by completing appropriate physical assessment to determine any physical changes or manifestations as needed. A policy and procedure titled Fall Management System included that each resident is assisted in attaining or maintaining their highest practicable level of functioning through providing the resident adequate supervision, assistive devices, and functional programs as appropriate to prevent accidents. A policy and procedure titled Physician's Orders included that it is the policy of the facility to accurately implement orders in addition to medication orders and that admission orders [REDACTED]. A policy and procedure titled Incidents and Accidents included that it is the policy of the facility to implement and maintain measures to avoid hazards and accidents. The policy included that should an accident occur, the resident will be provided immediate attention by a licensed nurse, who will notify the medical provider and obtain further treatment or [DIAGNOSES REDACTED].",2020-09-01
867,CORONADO HEALTHCARE CENTER,35132,11411 NORTH 19TH AVE,PHOENIX,AZ,85029,2019-03-14,552,D,0,1,ALHX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one of seven sampled residents (#22) and/or their representative was informed of the risks and benefits of psychoactive medications, prior to administration. The deficient practice can result in the resident and/or the resident representative not being aware of the benefits and the potential adverse side effects of taking psychoactive medications. Findings include: Resident #22 was admitted on (MONTH) 18, (YEAR) with [DIAGNOSES REDACTED]. Review of the clinical record revealed a physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. The admission Minimum Data Set assessment dated (MONTH) 25, (YEAR) revealed a BIMS (Brief Interview for Mental Status) score of 7, which indicated the resident had severe cognitive impairment. The assessment also included the resident received antipsychotic and antidepressant medications during the 7 day look-back period. However, no evidence was found in the clinical record that the resident's representative was informed of the risks and benefits of these medications until (MONTH) 17, (YEAR). An interview was conducted with a licensed practical nurse (LPN/staff #470) on (MONTH) 12, 2019 at 2:28 p.m. The LPN stated all psychoactive medications must have an informed consent signed prior to the administration of the medications. She stated the resident and/or the resident's responsible party are informed of the indication, risks, benefits and side effects associated with the use of the medication and that the information is on the consent form. She said if the resident is not alert and oriented and does not have family or a responsible party available to sign the consent, she will inform the physician who together with the medical director will give consent and sign the consent form. During an interview conducted with the Director of nursing (DON/staff #215) on (MONTH) 12, 2019 at 3:25 p.m., she stated a consent form that includes information and explanation of the risks, benefits and side effects associated with the use of any [MEDICAL CONDITION] medications must be signed by the resident or the resident's responsible party prior to the resident receiving the medications. The DON stated that if the resident is unable to sign the consent form and does not have family or a responsible party to sign the consent, two physicians must sign the consent before the medication can be administered to the resident. The facility's policy regarding [MEDICAL CONDITION] Drug Use revealed the Social Services designee shall review new admissions for any physician's orders [REDACTED].",2020-09-01
868,CORONADO HEALTHCARE CENTER,35132,11411 NORTH 19TH AVE,PHOENIX,AZ,85029,2019-03-14,578,D,0,1,ALHX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of policies and procedures, the facility failed to ensure the physician's order accurately reflected one resident's (#125) advance directive. The resident census was 175. This deficient practice could result in residents receiving emergent services, which are not in accordance with their wishes. Findings include: Resident #125 was admitted on (MONTH) 12, 2019 and readmitted on (MONTH) 23, 2019, with [DIAGNOSES REDACTED]. An admission MDS (Minimum Data Set) assessment dated (MONTH) 19, 2019, revealed a BIMS (Brief Interview for Mental Status) score of 13 which indicated the resident was cognitively intact. Review of the clinical record revealed an advance directive statement dated (MONTH) 23, 2019, signed by the resident, that the resident was a DNR (Do Not Resuscitate) status. However, review of the physician's orders dated (MONTH) 23, 2019, revealed the resident was a full code which included CPR (cardiac-pulmonary resuscitation). On (MONTH) 11, 2019 at 11:55 a.m., an interview was conducted with a LPN (Licensed Practical Nurse/staff #151). After reviewing the resident's advance directive and the physician's order, the LPN stated that she would have to follow up and fix it. Staff #151 stated the planners, are responsible for ensuring code status is complete. During an interview conducted with the Director of Nursing (DON/staff #215) on (MONTH) 11, 2019 at 12:18 p.m., the DON stated the case managers and/or the charge nurses are supposed to ensure documentation of advance directives accurately reflects the residents' wishes. The facility's policy regarding advance directives revealed staff would assist the resident in completing the desired document, if the resident expressed a desire to execute an Advance Directive. The policy included Advance Directive documents are completed and included in the resident's health record upon admission and that a physician's telephone order can be used for No CPR or DNR.",2020-09-01
869,CORONADO HEALTHCARE CENTER,35132,11411 NORTH 19TH AVE,PHOENIX,AZ,85029,2019-03-14,641,D,0,1,ALHX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based clinical record review, staff interview, and the RAI (Resident Assessment Instrument) manual, the facility failed to ensure that a MDS (Minimum Data Set) assessment for one of three sampled residents (#158) was accurate. This deficient practice has the potential to affect continuity of care. Findings include: Resident #158 was admitted on (MONTH) 3, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed a physician's orders [REDACTED]. The nursing discharge summary note dated (MONTH) 11, (YEAR) included the resident was being discharged to another facility per the resident's family request. However review of the discharge MDS assessment dated (MONTH) 11, (YEAR), revealed the resident was discharged to an acute hospital. During an interview conducted with the MDS Coordinator (staff #97) on (MONTH) 12, 2019 at 4:50 p.m., staff #97 stated that she obtains information and/or data from the documentation in the clinical record such as the nursing progress notes, therapy notes, and nursing assessments to ensure that she codes the MDS assessments accurately. After reviewing the clinical record, the MDS Coordinator stated that the discharge MDS assessment should have reflected the resident was discharged to another facility. The RAI manual instructs to review the clinical record including the discharge plan and discharge orders for documentation of a resident's discharge location. The manual also included .the importance of accurately completing and submitting the MDS cannot be over-emphasized . and that Federal regulations require the assessment accurately reflects the resident's status.",2020-09-01
870,CORONADO HEALTHCARE CENTER,35132,11411 NORTH 19TH AVE,PHOENIX,AZ,85029,2019-03-14,645,E,0,1,ALHX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure a referral for a PASARR (Pre-Admission Screening and Resident Review) level II determination was obtained timely for two of four residents (#119 and #9). This deficient practice could result in residents not receiving the appropriate level of services. Findings include: -Resident #9 was admitted on (MONTH) 25, (YEAR), with [DIAGNOSES REDACTED]. The PASARR level I screening dated (MONTH) 25, (YEAR), revealed the resident had no primary [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 2, (YEAR), revealed the resident had a [DIAGNOSES REDACTED]. Review of the care plan initiated (MONTH) 15, (YEAR), revealed the resident was at risk for impaired cognitive function or impaired thought processes related to a history of [MEDICAL CONDITION]. A psychiatry progress note dated (MONTH) 25, (YEAR) included the resident reported a decrease in auditory hallucinations (AH). The PASARR level I screening dated (MONTH) 3, (YEAR) revealed the resident had a primary [DIAGNOSES REDACTED]. The screening also included a referral was necessary for a PASARR Level II determination for mental illness. The annual MDS assessment dated (MONTH) 4, (YEAR) revealed [MEDICAL CONDITION] was coded as a diagnosis. Review of the social services progress note dated (MONTH) 6, (YEAR) revealed a request for a PASARR Level II was faxed. Despite documentations that the resident had a [DIAGNOSES REDACTED]. -Resident #119 was admitted on (MONTH) 12, 2014 with [DIAGNOSES REDACTED]. The physician's progress notes from (MONTH) 17, (YEAR) through (MONTH) 12, (YEAR) included a [MEDICAL CONDITION] disorder with plans to continue the [MEDICAL CONDITION] medication and psychiatry follow up. A psychiatry progress note dated (MONTH) 1, (YEAR) included a [DIAGNOSES REDACTED]. Review of the annual MDS assessment dated (MONTH) 25, (YEAR), revealed the resident had [DIAGNOSES REDACTED]. The quarterly MDS assessment dated (MONTH) 18, (YEAR) included [DIAGNOSES REDACTED]. It also included the resident received antipsychotic medication during the 7 day look-back period. However, despite documentation of [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder, no evidence was found that a PASARR level I (which included a referral for a PASARR level II) had been completed for this resident until (MONTH) 31, (YEAR). A social services note dated (MONTH) 4, 2019 revealed a PASARR level II was faxed. During an interview conducted with the social worker (staff #2) on (MONTH) 11, 2019 at 11:15 a.m., she stated that residents will not be admitted until the PASARR level I screening is completed. She said that when the resident's stay at the facility is longer than 30 days, another PASARR level I screening is completed and if a level II evaluation is recommended, she will send the request to the State PASARR coordinator. Staff #2 stated that she conducts monthly checks and reviews of requests made, conducts follow-up calls and documents the information in the clinical record. The social worker stated that she could not recall when, but last year the facility made a sweep and screened all the residents at the facility for a PASARR Level I. In an interview conducted with the Director of Nursing (DON/staff #215) on (MONTH) 12, 2019 at 3:25 p.m., she stated the social worker is responsible for ensuring that residents at the facility has PASARR level I screening and for following up on Level II evaluations. She stated that the admissions staff ensures a Level I screening was completed upon admission. The DON did not say why residents #9 and #119 did not have a PASARR level II evaluation. She stated that they made a sweep last year of all the residents to ensure a Level I screening was completed. The facility's policy on Pre-Admission Screening and Resident Review (PASARR) stated, .Nursing Facilities (NF) must complete a Level I PASARR screening, or verify that a screening has been conducted, in order to identify Mental Illness (MI) and/or an Intellectual Disability (ID) prior to initial admission of individuals to a NF bed . The policy also stated, If it is later determined that the admission will last longer than 30 consecutive days, a Level I PASARR screening must be completed as soon as possible or within 40 calendar days of the admitted . The policy included that it is the responsibility of the NF to make referrals for Level II PASARR evaluations if determined necessary.",2020-09-01
871,CORONADO HEALTHCARE CENTER,35132,11411 NORTH 19TH AVE,PHOENIX,AZ,85029,2019-03-14,658,E,0,1,ALHX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews and policy review, the facility failed to ensure that two of ten sampled residents (#73 and #307) were administered pain medication according to the parameters ordered by the physician. The deficient practice could result in residents not receiving medications as ordered. Findings include: -Resident #73 was admitted on (MONTH) 24, (YEAR), with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The admission MDS (Minimum Data Set) assessment dated (MONTH) 31, (YEAR) revealed a BIMS (Brief Interview for Mental Status) score of 14, which indicated the resident had intact cognition. The MDS also included the resident received scheduled and as needed pain medications. A care plan regarding pain dated (MONTH) 15, (YEAR) revealed the resident had acute/chronic pain. Interventions included conducting a pain assessment every shift and medicating the resident following the pain scale. Review of the Medication Administration Records (MARs) for October, (MONTH) and (MONTH) (YEAR), revealed the resident was administered [MEDICATION NAME] for a pain level of 8 on (MONTH) 30, for a pain level of 6 on (MONTH) 1, for a level of 5 on (MONTH) 5 and 6, and for a pain level of 7 on (MONTH) 10. -Resident #307 was admitted on (MONTH) 6, (YEAR), with [DIAGNOSES REDACTED]. The nursing admission record dated (MONTH) 6, (YEAR), included the resident was alert and oriented to time, place, person and was able to follow simple commands. Review of the clinical record revealed a physician's orders [REDACTED]. The care plan regarding pain dated (MONTH) 8, (YEAR) included the resident had acute/chronic pain related to a fractured left hip. Interventions included conducting a pain assessment every shift and medicating the resident following the pain scale. However, review of the MAR for (MONTH) (YEAR) revealed the resident was administered [MEDICATION NAME] 5 mg for a pain level of 9 on (MONTH) 7 and for a pain level of 7 on (MONTH) 9 and 10. During an interview conducted with a Licensed Practical Nurse (LPN/staff #126) on (MONTH) 11, 2019 at 10:50 a.m., she stated pain medications should be administered as ordered. The LPN stated that if the resident's pain level is outside of the ordered parameters, she would administer the medication and then call the physician. An interview was conducted with another LPN (staff #47) on (MONTH) 12, 2019 at 2:28 p.m. Staff #47 stated that all medications and/or treatments should be administered as ordered by the physician, which includes following the parameters ordered. The LPN stated that if the resident's pain level is outside of the parameter order for the medication, she would notify the physician and would not administer the medication. During an interview conducted with the Director of Nursing (DON/staff #215) on (MONTH) 12, 2019 at 3:25 p.m., she stated her expectation is that the nurses follow standards of practice when it comes to medication and treatment administration. The DON stated that medications and treatments, including pain parameters are expected to be followed, as ordered by the physician. A facility's policy on Pain Management stated, Residents are provided and receive care and services needed according to established practice guidelines. Review of the facility's policy on Physician order [REDACTED].in accordance with the resident's plan of care.",2020-09-01
872,CORONADO HEALTHCARE CENTER,35132,11411 NORTH 19TH AVE,PHOENIX,AZ,85029,2019-03-14,677,E,1,1,ALHX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews, and policy review, the facility failed to ensure two of two sampled residents (#'s 457 and 207) were provided and/or offered showers. The resident census was 175. This deficient practice could result in residents not being provided hygiene care and services. Findings include: -Resident #207 was admitted to the facility on (MONTH) 27, (YEAR) with [DIAGNOSES REDACTED]. The resident was discharged on (MONTH) 15, (YEAR). Review of a care plan dated (MONTH) 28, (YEAR) revealed the resident had self care deficit related to activities of daily living (ADL) and personal hygiene. Interventions included conversing with the resident while providing the necessary care and encouraging participation to the fullest extent possible. The admission Minimum Data Set (MDS) assessment dated (MONTH) 4, (YEAR) revealed a score of 14 on the Brief Interview for Mental Status (BIMS) which indicated the resident had no cognitive impairment. The assessment included the resident was totally dependent on staff for bathing. Review of the Certified Nursing Assistant (CNA) bathing Flowsheet for (MONTH) (YEAR) revealed bathing did not occur for this resident on (MONTH) 27, 28, 29, 30, and 31, (YEAR). Review of the clinical record and nursing notes revealed no evidence the resident had been offered a bath or shower and refused, or that baths or showers had been provided. Review of the (MONTH) (YEAR) CNA ADL Flowsheet revealed documentation the resident was provided a shower on (MONTH) 3, (YEAR). For the remaining 12 days the resident resided at the facility, there was no evidence a bath or shower had been offered or provided. In addition, there was no evidence in the nursing notes that the resident had been offered or provided a bath or shower. The Administrator (staff #219) stated on (MONTH) 7, 2019 at 12:46 p.m., that she could not locate paper shower sheets for resident #207 for (MONTH) and (MONTH) (YEAR). An interview was conducted with a CNA (staff #141) on (MONTH) 6, (YEAR) at 12:52 p.m. Staff #141 stated a resident is scheduled two times a week for a bath or shower. The CNA stated the shower/bath schedule is kept in a binder at nursing station on each unit. The CNA stated that when a resident is provided a bath or shower, the form is completed and placed back in the binder for the nurse to review. Staff #141 stated that if a bath or shower is offered and the resident refuses, the refusal is documented on the shower form and in the electronic chart. -Resident #457 was admitted on (MONTH) 12, (YEAR) with [DIAGNOSES REDACTED]. Review of the care plan initiated (MONTH) 14, (YEAR) revealed the resident had a self-care performance deficit and required assistance. The goal was that the resident would maintain his current level of function for grooming and personal hygiene. Interventions included encouraging the resident to participate to the fullest extent possible with each interactions. The admission MDS assessment dated (MONTH) 19, (YEAR) revealed a BIMS score of 14 which indicated the resident had intact cognition. The assessment also included the resident required extensive assistance with bed mobility, limited assistance with transfer and personal hygiene, and physical help limited to transfer only with bathing. Review of the task documentation for showers revealed the resident received one shower the week of (MONTH) 24 to 30, no showers the week of (MONTH) 8 to14, and no showers the week of (MONTH) 15 to 21, (YEAR). The clinical support staff (staff #216) stated on (MONTH) 6, 2019 at 8:15 a.m., they were unable to locate any shower sheets for this resident. Review of the progress notes did not reveal any further documentation of showers provided or refused. An interview was conducted with a CNA (staff #184) on (MONTH) 6, 2019 at 1:08 p.m. She stated that there is shower schedule for each resident and that each resident is scheduled for two showers a week. She stated that she documents a shower with how much assistance the resident required in the electronic record. The CNA stated that if the resident is independent for showers, a shower sheet would still be completed and the nurse would sign the shower sheet. The CNA also stated that all residents require at least supervision and set up and that no resident, including independent residents, should be left alone in the shower room. She stated that if a resident refuses a shower, the resident is asked to sign the sheet that he/she refused the shower. After reviewing the task documentation, the CNA stated that if there are no shower sheets, there would be no documentation that the resident was offered or received showers. An interview was conducted with a CNA (staff #23) on (MONTH) 6, 2019 at 3:00 p.m. She stated that there is a shower schedule and that each resident receives two showers a week. The CNA stated that she documents a shower on the paper shower form and in the electronic record. She stated that if a resident refuses a shower, she would offer a shower again. She stated if the resident refuses a second time, she would notify the nurse. She also stated that if the resident refused a third time, she would have the resident sign that he/she refused and why on the shower sheet. The CNA stated that she would also document the refusal in the electronic record. During an interview conducted with a Licensed Practical Nurse (LPN/staff #3) on (MONTH) 7, 2019 at 10:41 a.m., she stated that residents are scheduled for 2 showers a week. The LPN stated that if a resident refuses a shower, the CNA notifies the nurse. She stated the nurse would speak with the resident to find out why the resident refused the shower. She stated that if a resident still declined the shower, she would mark refused on the shower sheet and have the resident sign the sheet. The LPN stated that if the CNA did not chart a shower in the electronic record and there is no shower sheet, she would not be able to say whether a resident received a shower or if a shower was offered. An interview was conducted with the Administrator (staff #219) on (MONTH) 7, 2019 at 12:45 p.m. She stated that the short term residents do not have a set in stone shower schedule because many of them shower independently. She stated that her expectation is that residents' requests and personal hygiene needs be met. The Administrator stated that a resident should be offered a shower on the scheduled shower days and there should be documentation that the resident received the shower or refused the shower. Review of the facility's policy regarding ADL services revealed residents who are unable to carry out ADL's will receive necessary services to maintain grooming and personal hygiene. The policy also included residents are given the appropriate treatment and services to maintain or improve his/her abilities.",2020-09-01
873,CORONADO HEALTHCARE CENTER,35132,11411 NORTH 19TH AVE,PHOENIX,AZ,85029,2019-03-14,684,D,0,1,ALHX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, staff and resident interviews and policy review, the facility failed to ensure that one of two sampled resident's (#113) with a wound had thorough wound assessments completed, and that the wound assessments were documented. The deficient practice could result in wounds not being monitored for deterioration and healing. Findings include: Resident #113 was admitted on (MONTH) 10, 2019, with [DIAGNOSES REDACTED]. An Initial Admission Record dated (MONTH) 10, 2019 included the resident did not have any skin problems on admission. Admission physician orders dated (MONTH) 10, 2019 included for weekly skin checks on the night shift, every 7 days. Review of a physician admission progress note dated (MONTH) 11, 2019 revealed documentation under the assessment section that the resident had a sacral abscess, status [REDACTED]. A care plan dated (MONTH) 11, 2019 included for potential/actual impairment to skin integrity related to generalized weakness, deconditioning and protein malnutrition. The care plan also included the resident had a sacral abscess on (MONTH) 28, which was to be assessed by the wound nurse. Review of the wound nurse's note dated (MONTH) 11, 2019 revealed a skin assessment was completed and that the resident's skin was intact. A weekly Skin Evaluation dated (MONTH) 17, 2019 included the resident's skin was intact. A review of the admission MDS (Minimum Data Set) assessment dated (MONTH) 17, 2019, revealed the resident had a BIMS (Brief Interview for Mental Status) score of 10, which indicated moderate cognitive impairment. The MDS assessment further documented that the resident did not have any skin problems. Review of a physician's progress note dated (MONTH) 18, 2019 revealed under the assessment section that the resident had a sacral abscess, status [REDACTED]. A wound nursing note dated (MONTH) 23, 2019 revealed the resident reported that she had an old abscess on her coccyx area, which had reopened. Per the note, the wound was assessed and drainage was noted from the area. The physician was informed and gave an order for [REDACTED].>A physician's order dated (MONTH) 23, 2019 included for Bactrim DS tablet 800-160 mg (milligrams) 1 enterally bid (twice a day) for 10 days for abscess. Review of the clinical record revealed there was no documentation that an assessment of the coccyx/sacral wound was completed, which included a description of the wound and drainage. Review of a weekly Skin Evaluation dated (MONTH) 24, 2019 revealed the resident had an abscess to the coccyx and was started on an antibiotic, and the wound team was to evaluate. A nursing note dated (MONTH) 24, 2019, documented that the resident's skin color was normal and that the resident was receiving oral antibiotic treatment for [REDACTED]. A provider assessment dated (MONTH) 26, 2019, documented the resident has a spontaneous rupture of a buttock abscess and the resident reports that it is chronic and drains at times. The plan was for wound care to buttock abscess, monitor for symptoms of infection and to continue to use Bactrim. The note included the resident's wound healing has improved. However, there was no assessment of the condition of the buttocks wound on this note. Additional physician orders included the following: February 26: Bactrim DS 800-160 mg 1 enterally, two times a day for abscess on coccyx until (MONTH) 3. February 26-27: Bactrim DS 800-160 mg 1 by mouth, two times a day for abscess on coccyx until (MONTH) 7, 2019. February 27, 2019: Bactrim DS 800-160 mg 1 via [DEVICE], two times a day for abscess on coccyx until (MONTH) 7, 2019. According to the MAR for (MONTH) 2019, the resident did not receive two doses of the Bactrim on (MONTH) 25, and received only 1 dose on (MONTH) 26. Review of an Infectious Disease Initial Note by the Nurse Practioner (NP) dated (MONTH) 28, 2019, revealed that the NP was being asked to see the resident regarding starting Bactrim for a presumed abscess on the sacrum. The note included the resident had developed a sacral abscess which had spontaneously drained on (MONTH) 28, 2019 (while in hospital). The note further included that from asking around the Bactrim was for a closed sacral furuncle versus an abscess that is now self-limiting. The note did not include an assessment of the sacral area/abscess. Another provider assessment dated (MONTH) 4, 2019 documented the resident had an acute, cutaneous abscess. The plan was for wound care to buttock abscess, monitor for symptoms of infection and to continue the Bactrim. The note included the resident's wound healing has improved. The note did not include an assessment of the buttock abscess. A late entry physician's progress note dated (MONTH) 8, 2019 documented under the assessment section that the resident had a sacral abscess, status [REDACTED]. A weekly Skin Evaluation dated (MONTH) 9, 2019 included the following: no other skin issues at this time. Further review of the clinical record revealed there was no documentation that the sacral abscess wound was thoroughly assessed to include a description of the wound and drainage, nor any measurements from the time of admission through (MONTH) 9, 2019. There was also no documentation when the sacral abscess had actually healed. An observation of the resident's skin was conducted on (MONTH) 12, 2019 at 11:55 p.m., with a registered nurse (staff #41/who oversees the wound department). Observation of the resident's buttocks/coccyx area revealed the skin was intact and there were no open wounds. During the observation, the resident stated that she had an abscess on her bottom, but it's gone now. She said that she does not have any sores right now. Following the observation, staff #41 stated that when residents are admitted with wounds or develops one in the facility, the nurse is to assess it and document it on the nursing assessment. She said the nurse is to document if there is an open area, any dressing, drainage and describe the wound. She said the nurses do not measure or stage a wound as the wound nurse does this the following day. She said the nurse is to notify the wound nurse regarding any wounds and the wound nurse usually sees the resident the next day. She said the wound nurse completes a full skin assessment and if a wound is present, it is to be documented on either the pressure ulcer assessment or on the non pressure ulcer assessment. She said the assessment should include measurements, a description of the wound, any drainage and if any signs/symptoms of infection. She said the wound assessments are all documented in their computer system. She said the wound team consists of the wound Doctor and a nurse practitioner (NP), and that they make rounds three times a week and measure wounds 1-2 times per week. Staff #41 stated that the wound team have their own electronic documents for the assessments and those are sent to medical records and are scanned into the medical record. An interview was conducted on (MONTH) 12, 2019 at 2:31 p.m. with the Director of Nursing (DON/staff #215), who stated that the initial skin assessments included the resident's skin was intact and the nurses document by exception. Documentation was requested regarding any assessments of the resident's wound, however; she was unable to locate any additional wound assessment documentation. Review of the facility policy regarding Wound Management revealed the nurse is to complete a comprehensive admission assessment/evaluation to identify any alterations in skin integrity, develop comprehensive care plans if indicated and complete weekly head to toe skin assessments, with follow up as applicable. The policy included that once a wound has been identified, assessed and documented, nursing shall administer treatment to each affected area, per the physician's order.",2020-09-01
874,CORONADO HEALTHCARE CENTER,35132,11411 NORTH 19TH AVE,PHOENIX,AZ,85029,2019-03-14,686,D,0,1,ALHX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy review, the facility failed to ensure one (#207) of three sampled residents with pressure ulcers, was provided physician ordered treatment. There were 11 residents in the facility who were identified as having pressure ulcers. The deficient practice could result in delayed wound healing or worsening of the pressure ulcer. Findings include: Resident #207 was admitted to the facility on (MONTH) 27, (YEAR) with [DIAGNOSES REDACTED]. The resident was discharged on (MONTH) 15, (YEAR). A weekly pressure ulcer form dated (MONTH) 29, (YEAR), revealed the resident had a Stage 2 pressure ulcer located on the right buttock. Review of the clinical record revealed a physician's orders [REDACTED]. A care plan dated (MONTH) 29, (YEAR) regarding the stage 2 pressure ulcer included an intervention to administer treatments as ordered. A review of the Treatment Administration Record (TAR) for (MONTH) (YEAR) revealed no evidence the pressure ulcer treatment was provided on Tuesday, (MONTH) 10, (YEAR). Review of the nursing notes revealed no evidence the pressure ulcer treatment was provided or refused on (MONTH) 10, (YEAR). An interview was conducted with a Licensed Practical Nurse ( LPN/staff #151) on (MONTH) 7, 2019. Staff #151 stated all physician orders [REDACTED]. She stated that if a resident refuses the treatment, it must be documented on the TAR or in the nursing notes. The LPN also stated that if the treatment was not documented, it was not done. During an interview conducted with the Administrator (staff #219) on (MONTH) 7, 2019 at 12:45 p.m., she stated all nurses are to administer treatments as ordered by the physician. Staff #219 stated the nurses are to document the treatment provided or document the resident refused. The facility's policy regarding wound management and pressure ulcers revealed that it is their policy that a resident with a pressure ulcer receives necessary treatment and services to promote healing. The policy included the nursing staff shall administer treatment per the physician's orders [REDACTED].",2020-09-01
875,CORONADO HEALTHCARE CENTER,35132,11411 NORTH 19TH AVE,PHOENIX,AZ,85029,2019-03-14,698,E,0,1,ALHX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews and policy review, the facility failed to ensure one of one residents (#73) sampled on [MEDICAL TREATMENT] received ongoing assessments and monitoring, as ordered by the physician. The facility had seven residents who were receiving [MEDICAL TREATMENT] services. The deficient practice could result in [MEDICAL TREATMENT] related complications not being identified and treated timely. Findings include: Resident #73 was admitted on (MONTH) 24, (YEAR), with [DIAGNOSES REDACTED]. The initial admission record dated (MONTH) 24, (YEAR) included the resident was alert and oriented to time, place and person. It also included the resident received [MEDICAL TREATMENT] and had a AV (arteriovenous) shunt on the right upper extremity. The physician admission progress note dated (MONTH) 26, (YEAR) included the resident was alert and oriented x 4, had [MEDICAL CONDITION] and was on [MEDICAL TREATMENT]. The admission MDS (Minimum Data Set) assessment dated (MONTH) 31, (YEAR) included a BIMS (Brief Interview for Mental Status) score of 14, indicating the resident was cognitively intact. It also coded that the resident was receiving [MEDICAL TREATMENT]. Review of the recapitulation of physician's orders [REDACTED]. -Monitor AV shunt site for bruit and thrill every shift. Document (+) for present and (-) for not present (start date was (MONTH) 24, (YEAR)). -Monitor AV access site for signs and symptoms of infection every shift. Document any redness, swelling, pain, fever, oozing (+) present (-) not present (start date was (MONTH) 24, (YEAR)). -Post [MEDICAL TREATMENT] AV shunt site access care: Remove pressure dressing 2-4 hours after [MEDICAL TREATMENT]. If bleeding occurs, apply 4 x 4 until bleeding stops. If unable to stop bleeding, notify the physician (start date was (MONTH) 24, (YEAR)). Review of the clinical record revealed these orders continued to be active until (MONTH) 28, 2019, and were transcribed onto the MAR (medication administration record) from (MONTH) 24, (YEAR) through (MONTH) 28, 2019. Review of the MAR's from (MONTH) 24, (YEAR) through (MONTH) 28, 2019 revealed the following: -In the boxes for monitoring the AV shunt site for bruit, thrill and for signs and symptoms of infection, there were check marks instead of (+) for presence or (-) for absence, as ordered by the physician. -For post [MEDICAL TREATMENT] AV shunt site access care, the boxes were marked with an X. Further review of the clinical record from (MONTH) 24, (YEAR) through (MONTH) 28, 2019 revealed inconsistent documentation of the presence of bruit and thrill on the days that the resident did not have [MEDICAL TREATMENT]. Continued review of the clinical record revealed no documentation that the AV shunt site was monitored for signs and symptoms of infection and that the post [MEDICAL TREATMENT] AV shunt site care was administered as ordered by the physician on [MEDICAL TREATMENT] days and on the days when the resident did not go to [MEDICAL TREATMENT]. There was also no evidence found in the clinical record that the physician was notified or of the reasons why these orders were not administered. In an interview conducted on (MONTH) 3, 2019 at 12:20 p.m., resident #73 stated she goes to [MEDICAL TREATMENT] every Tuesday, Thursday and Saturday. She stated that staff does not check the [MEDICAL TREATMENT] on a daily basis. She said that staff checks her [MEDICAL TREATMENT] only on the days when she goes to [MEDICAL TREATMENT]. An interview with a licensed practical nurse (LPN/staff #153) was conducted on (MONTH) 6, 2019 at 11:21 a.m. Staff #153 stated that AV shunts should be checked before and after [MEDICAL TREATMENT]. She said that shunts should be checked every shift on and off [MEDICAL TREATMENT] days and documented in the MAR. In an interview with another LPN (staff #91) conducted on (MONTH) 11, 2019 at 11:56 a.m., she stated that AV shunts are monitored for the presence/absence of bruit and thrill and for signs and symptoms of infection. During an interview with the Director of Nursing (DON/staff #215) conducted on (MONTH) 12, 2019 at 3:25 p.m., she stated residents on [MEDICAL TREATMENT] should be checked for the presence and absence of bruit and thrill, for signs and symptoms of infection every shift, and that the findings will be documented in the clinical record. She stated when the nurse checks and initials the boxes in the MAR, it means that the AV shunt was monitored. When asked about marking the boxes in the MAR indicated [REDACTED]. Review of the policy titled, [MEDICAL TREATMENT] (Renal) Pre and Post Care revealed to assist residents in maintaining homeostasis pre and post-[MEDICAL TREATMENT] and to assess and maintain patency of [MEDICAL TREATMENT] access. The policy also included that the [MEDICAL TREATMENT] should be assessed upon return to the facility for patency, for any unusual redness or swelling and for post [MEDICAL TREATMENT] AV shunt access care as ordered.",2020-09-01
876,CORONADO HEALTHCARE CENTER,35132,11411 NORTH 19TH AVE,PHOENIX,AZ,85029,2019-03-14,761,D,0,1,ALHX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, staff interviews and policy review, the facility failed to ensure that intravenous (IV) medications on one of four medication carts for 4 residents (#58, #418, #458 and #460) were stored secured in a locked storage area. The deficient practice could result in the potential for misappropriation of resident's medications. Findings include: -Resident #58 was admitted (MONTH) 1, 2019, with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. -Resident #418 was admitted on (MONTH) 1, 2019, with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. -Resident #458 was admitted on (MONTH) 27, 2019, with a [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. -Resident #460 was admitted on (MONTH) 1, 2019, with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. An observation was conducted on (MONTH) 5, 2019 at 7:50 a.m., of the Phoenix South Medication cart #2. On top of the cart, there were four bags of IV medications. During this observation, the nurse (Licensed Practical Nurse/LPN/staff #3) was observed to leave the IV medications on top of the cart two different times and entered resident rooms. Other staff members were observed in the hallway when the IV medications were unsecured. The IV medications which were left on top of the cart were as follows: linezolid solution 600 mg for resident #58, [MEDICATION NAME] solution 500 mg for resident #418, [MEDICATION NAME] sodium solution 2 gm for resident #458, and [MEDICATION NAME] HCL solution 1 gm for resident #460. An interview was conducted with staff #3 on (MONTH) 5, 2019 at 8:09 a.m. She stated that she is not to leave pills on the cart. She stated that IV's are a medication and should be kept in the medication cart drawer, and that it was a mistake. She stated that the IV medications left on the cart would present the risk that someone could take the medications. An interview was conducted with the Director of Nursing (DON/staff #215) on (MONTH) 5, 2019 at 1:05 p.m. She stated that any medication on the medication cart needs to be under lock and key, if the nurse is not present at the cart. She stated that if medications were left unattended on the cart, it poses a risk that the medications could be misplaced, taken or utilized elsewhere. She stated that the medications left unattended on the cart did not meet policy or her expectations. Review of the policy for Medication Access and Storage revealed to store all drugs and biologicals in locked compartments and that only licensed nurses, the consultant pharmacist and those lawfully authorized to administer medications are allowed access to medications. The policy further noted that medication rooms, carts, and medication supplies are locked or attended by persons with authorized access.",2020-09-01
877,CORONADO HEALTHCARE CENTER,35132,11411 NORTH 19TH AVE,PHOENIX,AZ,85029,2019-03-14,777,D,1,1,ALHX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on closed clinical record review, staff interviews and policy review, the facility failed to ensure that a STAT chest x-ray was obtained as ordered by the physician for one resident (#307). The deficient practice has the potential to adversely affect care or treatment. Findings include: Resident #307 was readmitted on (MONTH) 6, (YEAR), with [DIAGNOSES REDACTED]. The initial admission record dated (MONTH) 6, (YEAR) included the resident was alert and oriented to time, place, person and was able to follow simple commands. The NP (nurse practitioner) progress note dated (MONTH) 8, (YEAR) included the resident was alert and oriented x 4. The note included [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. According to the MAR (medication administration record) for (MONTH) 12, (YEAR), the resident had a temperature of 99.4 degrees Fahrenheit. A physician's orders [REDACTED]. A late entry NP progress note dated (MONTH) 12, (YEAR) at 4:42 p.m. included that the NP was notified in the morning that resident was more somnolent than usual. Physical examination included the resident had no acute distress but not able to get comfortable. Neurological examination included the resident was awake and alert, followed some commands, but speech was slurred. The note included altered mental status, with unclear etiology. A nursing progress note dated (MONTH) 12, (YEAR) at 5:40 p.m. revealed the resident's speech was slurred and mentation was altered and that the resident was monitored hourly throughout the shift. Per the clinical record documentation, the resident was admitted to the hospital on (MONTH) 13, (YEAR). Further review of the clinical record revealed there was no evidence that the STAT chest x-ray was done as ordered. During an interview with a licensed practical nurse (LPN/staff #153) conducted on (MONTH) 6, 2019 at 11:21 a.m., she stated that she was on shift when resident had the change in condition. She stated the NP ordered a STAT chest x-ray, which was done. An interview with medical records staff (staff #112) was conducted on (MONTH) 7, 2019 at 2:03 p.m. She stated there was no record of any chest x-ray which was done for resident #307. An interview with another LPN (staff #47) was conducted on (MONTH) 12, 2019 at 2:28 p.m. Staff #47 stated when she receives a STAT order, she will transcribe it in the electronic record, complete a requisition form and call the laboratory. She said depending on what company the request was made and forwarded to, the turnaround time is between 1 and 4 hours for a STAT order. She stated she will follow up in an hour to ensure receipt of the order and requisition; and if the STAT order was not done after the turnaround time, she would call right away and inform them of the STAT order again. In an interview with the Director of Nursing (DON/staff #215) conducted on (MONTH) 12, 2019 at 3:25 p.m., she stated the window period for STAT laboratory orders including chest x-rays is 4 hours and that it should be done by then. She stated that she expects the nurses to follow up on the requests. Further, she stated the STAT chest x-ray ordered for resident #307 was not done and she does not know the reason why. Review of the policy regarding Physician order [REDACTED].in accordance with the resident's plan of care.",2020-09-01
878,CORONADO HEALTHCARE CENTER,35132,11411 NORTH 19TH AVE,PHOENIX,AZ,85029,2018-06-01,600,G,1,0,CUK111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on closed record review, staff interviews, facility documentation, and policy review, the facility failed to ensure one resident (#1) was free from neglect. Findings include: Resident #1 was admitted to the facility on (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. The initial admission record dated (MONTH) 27, (YEAR), included that the resident was alert and oriented to time, place, and person and had clear speech and was able to follow simple commands. A physician's note dated (MONTH) 27, (YEAR), revealed the resident was alert and oriented x 3. The note also included the resident had an abnormal CT (computed tomography) scan of the pancreatic head. The plan was for the resident to follow up with a [MEDICATION NAME] for possible EUS (endoscopic ultrasound). The IDT (interdisciplinary team) - Care Plan Review note dated (MONTH) 1, (YEAR), revealed the resident was not feeling well and had nausea and vomiting. The admission MDS (Minimum Data Set) assessment dated (MONTH) 4, (YEAR), included a BIMS (Brief Interview for Mental Status) score of 15 which indicated the resident was cognitively intact. Review of the physician's orders [REDACTED]. A physician's note dated (MONTH) 21, (YEAR), revealed the resident continued to be nauseated and that the resident's heart rate was tacky at 104 Review of the physician's note dated (MONTH) 23, (YEAR), revealed the resident was scheduled for a [MEDICATION NAME] follow-up visit on (MONTH) 24, (YEAR) regarding the possible pancreatic mass. The facility's documentation revealed an appointment with the [MEDICATION NAME] was scheduled for (MONTH) 24, (YEAR) at 2:30 p.m. Review of the MAR (medication administration record) dated (MONTH) (YEAR), revealed that on (MONTH) 24, the medication pass at 4:00 p.m., 5:00 p.m., 8:00 p.m., 10:00 p.m., and 11:00 p.m. were marked by day shift (staff #143) and second shift (staff #91) nurses with a number 8 which is a code for absent from facility. Review of the clinical record did not reveal any evidence that staff attempted to locate the resident, and no evidence that the physician, family, DON (Director of Nursing), the ED (Executive Director), nor the police were notified that resident did not return to the facility from the appointment. Review of the facility's report dated (MONTH) 30, (YEAR), revealed the following events that occurred on (MONTH) 24, (YEAR) (day of the GI appointment) and (MONTH) 25, (YEAR): -At approximately 1:30 p.m., the resident was transported by a transport service to her GI appointment. -At approximately 2:40 p.m., the GI office called and spoke with the medical records assistant (staff #46) to inform the facility that they did not have the resident's medical record. The GI office requested for the medical records and transport service information to be faxed to their office. -At around 4:00 p.m., the day shift nurse (staff #143) received a phone call from the GI office and was told that the resident was at the wrong physician's office. The GI office also asked staff #143 to call transportation to pick up the resident. Staff #143 made a call for transport but had called the wrong transport company. Per the documentation, staff #143 became busy and did not call the transport company again but reported to the oncoming second shift nurse (staff #91) that the resident was out at an appointment. The documentation also included that staff #143 did not let any staff know of the possible transport issue at that time. - Further review of the facility's investigation revealed, the information received by the facility from the hospital included that emergency personnel responded to the GI office on (MONTH) 24, (YEAR) at 7:04 p.m. after receiving a call from a concerned citizen. -During the facility's interview (no specified date/time of interview) conducted with the oncoming second shift nurse (staff #91), she confirmed that staff #143 told her that the resident remained out of the building. Per the documentation, staff #91 reported this information to her night supervisor (staff #72) but did not include what time it was reported to the supervisor. -The facility's investigation included an interview (no specified date/time of interview) conducted with the night supervisor (staff #72). She stated that she remembered staff #91 reporting to her that the resident was out of the facility. Per the documentation, staff #72 called the physician's office. The physician's answering service answered but was unable to assist her with information regarding the resident. Also included was that staff #72 did not think of calling the DON or the ED because she assumed the resident was taken to the hospital from the appointment. -On (MONTH) 25, (YEAR) at approximately 10:00 a.m., the weekend nurse supervisor (staff #208) reported to the ED (staff #218) that the facility was notified by the hospital that the resident was admitted . Review of the hospital ER (emergency room ) record revealed the patient was seen by provider on (MONTH) 24, (YEAR) at 7:34 p.m. The chief complaint was that the resident was found at the physician's office unresponsive. The History of Present Illness included the resident (named as a[NAME]Doe) was found minimally responsive by paramedics in her wheelchair outside of the physician's office. Per the documentation, the resident was initially responding to pain and was moaning unintelligible words with her eyes open. In route to the hospital, the resident became increasingly less responsive with a pulse oximetry reading of 50% oxygen saturation, and appeared apneic as they were unloading her from the ambulance. An oral airway was placed and the resident was bagged on her way to the ER. However, upon arrival to the ER, the resident was completely unresponsive. The assessment included hypoxic [MEDICAL CONDITION], oliguric kidney failure, [MEDICAL CONDITION], and profound dehydration. An interview was conducted with the executive director of the transport company that transported the resident to the appointment on (MONTH) 31, (YEAR) at 9:35 a.m. She stated that the resident was picked up from the facility on (MONTH) 24, (YEAR) at 1:39 p.m. and arrived at the physician's office at 2:28 p.m. During an interview conducted with the medical records assistant (staff #46) on (MONTH) 31, (YEAR) at 10:20 a.m., she stated that on (MONTH) 24, (YEAR) at approximately 1:30 p.m., she saw the resident's transportation packet at the nurse station. She stated that the resident had already left for the appointment. She stated that the doctor's office requested that she fax the resident's medical records and transportation information to them and that she faxed the information. Staff #46 stated that the transportation information is usually sent with the resident, so that the physician's office can call the transportation service after the appointment. An interview was conducted with the night supervisor (staff #72) on (MONTH) 31, (YEAR) at 11:47 a.m. Staff #72 stated that at the beginning of her night shift (12 midnight) on (MONTH) 24, (YEAR), she received a verbal list of 5 resident names (which included resident #1) who were still out of the facility and had not come back from either [MEDICAL TREATMENT] or a physician's appointment. She stated that the shift was overwhelming and that she had to call the police three times that night for different issues. She stated none of the reports were regarding resident #1 not returning from an appointment. The night supervisor stated that around 4:10 a.m. on (MONTH) 25, (YEAR), the resident's night nurse (she could not recall the nurse's name) reported that the resident never returned from an appointment. She later retracted the time to 2:30 a.m. instead of 4:10 a.m. Staff #72 stated that she then called the physician's office and got the answering service who was not helpful. She stated that she instructed the nurse to follow-up with the social worker later that day regarding the status of the resident. Staff #72 stated that she did not inform the DON or the ED because she heard during her shift that there were several residents who were transferred to the hospital from an appointment and she thought resident #1 was one of them. She also stated that never called the hospital or the police. During an interview conducted with the day shift (6:00 a.m. - 6:00 p.m.) nurse (staff #143) on (MONTH) 31, (YEAR) at 11:43 a.m., she stated that she was on shift when the resident had an appointment to see the GI physician on (MONTH) 24, (YEAR). She stated that at approximately 3:00 p.m. or 3:30 p.m. on (MONTH) 24, (YEAR), she received a call from the GI office stating they called transportation services but that transport was not there to pick up the resident. She stated she called the transport company but was told that they were not the one who transported the resident to the appointment and that they did not have the resident scheduled for pick up. Staff #143 stated her plan was to call another transport service, but that she got busy with two discharges. She stated by the time she finished with the discharges, it was time for shift change. She stated she reported to the oncoming second shift nurse that the resident was still out of the facility and that there were issues with transportation. On (MONTH) 31, (YEAR) at 2:55 p.m., an interview was conducted with a certified nurse assistant (CNA/staff #28) who worked from 6:30 a.m. to 10:30 p.m. on (MONTH) 24, (YEAR). She stated that the resident eats in her room and that when she was passing the meal trays at 5:00 p.m., the resident was not in her room and she could not locate her. She stated that she reported to the nurse that she could not locate the resident. She stated after the nurses changed shift between 7:00 p.m. and 8:00 p.m., she was doing her rounds and was unable to find the resident. She stated she reported this to the second shift nurse, and that the second shift nurse was also asking her where the resident was. She stated that between 9:00 p.m. and 10:30 p.m., just prior to the end of her shift, she made another round and was still unable to locate the resident. Staff #28 stated she report this to the second shift nurse again. An interview with another CNA (staff #128) was conducted on (MONTH) 31, (YEAR) at 3:10 p.m. She stated that she worked the evening shift from 2:30 p.m. through 10:30 p.m. on (MONTH) 24, (YEAR). She remembered there were a lot of things going on that day. She stated she was conducting random checks up and down the hall throughout her shift. Staff #128 stated she noticed the resident's privacy curtains were closed and that she had not seen the resident. She stated that she started looking for the resident and was told that the resident had an appointment. She stated that around 8:00 p.m. on (MONTH) 24, (YEAR), she still did not see the resident and was not sure whether she reported this to the nurse. Staff #128 also stated that she did not make a big deal out of this because based on her experience; residents who do not return from an appointment were probably sent out to the hospital. However, she stated that she did not know whether the resident was sent to the hospital or not. During an interview conducted with the second shift (6:00 p.m. - 6:00 a.m.) nurse (staff #91) on (MONTH) 1, (YEAR) at 7:36 a.m., she stated that at the beginning of her shift on (MONTH) 24, (YEAR), she received a report from staff #143 that the resident was out on an appointment. She stated that she was never told that the resident had transportation issues. She also stated that it was not reported to her during her shift that the resident had not returned from the appointment. Staff #91 stated that between 9:00 p.m. and 10:00 p.m., she reported to the nurse supervisor that the resident did not return from the appointment. During an interview conducted with the DON (staff #219) on (MONTH) 1, (YEAR) at 8:19 a.m., she stated that she was never notified that the resident had not returned from the appointment until (MONTH) 29, (YEAR). She stated that she was told the resident went out for an appointment and ended up in the hospital where the resident passed away. The DON stated that when an alert and oriented resident does not come back from an appointment, nurses are to call the physician office, the transport service, and notify the resident's family. She stated that it is expected that the nurses will try to find and locate the resident. She also stated that if these measures are implemented and the resident is still unable to be located, it will be assumed that the resident left AMA (against medical advice). The DON stated the nurses are aware of the residents who have appointments, because the schedule is posted at the nurse station. She stated the nurses are responsible to follow-up on a resident who has not returned from an appointment. An interview was conducted with the ED (staff #218) on (MONTH) 1, (YEAR) at 8:40 a.m. She stated that she received a call from the weekend supervisor (staff #208) on (MONTH) 25, (YEAR) at around 10:00 a.m. informing her that the hospital physician had notified her, that the resident was at the hospital. She stated that she conducted phone interviews with the involved staff (#143, #91 and #72) and that none of these staff provided her with specific times of events. The ED also stated that the night supervisor (staff #72) did not report the incident to her or the DON. An interview was conducted with the weekend nurse supervisor (staff #208) on (MONTH) 1, (YEAR) at 9:00 a.m. She stated that at the beginning of her 6:00 a.m. - 6:00 p.m. shift on (MONTH) 25, (YEAR), she did not receive any report from any of the nurses that worked prior to her shift that the resident was missing and had not returned from an appointment. She stated that at around 10:00 a.m., during the stand-up meeting, she was notified by the receptionist (staff #43) that the resident was at the hospital. She stated that she received a report from someone (she could not recall the name) that when the physician's office closed at 4:30 p.m. on (MONTH) 24, (YEAR), the resident was left outside the building waiting for transportation. Staff #208 stated that if she receives a report that a resident is missing or has not returned from an appointment, she will call the physician, transport service, and the emergency contact. She also stated that if the resident is unable to be located, she will call her immediate supervisor, the DON/ED, and the police. During an interview conducted with the receptionist (staff #43) on (MONTH) 1, (YEAR) at 9:16 a.m., she stated that she received a call from the physician's office late afternoon on (MONTH) 24, (YEAR), to inform them that they had called transportation and that the transport service had not arrived and that the resident needed transportation. The receptionist stated that the unit clerk who was responsible for appointment/transportation scheduling was not available so she transferred the call to medical records. She stated that on (MONTH) 25, (YEAR), she reported to the weekend nurse supervisor (staff #208) that the hospital had called to inform them that the resident was admitted to the ICU (intensive care unit). The facility's policy regarding Transportation to Specialty Appointment included that the facility will assist residents in arranging transportation to/from diagnostic appointments when necessary. It also included that a member of the medical records will remain in the facility until all patients out on specialty appointments have returned to facility and are accounted for. By 6:00 p.m. every weekday, medical records and nursing staff of each unit will account for all patients. Continued review of the policy revealed that in the event a patient does not return to the facility prior to 6:00 p.m., the DON or ED, family/emergency contact, physician, the transportation company, and the physician's office will be called for additional information. It also included that a missing person report will be filed if after calling these offices and contacts, the resident is still not accounted for. The policy also included that if after 6:00 p.m. the nursing supervisor receives information regarding a resident not in the building, the DON and/or the ED will be notified as soon as possible and the police will be contacted.",2020-09-01
879,CORONADO HEALTHCARE CENTER,35132,11411 NORTH 19TH AVE,PHOENIX,AZ,85029,2016-11-04,247,E,0,1,CI5F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, resident and staff interviews and policy review, the facility failed to ensure four residents (#'s 220, 435, 416, and 441) were notified, prior to room or roommate changes. The sample size was five residents. Findings include: -Resident #220 was readmitted to the facility on (MONTH) 21, (YEAR), with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated (MONTH) 28, (YEAR), included a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. A review of the resident census revealed the resident was moved to another room on (MONTH) 15, (YEAR). Review of the clinical record revealed no documented evidence that the resident was notified prior to the room change on (MONTH) 15. During an interview conducted at 12:42 p.m. on (MONTH) 3, (YEAR), the resident stated that she had a room change and was not provided prior notice. She stated she was only notified when staff arrived to move her. During an interview conducted at 12:23 p.m. on (MONTH) 3, (YEAR), the social service assistant (staff #110) stated that when resident's change from one room to another, the social service staff complete the Notice of Room Change form that documents the room the resident was in and the room they are moving to, the reason for the room change, the date the notice was given and the signature of the resident or resident's representative. The social service assistant also stated the room change occurred on a Sunday, and no Notice of Room Change form was completed. During an interview conducted at 12:42 p.m. on (MONTH) 3, (YEAR), the resident stated that she had a room change and was not provided prior notice. She stated she was only notified when staff arrived to move her. -Resident #416 was admitted to the facility on (MONTH) 23, (YEAR), with [DIAGNOSES REDACTED]. Review of the admission MDS assessment dated (MONTH) 30, (YEAR), revealed a BIMS score of 15, which indicated the resident was cognitively intact. A review of the census records revealed the resident received new roommates on (MONTH) 5, 14, and 29, (YEAR). However, there was no clinical record documentation that the resident was notified prior to receiving new roommates. -Resident #435 was admitted to the facility on (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. Review of the admission MDS assessment dated (MONTH) 26, (YEAR), revealed a BIMS score of 14, which indicated the resident was cognitively intact. A review of the daily census revealed the resident received a new roommate on (MONTH) 28, (YEAR). Review of the clinical record revealed no documented evidence that the resident was notified prior to the arrival of the new roommate. -Resident #441 was admitted to the facility on (MONTH) 22, (YEAR), with [DIAGNOSES REDACTED]. A review of the daily census revealed the resident received a new roommate on (MONTH) 24, (YEAR). Review of the clinical record revealed no documented evidence that the resident was notified prior to the arrival of the new roommate. During an interview conducted at 12:27 p.m. on (MONTH) 3, (YEAR), the Social Services Director (staff #14) stated that if a resident receives a new roommate who is being admitted to the facility, the staff member who prepares the room is suppose to notify the resident in the room that they are receiving a new roommate. She stated if a resident receives a new roommate because a resident was transferring from another room, a Notice of Room or Roommate change is filled out. She further stated there is no documented evidence that the residents were notified prior to the arrival of the new roommates. A review of the Room/Roommate Change Policy and Procedure revealed, It is the policy of this facility that the resident has the right to notification of room or roommate changes and to agree prior to the change taking place.",2020-09-01
880,CORONADO HEALTHCARE CENTER,35132,11411 NORTH 19TH AVE,PHOENIX,AZ,85029,2016-11-04,323,E,0,1,CI5F11,"Based on observations, staff interviews, and policy review, the facility failed to ensure the resident environment remained free of accident hazards, by failing to ensure safe hot water temperatures in multiple resident rooms. Findings include: An observation was conducted on (MONTH) 1, (YEAR) at 2:39 p.m. of resident room #211. At this time, the hot water temperature for the sink was tested and was found to be 124 degrees Farenheit (F). As a result, additional resident rooms were tested and revealed the following hot water temperatures: -room #210 was 122.6 degrees F. -room #209 was 122.6 degrees F. -room #208 was 121.8 degrees F. -room #207 was 121.7 degrees F. -room #206 was 121.7 degrees F. An interview was conducted on (MONTH) 1, (YEAR) at 2:43 p.m., with maintenance staff (staff #13). At this time, staff #13 tested the hot water temperature in room #211, with the facility's analog thermometer and the temperature was 122 F. He stated that he was not sure how often the facility tested the hot water temperatures in resident rooms, as he was newly hired. An interview was conducted on (MONTH) 2, (YEAR) at 10:54 a.m., with the Maintenance Supervisor (staff #97). He stated that maintenance staff have been monitoring the resident room hot water temperatures and they have not identified any concerns. He stated that he could not explain why the temperatures were high only on one side of the hall, since they share a common source. According to the Federal regulation under F323 Table 1., the time required for a 3rd degree burn to occur is 1 min at 127 degrees F; 3 minutes at 124 F; and 5 minutes at 120 degrees F. The regulation also included that a safe water temperature was 100 degrees F and that burns can occur even at temperatures below those identified in the table, depending on an individuals condition and the length of exposure. A policy regarding water temperatures included that it is the policy of this facility to test and maintain hot water temperatures below 120 degrees F. This applies to all water supplies with resident access. Water temperatures are to be taken at various resident access points, in each section on a weekly basis. Test sites are to be rotated weekly to ensure that all areas are monitored at least monthly. Any high water temperatures are to be addressed immediately.",2020-09-01
881,CORONADO HEALTHCARE CENTER,35132,11411 NORTH 19TH AVE,PHOENIX,AZ,85029,2016-11-04,431,D,0,1,CI5F11,"Based on observation, staff interview, and review of facility policy, the facility failed to ensure the treatment cart and the medication cart were locked when unattended. Findings include: During the initial facility tour conducted on (MONTH) 1, (YEAR) at 8:30 a.m., the treatment cart on the 300 hall was found to be unlocked and unattended. Inspection of the cart revealed four drawers which contained resident prescription wound treatment medications and floor stock wound treatment medications. The drawers also contained sterile supplies for the provision of wound care, 3 cc and 5 cc syringes, intravenous catheters, and needles. Some of the medications included Nystatin powder, Clotrimazole cream, Silver Sulfadiazone cream, Benadryl cream, Santyl cream, and Lidocaine 1% injection multidose vial. Another observation was conducted on (MONTH) 2, (YEAR) at 3:01 p.m. on the 300 hallway. A medication cart was observed to be unlocked and unattended. A resident was seated approximately 3 feet away from the medication cart. Multiple staff, residents, and visitors were observed walking up and down the hall. In addition, the LPN was seated at the desk in the nurses station, however, the counter partially obstructed the view of the medication cart. The medication cart contained resident prescribed medications and floor stock medications for residents on the 300 hall. In an interview at this time, a Licensed Practical Nurse (LPN/staff #177) stated she should have locked the cart. She further stated she was at the cart a few minutes ago and went to the desk to get additional medications. In an interview with the Director of Nursing (DON/staff #199), the DON stated the carts are to be locked any time they are unattended. Review of the facility policy titled Drug Storage, the policy included that the facility is to ensure the proper and safe storage of drugs and biologicals. The policy included 2. Drugs and/or biologicals should not be left unsecured/unattended .4. Medication and treatment carts will be kept locked when unattended.",2020-09-01
882,CORONADO HEALTHCARE CENTER,35132,11411 NORTH 19TH AVE,PHOENIX,AZ,85029,2017-12-21,558,E,0,1,9E4D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, resident and staff interviews, and facility policy, the facility failed to ensure one resident's (#48) call light was within reach. Findings include: Resident #48 was admitted (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment dated (MONTH) 8, (YEAR), revealed the resident required extensive assistance with activities of daily living and had impaired range of motion to bilateral upper extremities. Review of the fall care plan revealed an intervention to keep the call light within the resident's reach. An observation of resident #48 was conducted (MONTH) 15, (YEAR) at 10:25 a.m. The resident was observed lying in the bed with the call light tucked under his pillow. During this observation, an interview was conducted with resident #48. He stated he is blind and that he asks his roommate, who is always in the room, to call the nurse when he needs assistance. However, it was observed the roommate was not in the room. Another observation of resident #48 was conducted (MONTH) 18, (YEAR) at 7:55 a.m. The call light was observed hanging over the headboard. The resident was asked where his call light was. He stated on the right side of his bed and pointed to the right side of his bed. An interview with a Licensed Practical Nurse (staff #43) was conducted (MONTH) 18, (YEAR) at 10:03 a.m. Staff #43 stated residents with visual impairment should have their call light within their reach and that it should be clipped to their gown. She also stated staff should orient the resident to the location of the call light. During an observation conducted (MONTH) 19, (YEAR) at 10:20 a.m., resident #48 was observed sleeping and the call light was observed hanging over the edge of the foot board. An observation was conducted with a Certified Nursing Assistant (staff #103) (MONTH) 19, (YEAR) at 10:31 a.m. Staff #103 found the call light in between the bed and the wall lying on the floor. Staff #103 then picked up the call light and placed it on resident #48's chest. An interview was conducted (MONTH) 19, (YEAR) at 10:43 a.m. with a Licensed Practical Nurse (staff #154). Staff #154 stated resident #48 has severe visual impairment and should have the call light within reach. She stated the placement of the call light is checked by her every time she goes into the resident's room and that all staff should ensure for all residents that the call light is within reach. An interview was conducted with the Director of Nursing (staff #185) (MONTH) 20, (YEAR) at 12:56 p.m. She stated that residents should have their call light within reach and that staff should check that call light placement is within the residents reach each time they enter their rooms. A policy Call Light/[NAME] included to provide the resident a means of communication with nursing staff and to place the call device within the resident's reach before leaving the room.",2020-09-01
883,CORONADO HEALTHCARE CENTER,35132,11411 NORTH 19TH AVE,PHOENIX,AZ,85029,2017-12-21,580,D,0,1,9E4D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policies, the facility failed to ensure the resident's responsible party was notified timely when one resident (#508) sustained a fall. Findings include: Resident #508 was admitted (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. Review of a fall risk assessment dated (MONTH) 9, (YEAR) revealed the resident was a high risk for falls. Review of nurses' notes dated (MONTH) 15, (YEAR) revealed resident #508 sustained a fall at 5:58 a.m. Review of the clinical record revealed no documentation that the resident's Medical Power of Attorney (MPOA/family/resident representative) was notified of the fall on that date. Review of the fall incident report revealed the MPOA was not notified of the fall until (MONTH) 19, (YEAR). During an interview conducted (MONTH) 20, (YEAR) at 10:04 a.m. with a Licensed Practical Nurse (staff #125). Staff #125 stated when a resident has a fall, assess and take care of the resident, and then notify the physician and the family of the fall. An interview was conducted (MONTH) 20, (YEAR) at 10:38 a.m. with the Director of Nursing (staff #185). Staff #185 confirmed that there was no documentation the MPOA was notified timely of the fall. The policy Fall Management System included the attending physician and the family/ responsible party shall be notified of the fall and the resident status. The policy Change in Condition included that when there are changes in a resident's condition; all attempts to reach the physician and the responsible party will be documented in the nursing progress notes and will include the time and the response.",2020-09-01
884,CORONADO HEALTHCARE CENTER,35132,11411 NORTH 19TH AVE,PHOENIX,AZ,85029,2017-12-21,582,D,0,1,9E4D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure one resident (#158) signed and was issued a written Notice of Medicare Non-Coverage (NOMNC) when there was an ending of Medicare services. Findings include: Resident #158 was admitted (MONTH) 16, (YEAR), with [DIAGNOSES REDACTED]. The resident was discharged (MONTH) 12, (YEAR). Review of the Initial Admission Record dated (MONTH) 16, (YEAR), revealed the resident was alert and oriented to time, place, and person. The admission Minimum Data Set assessment dated (MONTH) 23, (YEAR), revealed a BIMS (Brief Interview for Mental Status) score of 12 indicating the resident had moderately impaired cognition. Review of the resident's face sheet revealed he was the financial responsible party. A physician note dated (MONTH) 8, (YEAR) revealed a plan for discharge planning for the following week. Review of the Physician order [REDACTED]. A review of the clinical record from (MONTH) 8 through 12, (YEAR) did not reveal evidence that the resident was informed in writing to the ending of Medicare services. Review of an undated NOMNC form revealed Medicare services would end (MONTH) 13, (YEAR). Continued review of the notice revealed documentation that the resident was verbally contacted (MONTH) 8, (YEAR) at 3:00 p.m. that the resident's liability would begin (MONTH) 14, (YEAR). However, this form was not signed and dated by the resident or the resident's responsible party. During an interview with the discharge planner (staff#193) and Case Manager (staff #50) conducted (MONTH) 20, (YEAR) at 1:31 p.m., staff #50 stated that NOMNC are issued to residents with Medicare and/or on Managed Care 48 hours prior to the discharge date . She stated the residents' right to appeal and their financial liabilities are discussed with the resident upon issuance of the NOMNC. Staff #50 further stated that a copy of the NOMNC form signed by the resident or the resident's responsible party would be scanned into the resident's electronic record. Review of the clinical record was conducted with staff #50 immediately following the interview. She stated that the NOMNC form found in the clinical record indicated the resident was informed verbally (MONTH) 8, (YEAR) at 3:00 p.m. but that the form was not signed by the resident. Staff #50 stated the resident was alert and oriented and should have been able to sign the form. In a later interview conducted with staff #50 (MONTH) 20, (YEAR) at 2:37 p.m., she stated that the NOMNC was issued verbally to the resident by another staff on (MONTH) 8, (YEAR) and that the resident was supposed to sign the form on the day of discharge. The policy Medicare Notice of Non-Coverage included that in completing the Notice of Medicare Non-Coverage form, the resident or the resident's representative must date and sign the form and a completed copy of the NOMNC must be given to the resident no later than two days before the termination of services.",2020-09-01
885,CORONADO HEALTHCARE CENTER,35132,11411 NORTH 19TH AVE,PHOENIX,AZ,85029,2017-12-21,607,D,0,1,9E4D11,"Based on facility documentation, staff interviews, and facility policy, the facility failed to implement their policy regarding two misappropriations of resident's property investigations for two residents (#151 and #462). Findings include: -Review of the facility's investigative report dated (MONTH) 15, (YEAR) revealed resident #151 reported (MONTH) 14, (YEAR) that she was missing $20. The report included the resident and the evening Certified Nursing Assistants (CNA) and regular nurses on the unit, were interviewed. The staff members interviewed were identified by three first names. -Review of the facility's investigative report dated (MONTH) 18, (YEAR) revealed on (MONTH) 13, (YEAR) resident #462 reported she was missing cigarettes. The report included the resident was interviewed and that a nurse and a CNA had no knowledge of missing cigarettes. However, there were no staff statements and no times identified for these staff interviews. There was no documentation that any residents were interviewed other than resident #151 and resident #462 or that staff on all shifts that may have information regarding the alleged incidents were interviewed. An interview was conducted (MONTH) 20, (YEAR) at 12:29 p.m. with corporate staff (#218 and #219). They stated that the paperwork received was the complete investigation conducted by the facility. An interview was conducted with the Executive Director (staff#220) (MONTH) 20, (YEAR) at 12:59 p.m. Staff #220 stated she interviewed the staff that normally works the unit that resident #151 resides on. She stated she spoke to the nurse in passing about resident #462 missing cigarettes. Staff #220 stated that she did not obtain written statements from the staff members that she interviewed. The policy Resident Rights/Abuse: Prevention of and Prohibition Against included the investigation into a reported event will include an interview with staff members (on all shifts) who may have information regarding the alleged incident, interviews with other residents who may have information regarding the alleged incident, and a review of all circumstances surrounding the incident. The policy also included the investigation and the results of the investigation will be documented.",2020-09-01
886,CORONADO HEALTHCARE CENTER,35132,11411 NORTH 19TH AVE,PHOENIX,AZ,85029,2017-12-21,610,D,0,1,9E4D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, facility documentation, and facility policy, the facility failed to thoroughly investigate two allegations of misappropriations of resident property for two residents (#151 and #462). Findings include: -Resident #151 was readmitted (MONTH) 16, (YEAR) with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment dated (MONTH) 6, (YEAR) revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. During an interview conducted (MONTH) 14, (YEAR) at 11:37 a.m. with resident #151, she stated two days ago she had $40 and now she has $20. Resident #151 stated she reported the missing money to a Certified Nursing Assistant (CNA) and the CNA told her that she did not know what to tell her because she was not working at that time. The resident further stated she reported the missing money to several other staff but that she is not able to identify the CNA or the other staff she spoke to. Resident #151 also stated she was unable to see and that she cannot prove anything but she that believes staff took her money. The executive director (ED/staff #220) was notified of the missing money (MONTH) 14, (YEAR) at 12:55 p.m. Staff #220 stated she did not know that resident #151 had reported missing money and that she would be reporting the incident and will start the investigation. -Resident #462 was admitted (MONTH) 8, (YEAR) with [DIAGNOSES REDACTED]. Review of the admission MDS assessment dated (MONTH) 15, (YEAR) revealed the resident had a BIMS score of 15 which indicated the resident was cognitively intact. An interview was conducted with resident #462 and her roommate resident #461 (MONTH) 15, (YEAR) at 10:45 a.m. Resident #461 stated that she believed the staff stole her roommate's almost new pack of cigarettes Wednesday night. She stated that the pack was in their room before they went out for the afternoon but when they returned to their room the pack was gone. Resident #462 stated she and resident #461 searched the room and could not find the cigarettes. She stated she asked the nurse if she had seen the cigarettes and the nurse stated she had not seen the cigarettes. The resident was unable to provide the name of the nurse that she spoke with. Resident #462 further stated she believed someone took her cigarettes. On (MONTH) 15, (YEAR) at 12:20 p.m., staff #220 and corporate support staff #219 were notified of resident #462 missing cigarettes. The facility's investigations of the allegations were received from corporate staff #216 (MONTH) 20, (YEAR) at 10:08 a.m. An interview was conducted (MONTH) 20, (YEAR) at 12:29 p.m. with corporate staff (#218 and #219). They stated the two reports that they provided was the facility complete investigations. Review of the facility's investigative reports revealed no evidence that any residents were interviewed other than the residents (#151 and #462) that made the allegations. The report for resident #151 refers to staff interviewed by ED. However, the staff members interviewed were not identified nor did the report include statements from the staff. Review of the report for resident #462 revealed no documentation that staff interviews were conducted. An interview was conducted (MONTH) 20, (YEAR) at 12:59 p.m. with staff #220. Regarding resident #151, staff #220 stated she interviewed the staff that normally works the unit that resident #151 resides on. She stated the staff members interviewed were asked if the resident ever mentioned that she was missing money. Staff #220 further stated the staff members stated that they had not received a report of missing money. She also stated that social services did not have a grievance form for the missing money. During the same interview, staff #220 stated she spoke to the nurse in passing about resident #462 missing cigarettes and that the nurse stated she had no knowledge of the missing cigarettes. Staff #220 stated that she did not obtain written statements from the staff members she interviewed but that she had written notes and would provide that information. She also stated that she did not notify law enforcement due to the low value of the missing items. Staff #220 further stated social services did not have a grievance form for the missing cigarettes. Also during this interview with staff #220, she stated when a resident reports missing items, interviews are conducted with the resident if the resident is able to be interviewed, the family if the resident is not able to be interviewed, and other residents residing on the same hall. Staff #220 stated social services would be notified, she would interview any staff that might have knowledge or may have been involved in the situation, and that she would obtain statements from identified staff. Staff #220 further stated the resident's inventory sheet would be reviewed to determine if the missing item was listed. On (MONTH) 20, (YEAR) following the interview, the facility provided additional investigation information. Review of the information for resident #151 revealed the evening Certified Nursing Assistants (CNA) and regular nurses on the unit were interviewed. The staff interviewed were identified by three first names. The form was dated (MONTH) 14, (YEAR) and signed by staff #220. Review of the information for resident #462 revealed one nurse identified by her first name had no knowledge of missing cigarettes. This form was dated (MONTH) 18, (YEAR) and signed by staff #220. The policy Resident Rights/Abuse: Prevention of and Prohibition Against included the investigation into a reported event will include an interview with staff members (on all shifts) who may have information regarding the alleged incident, interviews with other residents who may have information regarding the alleged incident, and a review of all circumstances surrounding the incident. The policy also included the investigation and the results of the investigation will be documented.",2020-09-01
887,CORONADO HEALTHCARE CENTER,35132,11411 NORTH 19TH AVE,PHOENIX,AZ,85029,2017-12-21,641,E,0,1,9E4D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure the quarterly Minimum Data Set (MDS) assessments accurately reflected one resident's (#43) oral status. Findings include: Resident #43 was admitted (MONTH) 30, (YEAR), with [DIAGNOSES REDACTED]. A review of a Social Service note dated (MONTH) 17, (YEAR), revealed the resident was seen by a dentist on (MONTH) 7, (YEAR) and that the dentist had stated the resident's dentures were over [AGE] years old and partially broken. Review of a nurse's note dated (MONTH) 24, (YEAR), revealed the resident had her own teeth. A review of a nurse's note dated (MONTH) 25, (YEAR), revealed the resident had her own teeth but that some of the teeth were missing. Review of the quarterly MDS assessments dated (MONTH) 27, (YEAR), (MONTH) 22, (YEAR), and (MONTH) 12, (YEAR), revealed the resident was not assessed to have Broken or loosely fitting full or partial dentures (chipped, cracked, uncleanable or loose). Continued review of the MDS assessments revealed the resident's Brief Interview for Mental Status score was 14 or 15, which indicated the resident was cognitively intact. A review of the nurses' note dated (MONTH) 16, (YEAR) and (MONTH) 12, (YEAR), revealed the resident had her own teeth and that her teeth were in good condition. During an observation conducted (MONTH) 20, (YEAR) at 9:16 a.m. with two MDS staff (staff #137 and staff #181), the resident was observed wearing an upper denture and had only one lower tooth located in the front on the right side. Also during the observation, the resident's upper denture was not removed to be assessed by the MDS staff. An interview was conducted (MONTH) 20, (YEAR) at 1:25 p.m. with staff #137. Staff #137 stated the quarterly MDS assessments regarding the resident's oral/dental status were not accurately assessed and that she could not remember if she had looked at the resident's dentures when she assessed the resident's oral/dental status. The policy Accuracy of Assessment (MDS 3.0) included each resident is to receive an assessment that accurately reflects the resident's status.",2020-09-01
888,CORONADO HEALTHCARE CENTER,35132,11411 NORTH 19TH AVE,PHOENIX,AZ,85029,2017-12-21,655,D,0,1,9E4D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy, the facility failed to develop a baseline care plan to address one resident (#114) oxygen needs. Findings include: Resident #114 was admitted (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. Review of multiple nursing notes dated (MONTH) 20 and 22, (YEAR) revealed the resident utilized oxygen via a nasal cannula at two liters per minute. Review of the baseline care plan revealed no evidence that a baseline care plan had been developed within 48 hours to address the resident's respiratory need for the use of oxygen. An interview was conducted with two corporate nurses (staff #218 and staff # 219) (MONTH) 19, (YEAR) at 1:16 p.m. After reviewing the clinical record, they stated they could not find any oxygen care plan in the chart. An interview was conducted with the Director of Nursing (staff #185) on (MONTH) 19, (YEAR) at 3:05 p.m. Staff #185 stated when a resident is admitted , the floor nurses perform the initial resident assessment and initiate the baseline care plan. She further stated that the next day, the care plan is further developed by the MDS coordinator based on the floor nurses assessments, the resident's history/physical, and physician orders. An interview was conducted (MONTH) 20, (YEAR) at 12:08 p.m. with MDS coordinators (staff #137 and staff #181). They stated when a resident is admitted , a baseline care plan is initiated within 48 hours of the admission. The policy Care Planning included a resident's care plan will be initiated within 24 hours of admission.",2020-09-01
889,CORONADO HEALTHCARE CENTER,35132,11411 NORTH 19TH AVE,PHOENIX,AZ,85029,2017-12-21,656,E,0,1,9E4D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, staff interviews, and policy, the facility failed to ensure that a care plan for activities was implemented for one resident (#137) and failed to ensure that a care plan was developed for the use of oxygen for one resident (#114). Findings include: Resident #137 was admitted (MONTH) 25, (YEAR), with [DIAGNOSES REDACTED]. A care plan for activities initiated (MONTH) 30, (YEAR), included that resident #137 enjoyed engaging in independent activities, including listening to country music and relaxing at her leisure, that she had little or no activity involvement, was non-verbal, and was partly catatonic. Interventions included staff were to invite the resident to scheduled activities, that the resident needed assistance/escort to activities, and that an activities calendar was to be provided monthly. Review of Certified Nursing Assistant (CNA) documentation for (MONTH) 25 through (MONTH) 30, (YEAR) revealed a flow record for documenting activity participation that included activities such as religious, social, independent, creative and entertainment activities, and also one on one activities. Review of the record revealed blank spaces for all activities in (MONTH) (YEAR), and did not reveal any documentation that the resident had been invited to activities, assisted to activities, or that she had refused to participate in activities. A Minimum Data Set (MDS) assessment dated (MONTH) 2, (YEAR), included that the resident had adequate hearing and vision, problems with memory, and her level of cognition was unable to be assessed. The assessment also included that activities including listening to music and going outside when the weather was good were somewhat important to the resident. Continued review of CNA documentation for (MONTH) 1 through (MONTH) 19, (YEAR), revealed blank spaces for activity participation for all activities in (MONTH) (YEAR), and did not reveal any documentation that the resident had been invited to activities, assisted to activities, or that she had refused to participate in activities. Observations conducted (MONTH) 15, (YEAR) from 9:30 a.m. through 10:30 a.m., resident #137 was observed lying on her bed (in the locked behavioral unit), facing a blank wall, and awake staring at the wall. A television located in the room was observed off. The resident's room was located next to a common room where a ball toss activity was in progress. There were no observations that resident #137 was invited to attend the ball toss activity or provided assistance to attend the activity. During observations conducted (MONTH) 19, (YEAR) from 9:30 a.m. through 11:30 a.m., the resident was observed lying on her bed, facing a blank wall, and awake staring at the wall. The television in the room was observed off. There was a group activity in progress in the common room. However, there were no observations that the resident had been invited to attend the activity or provided assistance to attend the activity. Observations conducted throughout the survey revealed no activity calendar posted in the resident rooms, the resident corridor, or anywhere in the locked unit. An interview was conducted with a CNA (staff #113) (MONTH) 19, (YEAR), at 10:07 a.m. Staff #113 stated that CNAs assigned to the unit were responsible for providing activities to the residents on the locked unit and that there was no activity calendar for the locked unit. An interview was conducted with a CNA (staff #158) (MONTH) 19, (YEAR) at 10:25 a.m. who also stated there was no activity calendar for the locked unit. During an interview conducted with a licensed practical nurse (staff #106) (MONTH) 19, (YEAR) at 10:35 a.m., staff #106 stated there were no scheduled organized activities on the locked unit, there was no activity calendar, and the CNAs were responsible for providing the residents activities. Staff #106 stated that records were not maintained regarding residents participation in activities, and since records were not maintained, there were no records regarding whether any resident had been offered activities and had refused. An interview was conducted with the Activity Director (staff #188) (MONTH) 19, (YEAR) at 10:58 a.m. Staff #188 stated there was no activity calendar for the locked unit and that the CNAs and nurses on the unit were responsible for providing activities to the residents. -Resident #114 was admitted (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment dated (MONTH) 25, (YEAR), revealed the resident was not coded for oxygen. Review of multiple nursing notes dated (MONTH) 20, 22, and 27, (YEAR) revealed the resident utilized oxygen via a nasal cannula at two liters per minute. However, review of the care plan revealed no care plan for oxygen. An observation was conducted (MONTH) 14, (YEAR) at 11:14 a.m. Resident #114 was observed lying in bed with her head facing the door wearing an oxygen nasal cannula connected to an oxygen concentrator. During an observation conducted (MONTH) 19, (YEAR) at 10:09 a.m., resident #114 was observed lying in bed wearing an oxygen nasal cannula connected to an oxygen concentrator. An interview was conducted with two corporate nurses (staff #218 and staff # 219) (MONTH) 19, (YEAR) at 1:16 p.m. After reviewing the clinical record, they stated they could not find any oxygen care plan in the clinical record. An interview was conducted (MONTH) 20, (YEAR) at 12:08 p.m. with MDS coordinators (staff #137 and staff #181). They stated the care plans are developed with the input of the floor nurse and other facility staff members. The policy Care Planning included the care plan is developed by the interdisciplinary team which includes the activity staff member responsible for the resident and that the care plan is be implemented by the members of the health care continuum accordingly. The policy also included a comprehensive care plan is developed within seven days of completion of the resident MDS assessment and reviewed and revised on an ongoing basis.",2020-09-01
890,CORONADO HEALTHCARE CENTER,35132,11411 NORTH 19TH AVE,PHOENIX,AZ,85029,2017-12-21,679,D,0,1,9E4D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, staff interviews, and facility policy, the facility failed to ensure that an ongoing program of activities were provided that met the interests and supported the well-being of one resident (#137). Findings include: Resident #137 was admitted (MONTH) 25, (YEAR), with [DIAGNOSES REDACTED]. An activity assessment dated (MONTH) 30, (YEAR), included that the resident was not oriented, had poor communication and cognition, sometimes understood others, and had adequate vision and hearing. The assessment was marked not interested for all of the activities listed and did not include any activity interests for resident #137. Also included in the assessment was that the resident had some confusion and was unable to verbalize her needs. A care plan for activities initiated (MONTH) 30, (YEAR), included that resident #137 enjoyed engaging in independent activities, including listening to country music and relaxing at her leisure, that she had little or no activity involvement, was non-verbal, and was partly catatonic. Interventions included staff were to invite the resident to scheduled activities, that the resident needed assistance/escort to activities, and that an activities calendar was to be provided monthly. Review of Certified Nursing Assistant (CNA) documentation for (MONTH) 25 through (MONTH) 30, (YEAR) revealed a flow record for documenting activity participation that included activities such as religious, social, independent, creative and entertainment activities, and also one on one activities. Review of the record revealed blank spaces for all activities in (MONTH) (YEAR). Review of the CNAs documentation for (MONTH) 1 through (MONTH) 19, (YEAR), revealed blank spaces for activity participation for all activities in (MONTH) (YEAR). A Minimum Data Set assessment dated (MONTH) 2, (YEAR), included that the resident had adequate hearing and vision, problems with memory, and her level of cognition was unable to be assessed. The assessment also included that activities including listening to music and going outside when the weather was good were somewhat important to the resident. Observations conducted (MONTH) 15, (YEAR) from 9:30 a.m. through 10:30 a.m., resident #137 was observed lying on her bed (in the locked behavioral unit), facing a blank wall, and awake staring at the wall. A television located in the room was observed off. The resident's room was located next to a common room where a ball toss activity was in progress. There were no observations that resident #137 was invited to attend the ball toss activity or provided assistance to attend the activity. During observations conducted (MONTH) 19, (YEAR) from 9:30 a.m. through 11:30 a.m., the resident was observed lying on her bed, facing a blank wall, and awake staring at the wall. The television in the room was observed off. There was a group activity in progress in the common room. However, there were no observations that the resident had been invited to attend the activity or provided assistance to attend the activity. An interview was conducted with a CNA (staff #113) (MONTH) 19, (YEAR) at 10:07 a.m. Staff #113 stated that the CNAs assigned to the unit were responsible for providing activities to the residents, that the CNAs change up the activities each day, and that the CNAs decide when and which activities to conduct with the residents. Staff #113 further stated that ball toss is conducted with resident #137 sometimes. An interview was conducted with a CNA (staff #158) (MONTH) 19, (YEAR) at 10:25 a.m. Staff #158 stated that the CNAs on the unit were responsible for providing activities to the residents on the unit, and that sometimes they were unable to provide an activity, or had to stop an activity in progress to provide care such as toileting to residents. Staff #158 stated the CNAs had not been provided education regarding how to provide activities or which activities would meet the needs of the residents. She further stated she was unaware of the residents' activity preferences and unaware that there was a flow record to document activity participation. During an interview conducted (MONTH) 19, (YEAR) at 10:35 a.m. with a Licensed Practical Nurse (staff #106), staff #106 stated there were no scheduled organized activities on the unit because the CNAs were responsible for providing the activities, that activities were provided when staff were available, and not according to a schedule. Staff #106 further stated residents' activity participation was not documented and that resident #137 had participated in a ball toss activity the previous week. An interview was conducted with the Activity Director (staff #188) (MONTH) 19, (YEAR) at 10:58 a.m. Staff #188 stated there was no activity calendar for the unit but that a list of suggested activities was provided to the staff on the unit to provide to residents when they could. She also stated she did not know which activities were being provided on the residents. During an interview conducted (MONTH) 19, (YEAR) at 11:10 a.m. with the Administrator (staff #220), staff #220 stated the staff on the unit did not know that they were to document the residents participation in activities, therefore there are no records of the residents activity participation including resident #137. Staff #220 further stated the residents on the unit had dementia and that residents with dementia do not benefit from a scheduled activity program. The policy Delivery of Activity Services included that activities could be adapted to accommodate the resident's cognitive limitations, including cognitive impairment. The policy further included a list of activities such as task segmentation, settings that recreate past experiences, smaller groups, and one-to-one activities for residents with cognitive impairment.",2020-09-01
891,CORONADO HEALTHCARE CENTER,35132,11411 NORTH 19TH AVE,PHOENIX,AZ,85029,2017-12-21,684,D,0,1,9E4D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure one resident (#508) received treatment and care in accordance with professional standards of practice by failing to monitor and provide neurological assessments for 72 hours after resident #508 sustained an unwitnessed fall. Findings include: Resident #508 was admitted (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. Review of a fall risk assessment evaluation dated (MONTH) 9, (YEAR), revealed the resident was a high risk for falls. Review of a nurse progress note dated (MONTH) 15, (YEAR) at 6:49 p.m., revealed the resident was one day status [REDACTED]. Review of an incident report dated (MONTH) 19, (YEAR) revealed the resident had an unwitnessed fall on (MONTH) 15, (YEAR) at 5:58 a.m. The report included that the resident was confused, disoriented, had impaired memory, and had a recent change in condition. Also included in the report was that the resident was assessed to have no new bruises, no skin tears, able to move upper extremities, and follow simple commands. The report included the resident denied any pain or discomfort and that vital signs and a neurological assessment was conducted. Additional review of the clinical record revealed no further documentation of the resident's fall, no documentation that the resident's neurological status had been evaluated for 72 hours after the (MONTH) 15, (YEAR) fall, and no documentation that follow-up assessments had been conducted for 72 hours after the fall. An interview was conducted (MONTH) 20, (YEAR) at 10:04 a.m. with a Licensed Practical Nurse (staff #125). Staff #125 stated for unwitnessed falls, neurological checks are to be conducted every 15 minutes for the first hour after the fall, then every hour for a while, then every four hours. Staff #125 stated that the fall is documented in the nursing progress note and an incident report is completed on the date of the incident. An interview was conducted with the Director of Nursing (staff #185), on (MONTH) 20, (YEAR) at 10:38 a.m. Staff #185 stated that licenses nurses are to complete a neurological check form when a resident has an unwitnessed fall. She also confirmed the fall occurred on (MONTH) 15, (YEAR) at 5:58 a.m. Another interview was conducted (MONTH) 20, (YEAR) at 1:56 p.m. with staff #185. She stated the expectation is that the nurses document the resident's condition every shift for 72 hours and complete neurological assessments after a resident has had an unwitnessed fall. Staff #185 confirmed that there was no documentation in the clinical record that the resident's condition had been assessed for the 72 hours after the fall. On (MONTH) 21, (YEAR), the facility provided a completed neurological assessment form dated (MONTH) 14, (YEAR), the form included neurological checks starting at 8:35 p.m. and ending at 3:00 a.m. However, the resident fell on (MONTH) 15, (YEAR) at 5:58 a.m., which was one day after the neurological checks had been conducted. The policy Fall Management System included a physical assessment will be completed and documented in the nursing progress notes by a licensed nurse when a resident sustains a fall. The policy further included follow-up assessments and documentation will be conducted for a minimum of 72 hours following the incident. The policy Neurological Evaluation included that any resident having an injury involving the head or an unobserved fall will have neurological checks completed and vital signs taken at least every eight hours for 24 hours per specific facility, policy, or physician order. The policy also included all incidents having trauma to the head will result in a comprehensive neurological assessment for a minimum of 72 hours. The policy further included comprehensive neurological assessment will be completed every 15 minutes times (x) 4 for one hour, every 30 minutes x 4 for two hours, every hour x 4 for four hours, and every shift x 72 hours.",2020-09-01
892,CORONADO HEALTHCARE CENTER,35132,11411 NORTH 19TH AVE,PHOENIX,AZ,85029,2017-12-21,686,D,0,1,9E4D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, staff interviews, and the National Pressure Ulcer Advisory Panel's (NPUAP) Pressure Injury Stages guidelines, the facility failed to ensure a pressure ulcer/injury was accurately assessed and staged for one resident (#52). Findings include: Resident #52 was readmitted (MONTH) 20, (YEAR), with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the care plan initiated (MONTH) 21, (YEAR) revealed the resident had shearing to the left buttock with interventions that included a pressure reducing cushion for the wheelchair and a low air loss mattress. A review of the Significant Change Minimum Data Set assessment dated (MONTH) 27, (YEAR) revealed the resident was rarely/never understood, required extensive assistance of one to two staff for activities of daily living and mobility, and had loss of movement to one side of her body and was coded as receiving hospice services. The assessment also included the resident was at risk for skin breakdown, but did not have a pressure ulcer at the time of the assessment and included a pressure relief device was present on the bed. Review of the weekly non-pressure skin ulcer assessment dated (MONTH) 13, (YEAR) revealed the resident had a non-pressure shearing wound to the left buttock with 100% slough to the wound bed. The onset date was (MONTH) 13, (YEAR). The wound measured 0.5 centimeters (cm) x 0.5 cm. The depth was unable to be measured due to 100% slough. The wound was described as a full thickness wound, scant serous exudate, unattached wound edges, with no odor. Further review of the assessment revealed the wound was being treated with [MEDICATION NAME] and a [MEDICATION NAME] dressing. Review of the physician's orders [REDACTED]. A review of the wound team administration record for (MONTH) (YEAR) revealed the treatments were provided as ordered. Continued review of the non-pressure skin ulcer assessments revealed an assessment dated (MONTH) 18, (YEAR), which included the shearing wound to the left buttock measured 0.4 cm x 0.5 cm, with the depth unable to be measured due to 100% slough. The wound was described as a full thickness wound, scant serous exudate, unattached wound edges, and no odor and continued to be treated with [MEDICATION NAME] and a [MEDICATION NAME] dressing. An interview was conducted (MONTH) 18, (YEAR) at 11:55 a.m. with the wound nurse (Registered Nurse/staff #105). Staff #105 stated the wound nurses and the wound physician assess and stage pressure ulcers and that the wound nurses provide most of the wound treatments in the facility. She also stated the physician would be notified of any wound complications. Review of the most recent Braden scale assessment dated (MONTH) 19, (YEAR) revealed a score of 13, which indicated the resident was at moderate risk for skin breakdown. During a wound observation conducted (MONTH) 19, (YEAR) at 11:23 a.m. with staff #105, the wound was observed to be located to the right of the coccyx in the upper buttock area instead of the left buttock as previously documented. No additional wounds were observed to the resident's back, coccyx, or the left buttock. The wound measured 1 cm x 1.4 cm with slough observed in the most of the wound bed and the edges of the wound bed were deep red. The peri wound was observed to have a bruised appearance. The mattress was observed to not be a low air loss mattress as care planned. A review of a copy of the care plan (initiated (MONTH) 21, (YEAR)) provided by the facility revealed shearing to the left buttock had been removed and replaced with pressure injury to right buttock. An interview was conducted (MONTH) 19, (YEAR) at 11:25 a.m. with staff #105. She stated the wound was initially classified as a shearing wound but that based on the appearance of the wound during the wound treatment, she will be reclassifying the wound as an unstageable pressure ulcer. Staff #105 stated the floor nurses told her that the resident's wound was from moving up and down in the bed. She also stated she will obtain a pressure relieving cushion for the wheelchair. Another interview was conducted (MONTH) 19, (YEAR) at 12:24 p.m. with staff #105. She stated all the facility mattresses have a pressure relieving layer and that if a resident is a high risk, staff would obtain a pressure relieving mattress and chair cushion. Review of the weekly pressure ulcer assessment dated (MONTH) 19, (YEAR) revealed the resident had an unstageable pressure ulcer to the right buttock with an onset date of (MONTH) 31, (YEAR). The wound was described as an open wound to the right buttock with 90% slough to the wound bed and 10% beefy red. The pressure ulcer measured 1 cm x 1.4 cm with scant amount of serous exudate, wound edges were unattached, there was no odor, and the surrounding tissue was normal and the wound continued to be treated with [MEDICATION NAME] and a [MEDICATION NAME] dressing. The documentation also included the shearing wound was changed to a pressure injury. Additional review of the physician orders [REDACTED]. On (MONTH) 20, (YEAR) at 10:08 a.m., an interview was conducted with a corporate support staff (staff #216) who stated the facility utilizes the NPUAP criteria for wound identification and that there was no policy for wound assessments. During another interview conducted (MONTH) 20, (YEAR) at 10:38 a.m. with staff #105, she stated she utilizes the NPUAP criteria to identify and stage wound. Staff #105 further stated the wound was initially from shearing and that when she initially assessed the wound, it appeared to be a wet scab/sloughy. An interview was conducted (MONTH) 20, (YEAR) at 11:00 a.m. with the Director of Nursing (staff #185). She stated that her expectation of the wound nurses is that they will use their knowledge base and experience to follow appropriate definitions for wound identification and documentation and obtain help if needed. Staff #185 stated that her expectation is that the wound documentation accurately portrays the wound identification. She also stated that the wound physician usually makes wound rounds on Tuesdays, but that he did not make wound rounds this week. Review of the NPUAP criteria revealed a pressure injury is localized damage to the skin and underlying soft tissue that results from intense and/or prolonged pressure or pressure in combination with shear. The criteria further included an unstageable pressure injury is defined as full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar.",2020-09-01
893,CORONADO HEALTHCARE CENTER,35132,11411 NORTH 19TH AVE,PHOENIX,AZ,85029,2017-12-21,693,E,0,1,9E4D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policies, the facility failed to ensure physician's tube feeding orders were followed for one resident (#23). Findings include: Resident #23 was admitted (MONTH) 30, (YEAR), with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment dated (MONTH) 30, (YEAR), revealed the resident was rarely or never understood and received nutrition via a feeding tube. A physician's orders [REDACTED]. Review of the care plan dated (MONTH) 13, (YEAR), revealed the resident required a tube feeding related to dysphagia and the interventions included checking the feeding tube for placement and residual volume per facility protocol and record. Review of the resident's MAR (Medication Administration Record) for (MONTH) (YEAR), revealed six occurrences where the documented amount of the feeding tube residual was 100. Review of the resident's MAR for (MONTH) (YEAR), revealed 13 occurrences where the documented amount of residual was 100. However, review of the clinical record revealed no evidence the tube feeding was held or the physician was notified on these occasions. During an interview conducted (MONTH) 19, (YEAR) at 11:10 a.m. with the Licensed Practical Nurse (LPN/staff #154) providing care for resident #23, she stated the tube feeding is checked for residual before the feeding is turned on and the residual amount is documented on the MAR. Staff #23 further stated if the residual is more than 60 ml, the tube feeding is held and the physician notified. She stated this would be documented in the clinical record. An interview was conducted (MONTH) 20, (YEAR) at 10:20 a.m. with the LPN (staff #153) providing care for this resident. Staff #153 stated before turning on the tube feeding, she checks for residual and documents the amount on the MAR. She also stated if the residual amount is over 60 ml, she would hold the tube feeding and notify the physician. During an interview conducted (MONTH) 20, (YEAR) at 2:25 p.m. with the Director of Nursing (staff #185), she stated the physician's tube feeding order should be followed. The policy Enteral Nutrition included, All procedures related to enteral nutrition will be documented in the resident's medical record. The policy Physician order [REDACTED]. of care.",2020-09-01
894,CORONADO HEALTHCARE CENTER,35132,11411 NORTH 19TH AVE,PHOENIX,AZ,85029,2017-12-21,695,E,0,1,9E4D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff and resident interviews, and facility policy, the facility failed to ensure there was a physician's order for the use of [REDACTED]. Findings include: Resident #114 was readmitted (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. Review of multiple nursing notes dated (MONTH) 20, 22, and 27, (YEAR) revealed the resident was using oxygen via a nasal cannula at two liters per minute. However, further review of the clinical record revealed no physician's order for the oxygen. An interview was conducted (MONTH) 19, (YEAR) at 12:51 p.m. with the Assistant Director of Nursing (staff #67). Staff #67 stated there should be an order for [REDACTED]. During an interview conducted (MONTH) 19, (YEAR) at 1:07 p.m. with a Licensed Practical Nurse (staff #210), staff #210 stated resident #114 has been using oxygen at two liters per minute since she was admitted . She stated the nursing staff can change the liter flow with a doctor's order. At this time an observation was conducted with staff #210. The resident was observed to have oxygen on per nasal cannula at three and a half liters per minute. An interview was conducted (MONTH) 19, (YEAR) at 1:16 p.m. with two corporate nurses (staff #218 and staff #219). After reviewing the clinical record, staff #218 stated she was unable to find a physician's order for the oxygen. During an interview conducted (MONTH) 19, (YEAR) at 1:39 p.m. with resident #114, she stated she had been using oxygen since the last time she was in the hospital. The policy Physician Orders included to accurately implement orders in addition to medication orders (treatment, procedures) only upon the written order of a person duly licensed and authorized to do so in accordance with the resident's plan of care.",2020-09-01
895,CORONADO HEALTHCARE CENTER,35132,11411 NORTH 19TH AVE,PHOENIX,AZ,85029,2017-12-21,838,D,0,1,9E4D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, facility assessment, and policy, the facility failed to ensure that required services determined in the facility assessment were implemented for one resident (#137). Findings include: Resident #137 was admitted on (MONTH) 25, (YEAR), with [DIAGNOSES REDACTED]. Observations were conducted of resident #137 on (MONTH) 15 and 19, (YEAR). During these observations, the resident was observed awake, lying in the bed staring at a blank wall. The television was observed off. The resident's room was located next to a common room where a ball toss activity was in progress on the 15th and a group activity was in progress on the 19th. However, the resident was not encouraged to attend or participate in the activities. Review of Certified Nursing Assistant (CNA) documentation for (MONTH) 25 - 30, (YEAR) and (MONTH) 1 - 19, (YEAR) revealed a flow record for documenting activity participation that included activities such as religious, social, independent, creative and entertainment activities, and also one on one activity. Review of the CNA documentation for (MONTH) 25 - 30, (YEAR) and (MONTH) 1 - 19, (YEAR), revealed blank spaces for the resident activity participation for all activities. An interview was conducted (MONTH) 19, (YEAR) at 10:25 a.m. with a CNA (staff #158). Staff #158 stated that the CNAs on the unit were responsible for providing activities to the residents and that sometimes they are unable to provide an activity or they have to stop an activity to provide care to the residents such as toileting, etc. She further stated that the CNAs had not been provided education regarding how to provide activities that meet the needs of the residents on the unit. Staff #158 also stated she did not know to document the residents' activity participation on a flow record and that she did not know the residents personal activity preferences. During an interview conducted (MONTH) 19, (YEAR) at 10:35 a.m. with a Licensed Practical nurse (staff #106), staff #106 stated there were no scheduled organized activities on the unit because the CNAs were responsible for providing the activities and that activities were provided when staff were available not according to a schedule. An interview was conducted (MONTH) 19, (YEAR) at 10:58 a.m. with the Activity Director (staff #188). Staff #188 stated a list of suggested activities was provided to the staff on the unit for the staff to provide to the residents when they were able to. She further stated she did not know if the suggested activities were being provided or what activities were being provided to the residents. During an interview conducted (MONTH) 19, (YEAR), at 11:10 a.m. with the Administrator (staff #220), staff #220 stated the staff on the unit did not know that they were to document the residents participation in activities, therefore there are no records of the residents activity participation including resident #137. Staff #220 also stated that there was no activity calendar on the unit because the residents on the unit have dementia and residents with dementia do not benefit from a scheduled activity program. Review of the facility assessment revealed the facility may accept residents with physical and cognitive disabilities including [MEDICAL CONDITION], impaired cognition, mental disorder, and depression. The facility assessment further included services and care that they offer based on the residents need include providing opportunities for social activities/life enrichment on an individual basis, small group, or community. The policy Facility Assessment included .The intent of the facility assessment is for the facility to evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services the residents require .",2020-09-01
896,CORONADO HEALTHCARE CENTER,35132,11411 NORTH 19TH AVE,PHOENIX,AZ,85029,2017-12-21,880,D,0,1,9E4D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and facility policies, the facility failed to ensure that unlabeled urinals were not stored in the common bathrooms of two resident rooms (#114 and #200). Findings include: -An observation was conducted (MONTH) 14, (YEAR) at 2:11 p.m. of the bathroom in room [ROOM NUMBER]. Two unbagged and unlabeled urinals were observed hanging on the grab bar near the toilet. During an observation conducted (MONTH) 18, (YEAR) at 8:20 a.m. of the bathroom in room [ROOM NUMBER], one unlabeled urinal was observed hanging on the sprayer and one unlabeled urinal was observed on the grab bar next to the wall. Interviews were conducted with one of the residents following each observation. The resident stated he does not know which urinal to use, that he just uses one of the urinals. An interview was conducted (MONTH) 18, (YEAR) at 11:45 a.m. with a Licensed Practical Nurse (staff #210). Staff #210 stated the urinal that the residents use is kept near their bed and should be labeled with the resident's name. She further stated if the urinals are not labeled, they should be discarded in the trash. During an interview conducted (MONTH) 18, (YEAR) at 12:04 p.m. with a Certified Nursing Assistant (CNA/staff #88), staff #88 stated she the urinals are supposed to be labeled with the resident's name and bed number. -An observation was conducted (MONTH) 15, (YEAR) at 8:39 a.m. of the bathroom in room [ROOM NUMBER]. An urinal was observed unlabeled and unbagged hanging on the grab bar. Two residents resided in the room. An observation was conducted (MONTH) 15, (YEAR) at 2:30 p.m. of the bathroom in room [ROOM NUMBER]. An unlabeled and unbagged urinal was observed hanging on the sprayer above the toilet. Interviews were conducted (MONTH) 18, (YEAR) at 9:45 a.m. with CNAs (staff #103, staff #133, and staff #26). Staff #103 stated residents' urinals are labeled with the bed number. Staff #133 stated urinals are labeled with the name of the resident and the bed number. She further stated when the urinals not being used, they are placed in a bag. Staff #26 stated the urinals are placed by the resident's bedside for accessibility. During an interview conducted (MONTH) 18, (YEAR) at 12:12 p.m. with the Director of Nursing (staff #185), staff #185 stated resident urinals are never to be stored in the resident's bathroom. An interview was conducted (MONTH) 18, (YEAR) at 12:40 p.m. with staff #185. She stated they do not have a facility policy for storing or labeling resident urinals. Staff #185 further stated the urinals are supposed to be at the resident's bedside. The policy Urinal, Placement and Removal of included that the resident's urinal is to be returned to the resident's room/bedside after each use. The policy Infection Control Program included the goal is to decrease the risk of infection to the residents and to identify and correct problems related to infection control practices.",2020-09-01
897,LIFE CARE CENTER OF YUMA,35133,2450 SOUTH 19TH AVENUE,YUMA,AZ,85364,2019-04-11,578,E,0,1,V39011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, interviews and policy review, the facility failed to ensure advanced directive information for 3 of 3 sampled residents (#10, #83 and #105) were accurate. The deficient practice could result in advance directive wishes not being followed, resulting in potential harm. Findings include: -Resident #10 was readmitted to the facility on (MONTH) 2, 2019, with [DIAGNOSES REDACTED]. A Prehospital Medical Care Directive (Do Not Resuscitate) Form dated (MONTH) 15, (YEAR) was located in the resident's clinical record. The Medical Care Directive form was signed by the resident's Power of Attorney (POA). Review of advanced directive statements dated (MONTH) 15, (YEAR) and (MONTH) 6, (YEAR) included revealed In the event I experience [MEDICAL CONDITION] I do not want cardiopulmonary resuscitation measures to be under taken on my behalf. The forms were signed by the resident's POA and a witness. A care plan updated on (MONTH) 19, 2019 included the resident was do not resuscitate (DNR) status. The goal included that advanced directives, care plan directives and physician's orders [REDACTED]. Approaches included the following: reassesses/review advanced directives as needed for any changes or wishes; refer resident to social services as needed; discuss advanced directives on admission and as needed; and to educate resident and/or responsible party regarding DNR verses full code risks and benefits. Despite the above documentation, a physician's orders [REDACTED]. The orders had an original order date of (MONTH) 2, 2019. Review of the (MONTH) and (MONTH) 2019 Medication Administration Record [REDACTED] A quarterly social services note dated (MONTH) 10, 2019 included a quarterly care plan meeting was held on (MONTH) 9, 2019. The documentation included the resident's advanced directive was reviewed and there were no changes at this time, and that the resident will continue under DNR. In an interview with a social service assistant (staff #170) on (MONTH) 11, 2019 at 10:02 a.m., she stated that social services will have a meeting with residents who are readmitted from the hospital and review the care plan with them to make sure nothing has changed, and that advanced directives are also discussed. She stated if the resident changes their advanced directive status, then social services will let the nurse know. She also stated advanced directives are reviewed at each care plan meeting. -Resident #83 was admitted to the facility on (MONTH) 29, 2019, with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. An advanced directive care plan dated (MONTH) 29, 2019 included the resident was a full code, per the advanced directive. The goal was that the advanced directives, care plan directives and physician orders [REDACTED]. Approaches included reassesses/review advanced directives as needed for any changes; refer resident to social services as needed; discuss advanced directives on admission and as needed; and to educate resident and/or responsible party regarding DNR verses full code risks and benefits. Review of physician orders [REDACTED]. However, a history and physical dated (MONTH) 4, 2019 included the resident's code status was DNR/DNH (Do not hospitalize). A physician's orders [REDACTED]. Nursing notes indicated the resident was sent to the hospital and returned on (MONTH) 7, 2019. Review of a social services admission note dated (MONTH) 26, 2019 included the resident was full code status. A physician's orders [REDACTED]. A physician's progress note dated (MONTH) 8, 2019 included the resident was a DNR/DNH. Review of the physician's orders [REDACTED]. Despite conflicting documentation regarding the resident's code status, there was no evidence that an Advanced Directive Statement form had been completed by the resident or the resident's representative, indicating their code status choices. During an interview with a registered nurse (RN/staff #179) on (MONTH) 11, 2019 at 12:29 p.m., he reviewed resident #83's chart and stated that normally there is a paper in the chart with the resident's code status. He was unable to locate this in the resident's chart. In an interview with the Director of Nursing (DON/staff #83) on (MONTH) 11, 2019 at 1:23 p.m., she stated that advanced directives are reviewed by the nurses every time a resident comes back from the hospital. She stated resident #83 had just recently been in the hospital and the physician was in to see her on (MONTH) 9. She stated when the physician comes to visit, he asks for a copy of the resident's advanced directive information. She stated she believes that paper was misplaced after making a copy for the physician. Another interview with staff #83 was conducted on (MONTH) 11, 2019 at 3:55 p.m. She stated the advanced directive information for resident #83 had not been located. -Resident #105 was admitted to the facility on (MONTH) 19, 1996 and was readmitted (MONTH) 29, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed documentation that on (MONTH) 30, 2012, the county court appointed the resident a public fiduciary. Review of the advance directive statement dated (MONTH) 9, (YEAR) revealed the resident's guardian had initialed next to the these statements: I do not want cardiopulmonary resuscitation; I do not want defibrillation performed; and next to I do not want life support. The advance directive statement was signed by the guardian and a witness. Review of a State of Arizona Do Not Resuscitate (DNR) form indicated that in the event of cardiac or respiratory arrest, the guardian refuses resuscitation measures, including cardiac compression, endotracheal intubation and other advanced airway management, artificial ventilation, defibrillation, administration of advance cardiac life support drugs and related emergency medical procedures. This form was signed by the guardian on (MONTH) 13, (YEAR). Review of the physician orders [REDACTED]. Despite advance directive documentation that the resident was a DNR status, there was still an active order for a full code status. An interview was conducted on (MONTH) 10, 2019 at 2:19 p.m. with a licensed practical nurse (LPN/staff #69). At this time, staff #60 reviewed the clinical record and stated that if the advance directives are updated by a guardian, then provider is notified and an order matching the advance directive is obtained. Staff #69 stated the most recent advance directive for the resident reflects a DNR status, however, the physician orders [REDACTED]. In a later interview at 2:51 p.m. staff #69 stated the provider was notified and a new order reflecting the DNR was obtained. An interview was conducted on (MONTH) 11, 2019 at 9:15 a.m. with the Director of Nursing (DON/staff #83). At this time, staff #83 reviewed the clinical record and stated the public fiduciary had completed the advance directive for the DNR in (YEAR) and an order was obtained, however, there was an error with the order being transcribed and the current order reflects a full code. Review of the facility's policy titled, Advance Directives revised in (MONTH) (YEAR), revealed a physician's orders [REDACTED]. The policy included that the DNR order should be flagged appropriately on the resident's chart to alert staff as to the resident's advance directive status.",2020-09-01
898,LIFE CARE CENTER OF YUMA,35133,2450 SOUTH 19TH AVENUE,YUMA,AZ,85364,2019-04-11,636,D,0,1,V39011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure a death in facility tracking Minimum Data Set (MDS) record was completed for one resident (#1). The deficient practice results in a lack of gathering important quality data and quality monitoring. Findings include: Resident #1 was admitted to the facility on (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. A nursing note dated (MONTH) 27, (YEAR) included the resident expired in the facility at 5:20 a.m. Two licensed practical nurses (LPN) verified absence of vital signs. The family and physician were notified and post mortem care was done. A Human Remains Release Form and Mortician's receipt were signed on (MONTH) 27, (YEAR). A Discharge Summary Form signed by the physician on (MONTH) 28, (YEAR) included the reason for discharge was the patient expired. However, there was no evidence a death in facility tracking MDS record was completed and transmitted to the Centers for Medicare and Medicaid Services (CMS) system. In an interview with the MDS coordinator (staff #9) on (MONTH) 10, 2019 at 1:20 p.m., she stated she gets a copy of the census every day to see if there are residents who have discharged and then she schedules a discharge MDS right away. Staff #9 said that if a resident has expired in the facility, she schedules a death in facility MDS assessment. She stated this resident was missing a death in facility MDS assessment and did not know how it got missed. A death in facility tracking MDS record was completed on (MONTH) 12, 2019. An interview was conducted with the Director of Nursing (DON/staff #83) on (MONTH) 11, 2019 at 9:47 a.m. She stated the facility did not have a specific policy related to MDS assessments, as they follow the RAI manual. In a later interview with staff #83 on the same date, she stated her expectation is that there should be a discharge MDS assessment completed for every discharged resident. The RAI manual included Death in the Facility refers to when a resident dies in the facility, the facility must complete a Death in Facility tracking record. The RAI manual also included that a Death in Facility tracing record must be completed no later than 7 calendar days after the discharge (death) date, and must be transmitted no later than 14 calendar days after the discharge (death) date.",2020-09-01
899,LIFE CARE CENTER OF YUMA,35133,2450 SOUTH 19TH AVENUE,YUMA,AZ,85364,2019-04-11,658,E,0,1,V39011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, facility documentation and policy review, the facility failed to ensure 2 of 24 (#70 and #100) sampled residents were administered medications as ordered and failed to ensure the physician was notified regarding the refusal of treatments for 1 of 24 sampled residents (#37). The deficient practice could result in potential medical complications [REDACTED]. Findings include -Resident #70 was admitted on (MONTH) 7, (YEAR), with [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set (MDS) assessment dated (MONTH) 13, (YEAR) revealed the resident scored a one on the Brief Interview for Mental Status (BIMS), indicating the resident had severe cognitive impairment. Further review revealed the resident did not have hallucinations, delusions, behavioral symptoms or refused care. The MDS included the resident received antipsychotic and antianxiety medications during the last 7 days of the assessment and that a gradual dose reduction (GDR) had not been attempted and the GDR was not clinically contraindicated. Review of the physician orders [REDACTED]. Physician orders [REDACTED]. Review of the annual MDS assessment dated (MONTH) 17, 2019, revealed the resident scored a zero on the BIMS, indicating the resident had severe cognitive impairment. The MDS included the resident did not have hallucinations, delusions or behavioral symptoms, and received antipsychotic and anti-anxiety medications during the last 7 days. Per the MDS, a GDR had not been attempted and was not clinically contraindicated. Review of the medication administration record (MAR) for (MONTH) 2019, revealed there were approximately 32 occasions when [MEDICATION NAME] was circled on the MAR, and there were approximately 16 occasions when [MEDICATION NAME] was circled, indicating the medications were not administered. The MAR notes indicated that the medications were not administered, due to unavailability. -Resident #100 was admitted on (MONTH) 16, 2019, with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. According to the (MONTH) 2019 MAR from (MONTH) 17 through the 27, there were more than 12 doses of [MEDICATION NAME] which were circled and more than 3 doses which were blank, indicating the medication was not administered. The MAR notes included that on a couple of days the medication was not administered, as the medication was unavailable from the pharmacy. An admission MDS assessment dated (MONTH) 29, 2019, revealed the resident scored a 14 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. The MDS included the resident was on a pain management program and received opioids. Further review of the clinical record revealed no evidence that the medication was administered as ordered, and there was no documentation the physician was notified regarding the medication not being administered, due to unavailability. An interview was conducted on (MONTH) 9, 2019 at 1:54 p.m. with a registered nurse (RN/staff #73). The RN stated that medications are to be administered and documented on the MAR. The RN stated if the medication is not administered it is indicated by a circle and on the MAR nursing notes the nurse is to document why the medication was not administered. An interview was conducted on (MONTH) 11, 2019 at 8:52 a.m. with the Assistance Director of Nursing (ADON/staff #18 and the Director of Nursing (DON/staff #83). The DON stated the administration of medications are documented on the MAR, as indicated by a nurse's initials. The DON stated if the medication is not administered, the nurses' initials would be circled and if the documentation is blank it indicates the medication was not administered. The DON stated if the initials are circled the reason for the medication not being administered is to be documented on the MAR. The DON stated if the medication was not given due to unavailability or the resident's refusal, after 3 days the nurse is to notify the physician and continuously follow up with the pharmacy to determine why the medication is not available. -Resident #37 was admitted to the facility on (MONTH) 5, (YEAR), with [DIAGNOSES REDACTED]. Review of a care plan dated (MONTH) 18, (YEAR), revealed the resident had a stage 2 bunion on the right foot. An intervention included offloading with wedge right foot at all times. A physician's orders [REDACTED]. Review of the nurses progress notes for (MONTH) 20 and 30, (YEAR), (MONTH) 6, 13, 20 and 25, (YEAR) and (MONTH) 4, 2019, revealed the resident was compliant with the wedge and is in place at all times. Review of the clinical record revealed there were no additional progress notes regarding the use of the wedge to offload the right foot or that the resident was refusing the wedge from (MONTH) 5, 2019 through (MONTH) 9, 2019. Further review of the care plan revealed no documentation that indicated the resident was refusing the wedge. An observation of the resident was conducted on (MONTH) 8, 2019 at 3:10 p.m. Resident #37 was laying in bed, with no wedge to the right foot. An interview was conducted with a Licensed Practical Nurse (LPN/staff #138) on (MONTH) 9, 2019 at 11:44 a.m. She stated the resident refuses to have the wedge under her right foot and this has been going on for a long time. At this time, the nurse offered to put the wedge in place and the resident refused stating that it hurts her hips. Another observation was conducted on (MONTH) 9, 2019 at 2:47 p.m. and the resident was sleeping in bed on her left side with legs pulled up and no wedge in place to the right foot. Additional observations were conducted on (MONTH) 9, 2019, and the resident was observed laying in bed, with no wedge in place. Multiple observations were conducted on (MONTH) 10, 2019 and resident was observed laying in bed, with no wedge in use for the right foot. Review of a nurses progress note dated (MONTH) 10, 2019, revealed a late entry for (MONTH) 9, and a note on (MONTH) 10, which now included the resident refused to have the wedge under right her foot to offload. In addition, there was no documentation that the care plan was updated to reflect the resident's refusal of the wedge. There was also no clinical record documentation that the physician was notified of the resident's refusal of the wedge for the right foot when in bed. An interview was conducted with the Director of Nursing (DON/staff #83) on (MONTH) 11. 2019 at 2:07 p.m. When asked about resident #37 refusing the wedge which was ordered to be on at all times when in bed, the DON stated that she would discuss the risk and benefits of not having the wedge on with the resident and family. She said that she would expect the staff to notify the physician and family about the refusal. Review of the facility's policy regarding changes in the resident's condition or status revealed the facility will notify the resident's primary care provider and representative of changes in the resident's condition or status. The policy also stated that notification of changes may also include a need to alter treatment or to discontinue an existing form of treatment.",2020-09-01
900,LIFE CARE CENTER OF YUMA,35133,2450 SOUTH 19TH AVENUE,YUMA,AZ,85364,2019-04-11,758,E,0,1,V39011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy review, the facility failed to ensure one of five sampled residents (#70) receiving [MEDICAL CONDITION] medications had adequate indications for their use, and that gradual dose reductions (GDR) were attempted or documentation that they were clinically contraindicated. The deficient practice could result in residents receiving [MEDICAL CONDITION] medications which are unnecessary, and could result in residents experiencing possible adverse consequences. Findings include: Resident #70 was admitted on (MONTH) 7, (YEAR), with [DIAGNOSES REDACTED]. Regarding [MEDICATION NAME]: Review of the physician's orders [REDACTED]. These orders had an original order date of (MONTH) 10, (YEAR). Review of the clinical record from (MONTH) 1, (YEAR) to (MONTH) 30, (YEAR) revealed no documentation that the resident had displayed any combative behaviors with care. In addition, there was clinical record documentation that the resident's medications had been reviewed, however, there were no changes made. A significant change Minimum Data Set (MDS) assessment dated (MONTH) 13, (YEAR), revealed the resident scored a one on the Brief Interview for Mental Status (BIMS), indicating the resident had severe cognitive impairment. Per the MDS, the resident did not have hallucinations, delusions, behavioral symptoms or rejected care. The MDS also included the resident received antipsychotic medications during the last 7 days of the assessment and that a gradual dose reduction (GDR) had not been attempted and was not documented by the physician as clinically contraindicated. The physician orders [REDACTED]. During this time frame, there was no clinical record documentation that the resident displayed any combative behaviors with care. Per the documentation, the resident's medications were reviewed and no changes were made. Review of the monthly behavior flowsheet record for (MONTH) (YEAR), revealed the resident had no episodes of combative behaviors with care. A physician's progress note dated (MONTH) 19, (YEAR), revealed no recommendations to reduce or discontinue the [MEDICATION NAME] due to a lack of behaviors. The monthly pharmacy reviews completed from (MONTH) (YEAR) to (MONTH) (YEAR) were requested, however, the facility was unable to provide the documents. A quarterly MDS assessment dated (MONTH) 23, (YEAR), revealed the resident had severe cognitive impairment and did not have hallucinations, delusions, behavioral symptoms or rejected care. The MDS included the resident received antipsychotic medications during the last 7 days and that a GDR had not been attempted and was not clinically contraindicated. The physician orders [REDACTED]. The clinical record documentation included that the [MEDICATION NAME] was reviewed and there were no changes made. The documentation also included for social services to monitor the resident's behaviors and mood. Review of the monthly behavior flowsheet records from (MONTH) 1, (YEAR) to (MONTH) 25, (YEAR), revealed no evidence that the resident had any episodes of combative behaviors with care. In addition, there was no clinical record documentation of any attempts for a GDR for the [MEDICATION NAME] from (MONTH) (YEAR) to (MONTH) 25, (YEAR). Review of the pharmacy consultation report dated (MONTH) 26, (YEAR) revealed the resident was receiving [MEDICATION NAME] 50 mg twice a day and 150 mg at bedtime for impulse control disorder since (MONTH) 10, (YEAR). Per the report, the pharmacist recommended a gradual dose reduction as follows: [MEDICATION NAME] 50 mg twice a day and 125 mg at bedtime, with the end goal of discontinuation while monitoring for re-emergence of target behaviors and withdrawal symptoms. The report included it is recommended for the prescriber to document the assessment of the risk verse benefits, indicating that the antipsychotic therapy continued to be a valid therapeutic intervention; ongoing monitoring of specific target behaviors and evaluation for potentially reversible causes of behavioral symptoms; and assessment of alternative interventions. Per the report, the provider agreed. Physician orders [REDACTED]. Despite the pharmacy recommendation, there was no evidence in the clinical record that the physician documented the clinical rationale for the continued use of [MEDICATION NAME]. The pharmacy review for (MONTH) 2019 included that [MEDICATION NAME] was started in (MONTH) of (YEAR) and the last gradual dose reduction was attempted in (MONTH) 2019, and the next reduction will be in (MONTH) 2020. Review of the monthly behavior flowsheet records from (MONTH) 1, 2019 to (MONTH) 28, 2019, revealed the resident had no episodes of combative behaviors with care. Further review of the clinical record from (MONTH) 1, 2019 to (MONTH) 28, 2019, revealed the [MEDICATION NAME] was reviewed and there were no changes made, and for social services to monitor the resident's behaviors and mood. The (MONTH) 2019 recapitulation of physician orders [REDACTED]. Review of the pharmacy review for (MONTH) and (MONTH) 2019, revealed no recommendations to decrease or discontinue the [MEDICATION NAME], despite the lack of behaviors. An annual MDS assessment dated (MONTH) 17, 2019 revealed the resident scored a zero on the BIMS, indicating the resident has severe cognitive impairment. Per the MDS, the resident did not have hallucinations, delusions or behavioral symptoms. The MDS also included the resident received antipsychotic medications during the last 7 days and that a GDR had not been attempted and the GDR was not documented by the physician as clinically contraindicated. Review of a care plan dated (MONTH) 17, 2019 revealed the resident is receiving [MEDICATION NAME] for [MEDICAL CONDITION] as evidenced by combative with care. Interventions included to monitor and document behavior at least every shift and report any abnormal observation to MD and evaluate the possibility of medication drug reduction at least quarterly. Review of the monthly behavior flowsheet record (MONTH) 2019, revealed on (MONTH) 15, 22 and 26, the resident was combative with care. The documentation included that non pharmacological interventions and medications were provided, which resulted in positive results. There was no additional description of the events. The clinical record documentation included that [MEDICATION NAME] was reviewed in (MONTH) 2019 and there were no changes made and for social services to monitor the resident's behaviors and mood. Despite documentation of only three episodes of the resident being combative with care from (MONTH) 1, (YEAR) through (MONTH) 31, 2019, a physician's orders [REDACTED]. In addition, there was no evidence found in the clinical record that the physician was notified of the lack of behaviors. Regarding [MEDICATION NAME]: A physician's orders [REDACTED]. A physician's orders [REDACTED]. Review of the clinical record from (MONTH) (YEAR) through (MONTH) 31, (YEAR) revealed no documentation that the resident was striking out at others during this period. Review of the monthly behavior flowsheets from (MONTH) 1, (YEAR) through (MONTH) 30, (YEAR), revealed no evidence of the resident striking out at others. Documentation of the monthly pharmacy reviews from (MONTH) (YEAR) through (MONTH) (YEAR) were requested, however, the facility was unable to provide these documents. Review of the monthly behavior flowsheet for (MONTH) (YEAR) revealed that on (MONTH) 24, the resident exhibited an episode of striking out and was provided redirection with a positive outcome. There was no additional description of the event. Review of the physician's progress note dated (MONTH) 14, 2019 revealed the resident had a [DIAGNOSES REDACTED]. The pharmacy review for (MONTH) 2019 included that [MEDICATION NAME] was started in (YEAR) and that the last GDR was attempted in (MONTH) (YEAR), and the next reduction will be in (MONTH) 2019. Per the report, a GDR was clinically contraindicated in (MONTH) (YEAR). Review of the clinical record from (MONTH) 1, 2019 through (MONTH) 31, 2019, revealed the [MEDICATION NAME] was periodically reviewed and there were no changes made. The documentation also included for social services to monitor the resident's behaviors and mood. Further, there was no evidence that the resident was striking out at others. Review of the monthly behavior flowsheets from (MONTH) 1, 2019 through (MONTH) 31, 2019, revealed no evidence the resident exhibited episodes of striking out at others. Review of a care plan dated (MONTH) 17, 2019 revealed the resident is receiving [MEDICATION NAME] for [MEDICAL CONDITION] as evidenced by striking out at others. Interventions included to monitor and document behavior at least every shift and report any abnormal observation to MD and evaluate the possibility of medication drug reduction at least quarterly. Despite documentation of only one episode of striking out from (MONTH) 1, 2019 through (MONTH) 31, 2019, the resident continued to receive [MEDICATION NAME], and there was no evidence that the physician was notified of the lack of behaviors. Review of the pharmacy reviews for (MONTH) 2019 and (MONTH) 2019 revealed no recommendations to decrease or discontinue [MEDICATION NAME], despite the lack of behaviors. Regarding [MEDICATION NAME]: Review of the physician orders [REDACTED]. The orders had an original order date of (MONTH) 22, (YEAR). Review of the clinical record from (MONTH) 1, (YEAR) to (MONTH) 30, (YEAR), revealed the [MEDICATION NAME] was reviewed and there were no changes made. Further, there was no evidence that the resident had any episodes of restlessness distressing to the resident, during this timeframe. A significant change MDS assessment dated (MONTH) 13, (YEAR) included the resident received antianxiety medications during the last 7 days of the assessment and that a GDR had not been attempted and was not documented by the physician as clinically contraindicated. Review of the clinical record from (MONTH) 1, (YEAR), (YEAR) to (MONTH) 30, (YEAR) revealed the [MEDICATION NAME] was reviewed and there were no changes made. Further, there was no evidence the resident had episodes of restlessness distressing to the resident. The documentation also included for social services to monitor the resident's behavior and mood. Review of the monthly behavior flowsheet record for (MONTH) (YEAR) revealed no episodes of restlessness. Documentation on the monthly pharmacy reviews completed from (MONTH) (YEAR) to (MONTH) (YEAR) were requested, however, the facility was unable to provide these documents. Review of the pharmacy consultation report dated (MONTH) 29, (YEAR) revealed a recommendation for a gradual dose reduction for [MEDICATION NAME], which included for [MEDICATION NAME] 0.5 mg twice a day and 0.25 mg at noon daily, with the eventual goal of discontinuation while concurrently monitoring for reemergence of target behaviors and withdrawal symptoms. Per the report, the provider agreed with the recommendation and the previous [MEDICATION NAME] order was discontinued and new orders were obtained. Physician orders [REDACTED]. A physician's progress note dated (MONTH) 19, (YEAR) included documentation to taper the [MEDICATION NAME]. Despite this recommendation, there were no new physician orders [REDACTED]. Review of the clinical record for (MONTH) (YEAR) revealed there was no evidence the resident had any episodes of restlessness distressing to the resident. A nursing note dated (MONTH) 18, (YEAR) and a social services note dated (MONTH) 19, 2019, included the resident would get scared and agitated in the past, due to his medical condition. Review of the physician's progress note dated (MONTH) 14, 2019 revealed the resident had anxiety and the medications were reviewed and updated. The monthly behavior flowsheets from (MONTH) (YEAR) through (MONTH) 2019 revealed there was no evidence that the resident experienced episodes of restlessness. The pharmacy reviews for (MONTH) 2019 and (MONTH) 2019 revealed no recommendations to decreased or discontinue [MEDICATION NAME], despite the lack of behaviors. Review of the physician's progress note dated (MONTH) 1, 2019 revealed the resident was in no apparent distress and the medications were reviewed and updated. Review of the annual MDS assessment dated (MONTH) 17, 2019, revealed the resident did not have hallucinations, delusions or behavioral symptoms and received anti-anxiety medications during the last 7 days. The MDS included that a GDR had not been attempted and the GDR was not documented by the physician as clinically contraindicated. Review of the monthly behavior flowsheet revealed that on (MONTH) 22, 2019, the resident experienced an episode of restlessness and non-pharmacological interventions and medications were provided, which resulted in a positive outcome. Despite documentation of only one episode of restlessness from (MONTH) 2019 through (MONTH) 2019, the resident continued to receive [MEDICATION NAME]. There was also no clinical record documentation that the physician was notified of the lack of behaviors. An observation of the resident was conducted on (MONTH) 9, 2019 at 11:35 a.m. The resident was in bed and appeared to be calm and was pleasant, with no signs of distress. An interview was conducted on (MONTH) 11, 2019 at 12:58 pm., with a certified nursing assistant (CNA/staff #84). Staff #84 stated the resident is not very physically aggressive and that his restlessness has improved since admission. An interview was conducted on (MONTH) 11, 2019 at 1:06 p.m., with a licensed practical nurse (LPN/staff #145). Staff #145 stated a resident receiving an [MEDICAL CONDITION] medication will be monitored for behaviors such as crying, kicking or aggression and the behaviors must be documented. Staff #145 stated once the behaviors have improved, the provider is notified and the medication is titrated. Staff #145 stated the resident is currently receiving [MEDICATION NAME] and [MEDICATION NAME]. Staff #145 stated on admission the resident was resistive to care, was crying and was a danger to self, however, the resident has improved overtime. An interview was conducted on (MONTH) 11, 2019 at 1:42 p.m., with the Director of Nursing (DON/staff # 83). The DON stated the physician is managing the resident's [MEDICAL CONDITION] medications, as it is difficult to get a psych evaluation in the area. The DON stated the resident came from a psychiatric facility and was receiving multiple [MEDICAL CONDITION] medications on admission. The DON stated the physician did not want to taper the [MEDICATION NAME] and [MEDICATION NAME] at the same time, and that gradual dose reductions have been attempted over the past two years. Review of a policy titled, Psychopharmacological Medication Management dated (MONTH) (YEAR), revealed the purpose was to support utilization of psychopharmacological medications in the appropriate treatment of [REDACTED]. The policy included that each resident's drug regimen must be free from unnecessary drugs. An necessary drug is any drug used in excessive dose including duplicate therapy, excessive duration, and without adequate indication for use. The policy also included the focus is on treating the resident's behavior indicators, with the most appropriate medication at the lowest dose and duration possible, which results in a decrease in behavior indicators that are new, unsafe, disruptive or threatening to the resident or others. The policy further stated the attending physician must document in the resident's medical record that identified irregularities have been reviewed and what, if any action has been taken to address it. If there is no change in the medication, the attending physician should document his or her rationale in the resident's medical record.",2020-09-01
901,LIFE CARE CENTER OF YUMA,35133,2450 SOUTH 19TH AVENUE,YUMA,AZ,85364,2016-12-01,281,E,0,1,XY6L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, a representative interview, facility documentation and manufacturer instructions, the facility failed to ensure that multiple residents were administered influenza vaccines, which had been stored at the proper temperature. Findings include: A medication storage observation was conducted on (MONTH) 1, (YEAR) at 11:45 a.m., of the medication storage room. Inside of the medication storage room was a medication refrigerator which contained numerous intravenous medications and fluids, insulin and eleven boxes of [MEDICAL CONDITION] Vaccine [MEDICATION NAME] (YEAR)-2017 formula. Each box contained ten pre-filled syringes. The thermometer inside the refrigerator read 32 F. A log on the outside of the medication refrigerator titled, Vaccine Storage Temperature Log included the temperature for (MONTH) 1, (YEAR) was 32 F. Further review of the log revealed that the log was in a table/grid format, with the range of temperatures down the left side of the form and the days of the month running across the top of the form. The instructions on the log included the Vaccine MUST be stored between 35 F and 46 F to maintain potency. This temperature range was identified in the white grid. The higher temperatures (greater than 46 F) and the lower temperatures (less that 35 F) were identified in the gray grid. Per the instructions, the temperatures were to be checked and documented twice each day (a.m. and p.m.). The instructions further included the following: if the temperature falls in the gray range: 1. Store the vaccines under proper conditions as quickly as possible. 2. Call the vaccine manufacturer to determine whether the potency of the vaccines has been affected, and 3. Call your VFC (Vaccine Free Clinic) Consultant. Additional Vaccine Storage Temperature Logs were reviewed and revealed the following: -September (YEAR): the temperatures documented were outside of the acceptable range (less than/equal to 32 F to 34 F) 48 out of 60 times. -October (YEAR): the temperatures documented were outside of the acceptable range (less than/equal to 32 F to 34 F) 55 out of 62 times. -November (YEAR): the temperatures were outside of the acceptable range (less than/equal to 32 F to 34 F) 60 out of 60 times. Review of the package insert instructions from the [MEDICAL CONDITION] Vaccine [MEDICATION NAME] (YEAR)-2017 formula revealed that the product should be refrigerated between 36 F and 46 F. The instructions also included to not freeze the contents and discard if the vaccine has been frozen. Review of the facility vaccination logs revealed that 45 residents had received the influenza vaccine between (MONTH) 1, (YEAR) and (MONTH) 1, (YEAR). In an interview with a Licensed Practical Nurse (Unit Manager/staff #37) on (MONTH) 1, (YEAR) at 11:45 a.m., staff #37 did not know if the steps from the log/insert had been taken. In an interview with a Registered Nurse (Assistant Director of Nursing/ADON/staff #71) on (MONTH) 1, (YEAR) at 11:48 a.m., the ADON stated the temperatures were in range, but did not realize that the temperatures in the gray area of the grid were out of range and was not aware of the instructions on the temperature logs. She stated that she had taken the temperature at 7:30 a.m. on (MONTH) 1, and that none of the required actions had been taken. She stated residents had received the vaccinations during the time when the temperatures were out of range. In a telephone call to the manufacturer on (MONTH) 1, (YEAR) at 12:14 p.m., the pharmacist stated that if there is any chance that the pre-filled syringes were frozen, they should not be used. She also stated that the company cannot guarantee the effectiveness of the vaccines, which were stored at those temperatures for that length of time. She stated it is likely that the vaccines have been affected and should be discarded. The facility Policies for Medication Administration indicated, All medication are administered safely and appropriately to help residents overcome illness, relieve/prevent symptoms, and help in diagnosis.",2020-09-01
902,LIFE CARE CENTER OF YUMA,35133,2450 SOUTH 19TH AVENUE,YUMA,AZ,85364,2016-12-01,311,D,0,1,XY6L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, and staff interviews, the facility failed to provide appropriate care and services to one resident (#38) on aspiration precautions. Findings include: Resident #38 was admitted to the facility on (MONTH) 13, 2013, with [DIAGNOSES REDACTED]. The resident was readmitted to the hospital on (MONTH) 11, (YEAR) with multiple diagnoses, which included health care associated pneumonia/aspiration. The resident was readmitted to the facility on (MONTH) 18, (YEAR). According to a care plan dated (MONTH) 18, (YEAR), the resident was at risk for aspiration related to difficulty swallowing, as evidenced by a [DIAGNOSES REDACTED]. Interventions included to assist resident to eat as needed, consult skilled therapies as ordered and to see the treatment plan, and observe for pocketing of food. Review of the speech therapy (ST) Daily Notes Report revealed a speech evaluation was completed on (MONTH) 19, (YEAR), with the recommendation for skilled ST services to address dysphagia. Review of the Speech Aspiration Precautions dated (MONTH) 20, (YEAR), revealed the following techniques for all oral intake (e.g. meals, snacks, pills, etc) for safe eating and drinking: take amounts of 1 teaspoon for each bite or sip, small sips of liquid via spoon only, alternate solids and liquids for [MEDICAL CONDITION] and to check the mouth after meals for food residue on the tongue, floor of the mouth or pocketed in the cheek. Review of a History and Physical dated (MONTH) 24, (YEAR), revealed the resident had aspiration pneumonia. Continued review of the ST Daily Notes Report from (MONTH) 20 through 28, (YEAR) revealed that ST provided education to CNAs regarding safe swallowing precautions to reduce the risk of aspiration. The note included to give 1/2 teaspoon-1 teaspoon for bites/sips. Review of a quarterly Minimum Data Set assessment dated (MONTH) 22, (YEAR) revealed the resident was assessed to have severe cognitive impairment. Under the section for swallowing disorder, the documentation included that the resident had coughing or choking during meals or when swallowing medications. A History and Physical dated (MONTH) 23, (YEAR) included the resident had dementia with recent aspiration, had a cough and congestion with shortness of breath. A nurse's note dated (MONTH) 29, (YEAR) included the resident was alert and oriented to self only, lungs had inspiratory wheezing in the left upper lobe and that oxygen was on. A dining observation was conducted on (MONTH) 30, (YEAR). A Certified Nursing Assistant/CNA #120) was observed feeding the resident. The CNA fed the resident approximately one cup of yogurt, with no liquids inbetween bites for [MEDICAL CONDITION]. After completing the yogurt, the CNA fed the resident one small glass of thickened orange juice. During the meal observation, the CNA was not observed to alternate between solid food and liquids, nor did the CNA perform any mouth checks after the meal, as per the aspiration precautions. An interview was conducted with staff #120 on (MONTH) 30, (YEAR) at 1:35 p.m. She stated that she knew and understood the feeding precautions and that she gave the resident what she needed. An interview was conducted with the speech pathologist (staff #139) on (MONTH) 1, (YEAR) at 10:00 a.m. She stated that she had educated all of the CNA's on how to feed this resident. She stated that as long as the resident's mouth was checked after each swallow of solid food, it would be acceptable to give multiple teaspoons of solid food without liquid.",2020-09-01
903,LIFE CARE CENTER OF YUMA,35133,2450 SOUTH 19TH AVENUE,YUMA,AZ,85364,2016-12-01,431,E,0,1,XY6L11,"Based on observations, staff interviews, a representative interview and manufacturer instructions, the facility failed to ensure influenza vaccines were maintained at the appropriate temperatures, per the manufacturer's guidelines. Findings include: A medication storage observation was conducted on (MONTH) 1, (YEAR) at 11:45 a.m., of the medication storage room. Inside of the medication storage room was a medication refrigerator, which contained numerous intravenous medications and fluids, insulin and eleven boxes of Influenza Virus Vaccine Fluvirin (YEAR)-2017 formula. Each box of the vaccines contained ten pre-filled syringes. The thermometer inside the refrigerator read 32 F. A log on the outside of the medication refrigerator titled, Vaccine Storage Temperature Log included the temperature for (MONTH) 1, (YEAR) was 32 F. Further review of the log revealed that the log was in a table/grid format, with the range of temperatures down the left side of the form and the days of the month running across the top of the form. The instructions on the log included the Vaccine MUST be stored between 35 F and 46 F to maintain potency. This temperature range was identified in the white grid. The higher temperatures (greater than 46 F) and the lower temperatures (less that 35 F) were identified in the gray grid. Per the instructions, the temperatures were to be checked and documented twice each day (a.m. and p.m.). The instructions further included the following: if the temperature falls in the gray range: 1. Store the vaccines under proper conditions as quickly as possible. 2. Call the vaccine manufacturer to determine whether the potency of the vaccines has been affected, and 3. Call your VFC (Vaccine Free Clinic) Consultant. Additional Vaccine Storage Temperature Logs were reviewed and revealed the following: -September (YEAR): the temperatures documented were outside of the acceptable range (less than/equal to 32 F to 34 F) 48 out of 60 times. -October (YEAR): the temperatures documented were outside of the acceptable range (less than/equal to 32 F to 34 F) 55 out of 62 times. -November (YEAR): the temperatures were outside of the acceptable range (less than/equal to 32 F to 34 F) 60 out of 60 times. Review of the package insert from the Influenza Virus Vaccine Fluvirin (YEAR)-2017 formula revealed that the product should be refrigerated between 36 F and 46 F. The instructions also included to not freeze the contents and discard if the vaccine has been frozen. In an interview with a Licensed Practical Nurse (Unit Manager/staff #37) on (MONTH) 1, (YEAR) at 11:45 a.m., staff #37 did not know if the steps from the log/insert had been taken. In an interview with a Registered Nurse (Assistant Director of Nursing/ADON/staff #71) on (MONTH) 1, (YEAR) at 11:48 a.m., the ADON stated the temperatures were in range, but did did not realize that the temperatures in the gray area of the grid were out of range and was not aware of the instructions on the temperature logs. She stated she had taken the temperature at 7:30 a.m. on (MONTH) 1, and that none of the required actions had been taken. She said that she takes the day temperatures and the nurses take the evening temperatures. In a telephone call to the manufacturer on (MONTH) 1, (YEAR) at 12:14 p.m., the pharmacist stated that if there is any chance that the pre-filled syringes were frozen, they should not be used. She also stated that the company cannot guarantee the effectiveness of the vaccines, which were stored at those temperatures for that length of time. She stated it is likely that the vaccines have been affected and should be discarded. Review of the facility policy titled Medication Storage and Security in the Facility revealed that medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The policy further indicated that medications requiring refrigeration or temperatures between 36 F and 46 F are kept in a refrigerator with a thermometer to allow temperature monitoring.",2020-09-01
904,RIM COUNTRY HEALTH & RETIREMENT COMMUNITY,35134,807 WEST LONGHORN ROAD,PAYSON,AZ,85541,2017-06-30,274,D,0,1,YFND11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility policy, and the RAI (Resident Assessment Instrument) manual, the facility failed to identify and complete a significant change Minimum Data Set (MDS) assessment for one resident (#35). Findings include: Resident #35 was admitted (MONTH) 31, 2014 with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment dated (MONTH) 14, (YEAR) revealed the resident required supervision with bed mobility, transfers, walking in room and corridor, locomotion on and off unit, dressing, eating, toilet use, and personal hygiene. The assessment also included the resident was continent of bladder and occasionally incontinent of bowel. Review of the quarterly MDS assessment dated (MONTH) 28, (YEAR) revealed the resident now required extensive assistance with bed mobility, transfers, locomotion on and off unit, dressing, toilet use, and personal hygiene, and was now frequently incontinent of urine and declined to frequently incontinent of bowel. The assessment revealed the resident had developed two unstageable pressure ulcers and had weight loss. An interview was conducted with the MDS coordinator (staff # 122) on (MONTH) 29, (YEAR) at 8:43 a.m. She stated that if a resident was hospitalized and returned to the facility and was assessed to have a significant change they would initiate a significant change MDS assessment unless they determined the change would resolve in a couple of weeks. She stated that a significant change assessment should have been identified and a significant change MDS assessment should have been completed. An interview conducted with the DON (staff #99) on (MONTH) 29, (YEAR) at 3:04 p.m. She stated her expectation is for the MDS assessment to be accurate. The facility policy Resident MDS Assessment included the assessment must accurately reflect the resident's status. The RAI manual instructs that a significant change is a decline or improvement in a resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, is not self-limiting (for declines only), impacts more than one area of the resident's health status, and requires interdisciplinary review and/or revision of the care plan. If the criteria are met, complete a Significant Change in Status assessment by the end of the 14th calendar day after determination that a significant change has occurred.",2020-09-01
905,RIM COUNTRY HEALTH & RETIREMENT COMMUNITY,35134,807 WEST LONGHORN ROAD,PAYSON,AZ,85541,2017-06-30,278,D,0,1,YFND11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility policy, and the RAI (Resident Assessment Instrument) manual, the facility failed to ensure one resident's (#114) annual Minimum Data Set (MDS) assessment was accurate. Findings include: Resident #114 was admitted (MONTH) 24, (YEAR), with [DIAGNOSES REDACTED]. Review of the annual MDS assessment dated (MONTH) 16, (YEAR) revealed the resident was administered 7 days of an antipsychotic medication and 7 days of an antidepressant medication. However, review of the Medication Administration Record [REDACTED]. An interview was conducted with the MDS coordinator (staff #122) on (MONTH) 29, (YEAR) at 2:44 p.m. After reviewing the (MONTH) (YEAR) MAR indicated [REDACTED]. She also stated that the resident had an antidepressant medication administered for 6 days, and that the MDS assessment should have coded an antidepressant medication administered for 6 days. An interview was conducted with LPN (staff #34), the nurse who completed this section, on (MONTH) 29, (YEAR) at 2:52 p.m. She stated that no antianxiety medication was coded on the annual MDS assessment dated (MONTH) 16, (YEAR); however, an antianxiety medication was administered for 7 days. She stated that the antidepressant medication was administered 6 times. Staff #34 stated that the MDS assessment should have been coded for an antianxiety medication administered for 7 days and an antidepressant medication administered for 6 days. An interview was conducted with the Director of Nurses (DON) (staff #99) on (MONTH) 29, (YEAR) at 3:04 p.m. She stated that her expectation is for the MDS assessment to be accurate. The facility policy Resident MDS Assessment included the assessment must accurately reflect the resident's status. The RAI manual instructs to record the number of days an antidepressant and antianxiety medication was administered to the resident at any time during the 7 day look back period.",2020-09-01
906,RIM COUNTRY HEALTH & RETIREMENT COMMUNITY,35134,807 WEST LONGHORN ROAD,PAYSON,AZ,85541,2017-06-30,281,E,0,1,YFND11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of a clinical record and staff interview, the facility failed to ensure one resident's (#61) antipsychotic medication was administered per the physician's orders [REDACTED]. Findings include: Resident #61 was admitted (MONTH) 31, 2013, with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A review of the annual Minimum Data Set assessment dated (MONTH) 6, (YEAR), revealed the resident was receiving an antipsychotic medication for 7 days of the 7 day look back period. The MDS assessment further revealed, [MEDICAL CONDITION] drug use triggered as a problem area and a decision was made to proceed to care planning. A review of the care plan revealed the problem for the use of the antipsychotic medication because of behavioral symptoms of aggressive behavior and resistive to care related to dementia with behaviors, anxiety and depression. The interventions included Give medications and monitor side effects per orders. A review of the (MONTH) (YEAR), Medication Administration Record [REDACTED]. A review of the (MONTH) (YEAR), Medication Administration Record [REDACTED]. A review of the (MONTH) (YEAR), Medication Administration Record [REDACTED]. A review of the clinical record revealed no documented evidence regarding the reason the [MEDICATION NAME] was not administered per the physician's orders [REDACTED]. During an interview conducted at 8:40 a.m. on (MONTH) 30, (YEAR), the Assistant Director of Nursing stated, after reviewing the clinical record, there was no documentation to explain why the [MEDICATION NAME] was not administered per the physician's orders [REDACTED]. She also stated without documentation explaining the reason for not administering the medication, and documentation indicating the physician was notified the medication was not administered per the orders, the failure to administer the medication on the identified days were six medication errors.",2020-09-01
907,RIM COUNTRY HEALTH & RETIREMENT COMMUNITY,35134,807 WEST LONGHORN ROAD,PAYSON,AZ,85541,2017-06-30,323,D,1,1,YFND11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of clinical records, facility documents, and staff interviews, the facility failed to ensure the staff had adequate training to safely transfer one resident (#126) using a facility stretcher. Findings include: Resident #126 was admitted to the facility on (MONTH) 28, (YEAR), and discharged on (MONTH) 27, (YEAR), with return anticipated. The resident was readmitted to the facility on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. A review of the annual Minimum Data Set assessment dated (MONTH) 1, (YEAR), revealed the resident required extensive assistance of two for transfers. The resident was also assessed as having both long and short term memory problems. A review of the quarterly/discharge MDS assessment dated (MONTH) 28, (YEAR), revealed the resident required extensive assistance of two people for transfers. A review of the Nurses Notes dated (MONTH) 28, (YEAR), revealed the resident was transferred to the hospital emergency room with labored breathing, wheezing in upper lobes and oxygen saturation level of 87%. A review of the Nurses Notes dated (MONTH) 29, (YEAR), revealed the resident was brought to the facility from the hospital on the facility's gurney, and was in the process of being transferred from the gurney to the bed by a nurse (staff #81), the facility's van driver (#157), and a Certified Nursing Assistant (CNA/ staff #63) when the gurney declined to the floor rapidly. The Nurses Note also revealed Gurney tilted when it was on the ground at that point and resident was tilted to his left side as well. The Nurse Notes further revealed the resident was transferred back to the hospital after the fall. A review of the written statement by the Licensed Practical Nurse (LPN/staff #81) dated (MONTH) 29, (YEAR), revealed the resident arrived at the facility at 2:15 p.m. on (MONTH) 29, (YEAR). The resident was strapped on the gurney. The gurney was positioned next to the bed, and the LPN was at the head of the gurney. She documented the van driver was positioned at the foot of the gurney and told her to grab on tight because as soon as the knob is turned, the gurney will go down fast. The nurse's statement revealed she grabbed tight and braced her legs but was not aware of how fast the gurney would go down, and was unable to hold on. The gurney came out of her hands and fell on to the floor, tipping over. During an interview conducted at 9:00 a.m. on (MONTH) 28, (YEAR), the administrator (Staff #156) stated that the van driver should have waited for additional assistance before releasing the knob on the stretcher/gurney. The van driver was aware that the stretcher would drop suddenly and the nurse on the other end was a small woman. He stated that a male CNA was on his way into the room to help, when the van driver released the knob to lower the stretcher, causing it to fall, and tip over with the resident strapped to the stretcher. The administrator stated, after the accident he got on the stretcher and had staff lower him on it. He stated that the stretcher would drop suddenly. He stated that he had the stretcher removed from the facility and discarded. He also stated that he has ordered a new hydraulic stretcher, however the facility currently does not have a stretcher for transporting residents. During an interview conducted at 12:35 p.m. on (MONTH) 28, (YEAR), the Maintenance Director (staff #93) stated the stretcher was a cheap stretcher that did not have a hydraulic system in place, so when the lever was pulled the base would collapse down, and only stop if two people at each end would support the weight of the resident and the stretcher. He also stated they had only gotten the stretcher a few months before the accident, and that they had the local ambulance company employees come to the facility and showed the previous Maintenance Director and himself how to operate the stretcher. He further stated that he and the previous Maintenance Director trained the van driver how to use the stretcher. During an interview conducted by telephone at 1:00 p.m. on (MONTH) 28, (YEAR), Van Driver (staff #157) stated that the stretcher used did not work very well and took two to three staff to use it. He also stated the stretcher had no hydraulics and when the lever was released the legs of the stretcher would collapse down to the ground. He further stated he had been trained on the use of the stretcher and even though he warned the nurse that she needed to grab and hold the stretcher, he did not explain to the nurse that the stretcher would collapse unless you physically held it up when the level was released. He stated he was unsure why the stretcher tipped over after falling down, but stated the nurse was unable to hold up her end of the stretcher, causing stretcher legs to collapse, dropping the stretcher with the resident strapped to it to the floor, before tipping over. During an interview conducted with at 8:50 a.m. on (MONTH) 29, (YEAR), the Director of Nursing (Elizabeth McClure #99) stated that the LPN involved in the fall with the resident on the gurney came and got her immediately after the fall. She also stated the nursing staff had never been trained on the use of the gurney. An interview was conducted on the telephone at 9:15 a.m. on (MONTH) 29, (YEAR), with the resident's family member who stated he was in the room when the van driver pushed the stretcher into the room with the resident strapped onto the stretcher. He stated the nurse and the CNA were also in the room. He reported the male CNA was on the other side of the bed and not next to the stretcher, the nurse was at the head of the stretcher and the driver was at the foot. He also stated the driver appeared to be rushing and pushed the button, releasing the legs, causing the stretcher to fall and flip over. He stated that he did not feel the nurse or CNA did anything wrong and the responsibility for the fall was due to the driver. During a telephone interview conducted at 9:40 a.m. on (MONTH) 29, (YEAR), the LPN stated that she and the CNA entered the room with the van driver, with the resident, who was strapped to the gurney. She stated the stretcher was placed next to the bed and the CNA was on the opposite side of the bed. The van driver told her to go the head of the gurney and he positioned himself at the foot of the gurney. The van driver told her to grab tight because the gurney goes fast. She stated that when he pushed the button, the gurney legs collapsed, dropping the resident and the gurney to the floor and tipping over. She also stated she did not know why the gurney tipped over. She further stated she had never had any training or experience in lower the gurney that was being used. She reported that the gurneys she had worked with in the past were all hydraulic and lowered slowly. After requesting a copy of the owner's manual, manufactures instructions or other documents regarding the of the gurney, the Administrator stated the facility had no such documents. He also stated that there was no policy and procedure for the use of the gurney/stretcher.",2020-09-01
908,RIM COUNTRY HEALTH & RETIREMENT COMMUNITY,35134,807 WEST LONGHORN ROAD,PAYSON,AZ,85541,2018-09-25,550,D,0,1,P4TT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interviews, and policy review, the facility failed to ensure a blood glucose test was not performed at the dining table during a meal for one resident (#4). Findings include: Resident #4 was admitted to the facility on (MONTH) 24, 2013, with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A review of the significant change Minimum Data Set (MDS) assessment dated (MONTH) 26, (YEAR) revealed the resident had a Brief Interview for Mental Status (BIMS) score of 01, which indicated the resident was severely cognitively impaired. The medication section of the MDS assessment included the resident was receiving insulin injections. Review of the care plan revealed the resident has diabetes mellitus with interventions that included providing diabetes medications as ordered by the doctor. During a dining observation conducted on (MONTH) 17, (YEAR) at 11:29 a.m. in the pony dining room, approximately 11 other residents were in the dining room eating their meals when a licensed practical nurse (LPN/staff #42) was observed walking into the dining room. Staff #42 approached resident #4 and stated to the resident that she was going to take her blood sugar. She was observed to take the resident's blood sugar at the table. An interview was conducted on (MONTH) 19, (YEAR) at 8:37 a.m. with a registered nurse (RN/staff # 71). Staff #71 stated blood sugar checks should be obtained in a private setting not in a dining room. He stated that the resident should be taken to a room with no other residents around to ensure resident privacy. The RN further stated taking a resident's blood sugar in the dining room is disrespectful and not treating the resident with dignity. An interview was conducted on (MONTH) 19, (YEAR) at 10:58 a.m. with the LPN (staff #42). Staff #42 stated that it was inappropriate to take the resident's blood sugar in the dining room. The LPN stated that taking the resident's blood sugar in the dining room is not treating the resident with dignity. An interview was conducted on (MONTH) 20, (YEAR) at 11:45 a.m. with the Director of Nursing (staff #37/DON). She stated residents should be treated with respect and dignity during each and every time the staff members interact with residents. She further stated care should be provided with the resident, not to the resident. Review of the facility's policy titled Resident right to privacy and confidentiality revealed staff will respect the resident's privacy during all care and treatment as appropriate.",2020-09-01
909,RIM COUNTRY HEALTH & RETIREMENT COMMUNITY,35134,807 WEST LONGHORN ROAD,PAYSON,AZ,85541,2018-09-25,552,D,0,1,P4TT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, and policy and procedure, the facility failed to ensure two residents (#25 and #43) were informed of the risks and benefits of [MEDICAL CONDITION] medications prior to the administration of the medications. Findings include: -Resident #25 was readmitted to the facility on (MONTH) 2, (YEAR), with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. pain. Review of the Medication Administration Record [REDACTED]. The annual Minimum Data Set (MDS) assessment dated (MONTH) 6, (YEAR) revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident's cognition was intact. The MDS assessment also included the resident was administered an antidepressant medication. Review of the current physician's orders [REDACTED]. Review of the MAR for (MONTH) and (MONTH) (YEAR), revealed the resident was administered the [MEDICATION NAME] as ordered. Additional review of the clinical record revealed the resident was not informed of the risks and benefits of [MEDICATION NAME] until (MONTH) 8, (YEAR). -Resident #43 was admitted to the facility on (MONTH) 18, (YEAR), with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. The quarterly MDS assessment dated (MONTH) 27, (YEAR) revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident's cognition was intact. The MDS assessment also included the resident was administered an antianxiety medication. Review of the MAR for (MONTH) and (MONTH) (YEAR), revealed that the resident was administered the [MEDICATION NAME] as ordered. A review of the clinical record for resident #43 revealed no evidence that the resident or the resident's representative was informed of the risks and benefits of the antianxiety medication, [MEDICATION NAME], prior to administration. During an interview conducted with a Licensed Practical Nurse (LPN/staff #86) on (MONTH) 20, (YEAR) at 11:52 a.m., she stated that they must obtain informed consent before administering a [MEDICAL CONDITION] medication to a resident. During an interview conducted with a Registered Nurse (RN/staff #71) on (MONTH) 21, (YEAR) at 10:39 a.m., he stated that they cannot administer a [MEDICAL CONDITION] medication without a consent from the resident/responsible party that includes the risks and benefits, the type of medication, and the reason for administering the medication. An interview was conducted with the Assistant Director of Nursing/LPN (ADON/staff #3) on (MONTH) 25, (YEAR) at 12:31 p.m. She stated that the resident/resident representative must consent to a [MEDICAL CONDITION] medication before it is administered. The ADON stated obtaining consent means the resident/resident representative is informed about the medication name and type, the side effect risks, the reason for administering the medication, and the right to refuse the treatment. She stated that the process for obtaining informed consent is that the psychiatric physician meets with the resident/responsible party and obtains a verbal consent for the [MEDICAL CONDITION] medication. The ADON states this discussion should be included in the physician's progress note. She stated that she or the nurse would then follow up with the resident/responsible party to obtain the written consent. The ADON stated that she reviews the pharmacy report monthly which includes all ordered psychoactive medications and whether consent was present. She stated that resident #25 had been receiving the [MEDICATION NAME] since (MONTH) 4, (YEAR) and that an informed consent was not obtained until (MONTH) (YEAR). She also stated that no informed consent had been obtained for the use of [MEDICATION NAME] for resident #43. An interview was conducted with the Director of Nurses (DON) on (MONTH) 25, (YEAR) at 1:34 p.m. She stated that the ADON does the monitoring and tracking of [MEDICAL CONDITION] medications. The DON also stated that she expects staff to obtain an informed consent prior to administering a [MEDICAL CONDITION] medication. She stated that obtaining an informed consent is important so that the resident/representative is aware of the risks and benefits of the medication and the goals of treatment. The facility's policy regarding psychoactive medication administration revealed the resident/family/legal representative will be provided with information and education about their medications and that an informed consent is required prior to use.",2020-09-01
910,RIM COUNTRY HEALTH & RETIREMENT COMMUNITY,35134,807 WEST LONGHORN ROAD,PAYSON,AZ,85541,2018-09-25,583,E,0,1,P4TT11,"Based on observation, staff interview, and policy, the facility failed to ensure that confidential resident information was private. Findings include: During an observation conducted in the secured unit dining room on (MONTH) 19, (YEAR) at approximately 7:45 a.m., two forms were observed hanging on the wall just inside the doorway. The two forms contained a list of resident names, inclusive of both first and last names, with room numbers listed and diet/modifications and diet additions. The forms also contained specific information for multiple residents, such as regular puree diet, level 1 diet, and may request mechanical diet. At the time of the observation, there were multiple residents in the dining room for breakfast. An interview was conducted with the Assistant Director of Nursing (ADON/staff #3) on (MONTH) 20, (YEAR) at 11:21 a.m. After observing the forms, she stated that the posting was a privacy issue as the information listed was considered confidential. The ADON stated any resident information that others could see was a privacy violation. She further stated that if a visitor would be in the dining room, the postings would be visible for them to see. The ADON stated that the forms needed to come down right away and removed the forms. The facility's policy regarding resident right to privacy and confidentiality included: Based on the Health Insurance Portability Act regulations all facility staff will be aware of and exhibit sensitivity to the personal privacy and confidentiality rights and needs of every resident and will demonstrate respect for the resident. Personal information included medical treatment. Guidelines included safeguarding the resident's information.",2020-09-01
911,RIM COUNTRY HEALTH & RETIREMENT COMMUNITY,35134,807 WEST LONGHORN ROAD,PAYSON,AZ,85541,2018-09-25,600,E,1,1,P4TT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff and resident interviews, facility documentation, and policy, the facility failed to ensure that one resident (#243) did not sexually abuse another resident (#10), that two residents (#52 and #57) did not physically abuse each other, and that one resident (#12) was free from neglect. Findings include: -Resident #10 was admitted on (MONTH) 15, 2006, with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 17, (YEAR) revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. -Resident #243 was admitted on (MONTH) 5, (YEAR), with [DIAGNOSES REDACTED]. Review of the current care plan for resident #243 revealed behaviors of yelling, agitation, hitting side of wheel or close by objects with hands, inappropriate disrobing, and restlessness related to dementia. The goal was that behaviors would be managed through staff monitoring and interventions. The approaches included to allow the resident to express thoughts and feelings, keep environment calm and relaxed, orient as needed, and psychiatric evaluation. The nurse progress note dated (MONTH) 11, (YEAR) revealed resident #243 was sexually inappropriate while sitting next to a female resident (#10). The note included the resident ran his glasses up between resident #10's legs, and then put his hand between her legs. Review of the psychoactive medication monitoring/review notes dated (MONTH) 11, (YEAR), revealed the resident was having sexually inappropriate behaviors. The admission MDS assessment dated (MONTH) 12, (YEAR) for resident #243 revealed a BIMS score of 1, which indicated the resident had severe cognitive impairment. The MDS also included the resident had physical symptoms directed toward others, during 1 to 3 days of the 7 day lookback period. Review of the facility's investigation revealed that resident #243 was sitting beside a female resident (#10) in the television room of the secured memory care unit. Resident #243 was observed by an activity assistant (staff #8) to touch resident #10's lap area on the outside of her clothing. The investigation included that resident #243 was redirected by staff #8, who remained in the area to monitor the resident. Per the investigation, a few minutes later, staff #8 witnessed resident #243 touch resident #10's thigh and staff #8 again re-directed resident #243. The investigation further included that resident #243 was moved to a secure unit to better monitor his behaviors. An interview was conducted with resident #243 on (MONTH) 19, (YEAR) at 6:51 a.m. He stated that he had no recollection of touching any other resident. An interview was conducted with staff #8 on (MONTH) 19, (YEAR) at 11:40 a.m. She stated that on (MONTH) 11, 1018 at 4:45 p.m., she was standing with the residents during an evening activity. She stated that she saw resident #243 push his hand between the legs of resident #10. She stated that she walked over and moved his hand off of resident #10 and talked with him. She stated that is when she noticed that he was holding a pair of glasses in the hand that was between resident's #10 legs. She stated that she then hung his glasses on his shirt where he usually keeps them and asked him to please not do that to resident #10. She stated that she started to walk away, but then saw resident #243 again put his hand between the legs of resident #10. Staff #8 stated that she moved his hand away and told him to please keep his hands to himself. She stated that she then walked behind them and looked at both residents, and saw resident #243 with his hand just above the knee of resident #10. Staff #8 stated that she told resident #243 to keep his hands to himself and not to be touching other people. She stated that at that point resident #10 got up and went into the dining room. An interview was conducted with resident #10 on (MONTH) 19, (YEAR) at 1:11 p.m. She stated that she remembered resident (#243) and that he was new. She first stated that she did not remember him touching her, but that she knew she wanted to avoid him. She then stated that he touched her on the side of her vagina with her clothes on, and that she remembers feeling that he should not touch her. She stated that staff #8 told him to stop and when he tried again, he was told again to stop. She stated that she feels safe, as he is not there anymore. An interview was conducted with a Certified Nursing Assistant (CNA/staff #83) on (MONTH) 20, (YEAR) at 8:32 a.m. She stated that it was reported to her by an activity staff member that resident #243 had his hands between the legs of resident #10 and was stuffing his eye glasses between her legs. She stated that when she looked over at the resident, he had his right hand on resident #10's lap. The CNA stated that she reported what she was told to another CNA, as she was going on break. She stated that she has received training on abuse and that the behavior of resident #243 could have been suspicious or has a potential to be sexual abuse. The CNA stated that if there is an allegation of or suspicion of abuse they are to notify the nurse. She stated that the nurse had been informed of resident #243's behavior. An interview was conducted with the Director of Nursing (DON/staff #37) on (MONTH) 20, (YEAR) at 10:20 a.m. She stated that if a staff member sees a patient being abused, the staff is to separate the abuser from the victim and report it immediately to the charge nurse. The DON stated that the charge nurse would report it immediately to her or the Executive Director (ED). She stated that after she receives the report, she would start the investigation. -Resident #52 was admitted on (MONTH) 10, (YEAR), with [DIAGNOSES REDACTED]. A review of the resident's comprehensive change of condition Minimum Data Set (MDS) assessment dated (MONTH) 7, (YEAR), revealed the resident's cognitive skills for daily decision making were severely impaired, and that she demonstrated verbal and physical behaviors directed at others on 1 to 3 days of the 7 day assessment period. The assessment also included the resident required extensive assistance with all activities of daily living and used a wheelchair for mobility. Review of the care plan revealed the resident exhibited the following behaviors: resisting care, grabbing people walking by, banging on her chair, and yelling out. Goals included management of her behaviors through staff monitoring and interventions. The interventions included providing extra staff when abusive or resistive, maintaining a calm and relaxed environment, and to provide simple, concrete explanations and simple, firm limits. -Resident #57 was admitted on (MONTH) 3, (YEAR), with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment dated (MONTH) 12, (YEAR) revealed the resident had a Brief Interview for Mental Status (BIMS) score of 1, which indicated severe cognitive impairment. The assessment also included the resident had verbal behaviors directed toward others on 4-6 days of the 7 day observation period and wandering on 1-3 days of the 7 day observation period. Review of the care plan revealed that she exhibited the following behaviors: wandering the unit, screaming, yelling, rejecting care, and following staff constantly and asking to go outside to smoke. The care plan goal was that her behaviors would be managed through staff monitoring. Interventions included to keep the environment calm and relaxed, and to redirect her with diversional activities. During an observation conducted on (MONTH) 17, (YEAR) at 11:17 [NAME]M. in the hallway on the Pony unit, resident #52 was observed sitting in a Geri chair in the hallway and resident #57 was observed ambulating in the hallway. Resident #57 was observed to strike resident #52 on the right forearm with her open right hand as she walked by resident #52. Resident #52 was then observed to strike resident #57 on the right buttock, with her open right hand. No verbal exchange was observed between the residents preceding the physical exchange. Resident #57 was observed to continue to walk down the hallway, away from resident #52. The incident was reported to the administrator (staff #128). A review of the Reportable Event Record/Report dated (MONTH) 18, (YEAR) revealed that on (MONTH) 17, (YEAR) at 11:17 AM, it was reported resident #57 struck resident #52 on the right forearm with an open right hand and that resident #52 struck resident #57 on the right buttock with an open right hand. The report included that the residents were unable to recall the incident and that there were no injuries to either resident. During an interview conducted on (MONTH) 21, (YEAR) at 9:23 [NAME]M. with a Certified Nursing Assistant (CNA/staff #110), the CNA stated that if she witnessed a resident striking another resident, she would separate the residents, chart it, and report it to the nurse. -Resident #12 was admitted to the facility on (MONTH) 24, (YEAR) with [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS) assessment dated (MONTH) 19, (YEAR) revealed a brief interview for mental status score of 15, which indicated the resident had no cognitive impairment. In addition, the resident was assessed to always be incontinent of urine and frequently incontinent of bowel. The resident was totally dependent on staff for toileting. A care plan with a revision date of (MONTH) 4, (YEAR) included a problem area of incontinence with interventions that included assistance to the commode/toilet every 2 hours. In addition, the resident was to be checked every 2 hours for incontinence needs with the goal to address incontinence issues. Review of the facility's report dated (MONTH) 5, (YEAR) revealed the resident had informed a Physical Therapy Assistant (staff #38) on (MONTH) 31, (YEAR) that she was not changed in a timely manner on (MONTH) 30, (YEAR). The report included that when the resident puts on her call light, no one comes to assist her. Continued review of the report revealed an interview with the resident. The resident stated a Certified Nursing Assistant (CNA/staff#129) answered her light on (MONTH) 30, (YEAR), but that the CNA did not respond to her when she asked for assistance. The resident stated that she put her call light on numerous times and that staff #129 told her You need to wait, I am busy and then would not return to the resident's room for a long time. The resident was unsure of how long she waited but stated that it seemed like forever. The resident further stated she had been in a soiled brief for so long, she felt like she was getting a sore on her bottom. The resident stated she asked staff #129 to get a nurse to look at her bottom, but that the nurse never came. The facility's report also included a written statement from CNA/staff #129. The written statement revealed the CNA changed the resident two times during her shift. The CNA's written statement included that when the resident was changed around 2:00 p.m., the resident did not complain of pain and there was no redness or sores on her bottom. The written statement revealed that during the next brief change (no time was written), the CNA observed a small opening on the resident's bottom. The CNA's written statement further included that the resident requested to see a nurse and that she notified the nurse. A review of the personnel file for staff #129, revealed training and education on neglect had been provided. The file also included that due to the lack of resident care, the CNA was terminated on (MONTH) 16, (YEAR) and that the last day of work was (MONTH) 30, (YEAR). An interview was conducted with resident #12 on (MONTH) 18, (YEAR) at 1:37 p.m. She stated that she remembered the incident with staff #129. She stated that she asked staff #129 to change her soiled brief and that the CNA entered her room and left without helping her. The resident stated staff #129 did not come back and that later the same day there was a skin opening on her buttocks. She further stated staff #129 neglected her and that the actions of staff #129 were not right. An interview was conducted with the Assistant Director of Nursing (staff #3) on (MONTH) 20, (YEAR) at 11:09 a.m. She stated that she was notified on (MONTH) 1, (YEAR) the resident had made an allegation of neglect regarding the lack of incontinence care from staff #129. She stated that the incident was identified as neglect. An interview was conducted with a Registered Nurse (staff #57) on (MONTH) 20, (YEAR) at 12:35 p.m. She stated any resident who is incontinent must be checked every 2 hours or more as needed. She further stated it would be considered neglect for any staff to be called to a resident's room to change the resident's brief and not provide the care right away. During an interview conducted with a CNA (staff #81) on (MONTH) 20, (YEAR) at 12:50 p.m., she stated that it is the policy of the facility that all residents who were incontinent be checked at least every 2 hours or more often if necessary. She stated that if the resident needed a brief change, the brief would need to be changed as soon as possible. The CNA stated not changing the brief as soon as possible would be neglect. During an interview conducted with a CNA (staff #53) on (MONTH) 20, (YEAR) at 1:39 p.m., she stated any resident who is incontinent must be provided care as soon as possible. She stated it would be considered neglect if the staff did not provide the care. Multiple attempts to contact staff #129 were unsuccessful. The facility's policy regarding abuse and neglect included the following: This facility is committed to the physical, mental, social, and emotional well-being of the residents and to that end the facility has adopted a zero tolerance policy related to resident abuse. This facility will not condone abuse by anyone, including, but not limited, to staff or other residents. The definition of abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish. The policy also included that physical abuse is hitting, slapping, pinching, and kicking. Neglect means failure to provide goods and services to avoid physical harm, mental anguish, or mental illness. The policy included an additional definition of neglect: Being ignored or being treated with indifference, not receiving basic medical or personal care (such as assistance with personal hygiene).",2020-09-01
912,RIM COUNTRY HEALTH & RETIREMENT COMMUNITY,35134,807 WEST LONGHORN ROAD,PAYSON,AZ,85541,2018-09-25,602,E,1,1,P4TT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews, pharmacy and facility documentation, and policy, the facility failed to ensure six residents (#25, #62, #41, #246, #47, and 74) did not have their medications misappropriated. Findings include: Review of a facility's investigation regarding missing narcotics dated 09/06/18, revealed that on 09/06/18 at approximately 8:30 a.m., staff reported to the Director of Nursing (DON/staff #37) that there were missing narcotics from the Pine Unit for two residents (#41 and #246). The investigation included the boxes where papers are placed for shredding on each unit were searched for evidence, and that the Controlled Substance Records (CSR/used to sign out narcotics from the secured drawer on the medication carts) for three residents (#47, #74 and #246) were found. Also found in the shredding box was an empty dose pack of [MEDICATION NAME] ([MEDICATION NAME]) for resident #246. According to the pieced together CSRs, the facility determined that there was a total of 84 narcotic pills missing and unaccounted for. Per the report, it was determined that the shred boxes were last emptied on 08/30/18, so every nurse that had worked since that date was brought in and drug tested . A total of 15 nurses were drug tested and only one tested positive for narcotics, however, that nurse produced a prescription (belonging to a family member) for the medication that she was positive for. Per the report, one nurse's name (licensed practical nurse/staff #63) came up multiple times on the narcotic sheets, but she was unable to provide any information regarding the missing narcotics. The report included statements from 15 nurses who denied taking the medications or having knowledge of what happened to the narcotics. The investigation included that the DON was unable to definitively determine who took the medications or what happened to the medications. -Resident #25 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of the 30-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The Health Conditions section of the MDS assessment revealed the resident was on a pain management program and received scheduled and as needed pain medications. Review of the physician's orders [REDACTED]. The frequency ranged from every 4 hours as needed initially to every 8 hours as needed. A comparison of the Medication Administration Records (MAR) and the CSRs for July, (MONTH) and (MONTH) (YEAR) revealed the following: July (YEAR): There were 112 doses of [MEDICATION NAME] that were documented on the MAR as being administered, and there were 121 doses of [MEDICATION NAME] signed out on the CSR. August (YEAR): There were 94 doses of [MEDICATION NAME] that were documented on the MAR as being administered, and there were 85 doses of [MEDICATION NAME] signed out on the CSR. Also, there were two CSR for the [MEDICATION NAME]; however, page 2 from 08/18/18 was missing per the DON. September (YEAR): There were 50 doses of [MEDICATION NAME] that were documented on the MAR as being administered, however, there were 57 doses signed out on the CSR. -Resident #62 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Another physician's orders [REDACTED]. Review of a CSR for the MS 15 mg which had been found in the shred box by facility staff, revealed that the 12 tablets of medication was received on 6/13/18. However, the facility was unable to locate the corresponding dose pack of 12 tablets. In addition, a comparison of the MARs and the CSRs revealed the following: August (YEAR): There were 29 doses of [MEDICATION NAME] that were documented on the MAR as being administered; two doses were refused. However, there were only 28 doses of [MEDICATION NAME] signed out on the CSR. There was also one dose of MS 15 mg that was documented on the MAR as being administered that was not signed out on the CSR. -Resident #41 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the annual MDS assessment dated [DATE] revealed a BIMS score of 3, which indicated the resident had severe cognitive impairment. A physician's orders [REDACTED]. A comparison of the MARs and/or E-MAR progress notes and the CSRs revealed the following: July (YEAR): The E-MAR progress notes revealed there were at least seven instances of [MEDICATION NAME] being administered for a total of 12 tablets. However, there was no CSR for the [MEDICATION NAME] for this month. August (YEAR): The MAR from 08/01/18 through 08/20/18 revealed [MEDICATION NAME] was administered 11 times for a total of 18 tablets. There was no CSR to correspond with these administrations. The MAR from 08/21/18 through 08/31/18 revealed [MEDICATION NAME] was administered 7 times for a total of 12 tablets. However, the corresponding CSR for the same time frame revealed the [MEDICATION NAME] was signed out 16 times for a total of 30 tablets. An interview was conducted on 09/20/18 at 10:05 a.m. with a Licensed Practical Nurse (LPN/MDS Coordinator/staff #97), who stated that she overheard two nurses talking on 09/06/18 around 8:00 a.m. in the parking lot. Staff #97 stated the two nurses were LPN (staff #63), who was going off duty and LPN (staff #88), who was coming on duty. She stated that they were talking about missing medications. Staff #97 stated that she then asked the nurses about it and staff #88 stated that she had been at the facility on 09/03/18 and had ordered narcotic medications for some residents, but not for a couple of residents, because she knew they had enough medications, but when she returned to work on 09/06/18, the meds were no longer there, and that she knew they had been there. Staff #97 stated that she went straight to the DON and reported the missing medications. A telephone interview was conducted on 09/20/18 at 10:58 a.m. with the LPN (staff #88). The LPN stated that the process for counting and reconciling narcotics and controlled medications is to be completed with two nurses at the end of each shift. She stated that one nurse verifies the remaining quantity of medication in the med drawer and the other nurse verifies the remaining quantity on the CSR. She stated that both nurses sign the Control Drug Reconciling Record after the count. Staff #88 stated that medications are delivered from the pharmacy twice each day, once on the day shift between 3:00 PM and 4:00 PM, then once on the night shift. The LPN stated that when the pharmacy delivers controlled medications and narcotics they come in a separate sealed black bag and there is a Controlled Substance Record (CSR) with each medication. She stated that each signed receipt is photographed via cell phone by the pharmacy delivery person and that the image is signed on the phone. Staff #88 stated that received medications are then entered into the electronic medical record as received under the Medication Administration Record. Staff #88 stated she was aware of a concern about some medications that were missing and that staff #63 had stated it seemed like some of the medications were missing when they talked about it in the parking lot exactly 2 weeks ago. Staff #88 stated that she had worked on 09/03/18 and that she went through all of the medications to see what might be needed for the next week. Staff #88 stated she had not medicated resident #41 at all and knew he had [MEDICATION NAME] available. The LPN stated that she had medicated resident #246 quite a bit and that the resident had plenty of pain medications and did not need any reorder. Staff #88 stated that when staff #63 told her that these two residents did not have enough medications, she told her it was wrong. She stated when doing the narcotic count at shift change, the nurse who has the medications card states a number for each card and the other nurse is verifying that number with the Controlled Substance Records. The LPN stated that she never took any resident's narcotics and did not tear up any Controlled Substance Records and throw them in the shredder bin. A telephone interview was conducted on 09/20/18 at 11:26 a.m. with a LPN (staff #67), who stated that narcotics are ordered through the pharmacy and delivered on the night shift between 3:00 a.m. and 4:00 a.m. The LPN stated he signs the invoice for the medications, and then the delivery person takes a picture of the invoice with his phone and signs for it on the phone. Staff #67 stated the completed Controlled Substance Records are sent to medical records, and are not thrown into the shredder. An interview was conducted on 09/20/18 at 11:45 a.m. with the Director of Nursing (DON/staff #37), who stated that on the morning of 9/6/18, she was informed by staff #97 of missing narcotic medications. The DON stated she immediately went to the unit and checked the narcotics on the medication cart and checked the shred box. She stated that she determined that there was a problem with missing narcotics. The DON stated that staff #63 immediately left the building and left town, but came back in for a drug test and interview. The DON also stated that staff #63 turned in her resignation on 09/10/18. A telephone interview was conducted on 09/21/18 at 3:08 p.m. with staff #63, who stated that she had a conversation with staff #88 about missing [MEDICATION NAME] and [MEDICATION NAME] medications. She stated that she reported it to the previous DON. Staff #63 further stated that she and staff #88 had talked about the suspected missing medications an additional 3-4 times in August, but did not say anything to anyone, because it was just a suspicion. Staff #63 denied taking any medications. -Resident #246 was admitted to the facility on [DATE] and readmitted [DATE], with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment dated [DATE] revealed the resident was rarely or never understood. The Health Condition section included the resident was on a pain and anxiety management program. Review of the physician's orders [REDACTED]. Further review of physician's orders [REDACTED]. The frequency ranged from every 6 hours as needed to a routine scheduled dose. A comparison of the MARs and the CRSs for July, August, and (MONTH) (YEAR) revealed the following: July (YEAR): There were 32 doses of [MEDICATION NAME] that were documented on the MAR as being administered, and there was no evidence of [MEDICATION NAME] signed out on the CSR for (MONTH) (YEAR). July (YEAR): There were 12 doses of [MEDICATION NAME] that were documented on the MAR as being administered, and there were 13 doses of [MEDICATION NAME] which were signed out on the CSR. August (YEAR): There were 36 doses of [MEDICATION NAME] that were documented on the MAR as being administered, and there were 38 doses of [MEDICATION NAME] which were signed out on the CSR. (MONTH) (YEAR): There were 14 doses of [MEDICATION NAME] that were documented on the MAR as being administered, and there were 15 doses of [MEDICATION NAME] which were signed out on the CSR. September (YEAR): There were 8 doses of [MEDICATION NAME] that were documented on the MAR as being administered, and there were 11 doses of [MEDICATION NAME] which were signed out on the CSR. September (YEAR): There were 8 doses of [MEDICATION NAME] that were documented on the MAR as being administered, and there were 8 doses of [MEDICATION NAME] that were signed out on the CSR. -Resident #47 was admitted to the facility on [DATE] and readmitted [DATE], with [DIAGNOSES REDACTED]. A review the significant change MDS assessment dated [DATE] revealed the resident had a BIMS score of 7, which indicated the resident had severe cognitive impairment. The Health Condition section of the MDS included the resident was on a pain management program and received scheduled and as needed pain medications. A physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. A comparison of the MARs and the CSRs for July, August, and (MONTH) (YEAR) revealed the following: July (YEAR): There were 50 doses of [MEDICATION NAME] documented on the MAR as administered, 8 doses refused, 8 doses in which the resident was absent and unable to receive medication, however, there were 57 doses of [MEDICATION NAME] which were signed out on the CSR. July (YEAR): There were 7 doses of [MEDICATION NAME] documented on the MAR as administered; however, there was no evidence of [MEDICATION NAME] signed out for the month of July. There were six [MEDICATION NAME] CSRs sheets, however, only the sixth CSR sheet was located per the DON. August (YEAR): There were 72 doses of [MEDICATION NAME] documented on the MAR as administered, 3 doses refused, 1 dose in which the resident was absent and unable to receive the medication, and 1 dose the resident was sleeping, however, there were 68 doses of [MEDICATION NAME] signed out on the CSR. August (YEAR): There were 6 doses of [MEDICATION NAME] documented on the MAR as administered; however, there was no evidence of [MEDICATION NAME] signed out on the CSR available. September (YEAR): There were 41 doses of [MEDICATION NAME] documented on the MAR as administered, 1 dose was refused, and 1 dose the resident was sleeping. There were 42 doses of [MEDICATION NAME] which were signed out on the CSR. September (YEAR): [MEDICATION NAME] was not documented on the MAR as administered, and there was no evidence that [MEDICATION NAME] was signed out on the CSR for September. -Resident #74 was admitted to the facility on [DATE] and readmitted on [DATE], with the [DIAGNOSES REDACTED]. A review of the 60 day MDS assessment dated [DATE] revealed the resident has a BIMS score of 5, which indicated the resident had severe cognitive impairment. Review of the physician orders [REDACTED]. In addition, orders for [MEDICATION NAME] (narcotic pain medication) 5-325 mg tablet my mouth every 4 hours for pain. A comparison of the MARs and the CSRs revealed the following: July (YEAR): There were 2 doses of [MEDICATION NAME] that were documented on the MAR as administered, however there was no evidence of CSRs for the resident. July (YEAR): There were 9 doses of [MEDICATION NAME] that were documented on the MAR as administered, however there was no evidence of the medications signed out on the CSRs. Documented on the CSRs for [MEDICATION NAME] were six pages of CSRs for [MEDICATION NAME]. However, there was no evidence of the first page and per the DON pages two and three were pieced together from the shred box and several pieces were not located. August (YEAR): There was 1 dose of [MEDICATION NAME] that was documented on the MAR as administered; however, there was no evidence of a CSR for the resident. August (YEAR): There were 2 doses of [MEDICATION NAME] that were documented on the MAR as administered, and there were 3 doses of [MEDICATION NAME] signed out on the CSR. An interview was conducted on 09/20/18 at 10:05 a.m. with a Licensed Practical Nurse (LPN/MDS Coordinator/staff #97), who stated that she overheard two nurses talking on 09/06/18 around 8:00 a.m. in the parking lot. Staff #97 stated the two nurses were LPN (staff #63), who was going off duty and LPN (staff #88), who was coming on duty. She stated that they were talking about missing medications. Staff #97 stated that she then asked the nurses about it and staff #88 stated that she had been at the facility on 09/03/18 and had ordered narcotic medications for some residents, but not for a couple of residents, because she knew they had enough medications, but when she returned to work on 09/06/18, the meds were no longer there, and that she knew they had been there. Staff #97 stated that she went straight to the DON and reported the missing medications. A telephone interview was conducted on 09/20/18 at 10:58 a.m. with the LPN (staff #88). The LPN stated that the process for counting and reconciling narcotics and controlled medications is to be completed with two nurses at the end of each shift. She stated that one nurse verifies the remaining quantity of medication in the med drawer and the other nurse verifies the remaining quantity on the CSR. She stated that both nurses sign the Control Drug Reconciling Record after the count. Staff #88 stated that medications are delivered from the pharmacy twice each day, once on the day shift between 3:00 PM and 4:00 PM, then once on the night shift. The LPN stated that when the pharmacy delivers controlled medications and narcotics they come in a separate sealed black bag and there is a Controlled Substance Record (CSR) with each medication. She stated that each signed receipt is photographed via cell phone by the pharmacy delivery person and that the image is signed on the phone. Staff #88 stated that received medications are then entered into the electronic medical record as received under the Medication Administration Record. Staff #88 stated she was aware of a concern about some medications that were missing and that staff #63 had stated it seemed like some of the medications were missing when they talked about it in the parking lot exactly 2 weeks ago. Staff #88 stated that she had worked on 09/03/18 and that she went through all of the medications to see what might be needed for the next week. Staff #88 stated she had not medicated resident #41 at all and knew he had [MEDICATION NAME] available. The LPN stated that she had medicated resident #246 quite a bit and that the resident had plenty of pain medications and did not need any reorder. Staff #88 stated that when staff #63 told her that these two residents did not have enough medications, she told her it was wrong. She stated when doing the narcotic count at shift change, the nurse who has the medications card states a number for each card and the other nurse is verifying that number with the Controlled Substance Records. The LPN stated that she never took any resident's narcotics and did not tear up any Controlled Substance Records and throw them in the shredder bin. A telephone interview was conducted on 09/20/18 at 11:26 a.m. with a LPN (staff #67), who stated that narcotics are ordered through the pharmacy and delivered on the night shift between 3:00 a.m. and 4:00 a.m. The LPN stated he signs the invoice for the medications, and then the delivery person takes a picture of the invoice with his phone and signs for it on the phone. Staff #67 stated the completed Controlled Substance Records are sent to medical records, and are not thrown into the shredder. An interview was conducted on 09/20/18 at 11:45 a.m. with the Director of Nursing (DON/staff #37), who stated that on the morning of 9/6/18, she was informed by staff #97 of missing narcotic medications. The DON stated she immediately went to the unit and checked the narcotics on the medication cart and checked the shred box. She stated that she determined that there was a problem with missing narcotics. The DON stated that staff #63 immediately left the building and left town, but came back in for a drug test and interview. The DON also stated that staff #63 turned in her resignation on 09/10/18. A telephone interview was conducted on 09/21/18 at 3:08 p.m. with staff #63, who stated that she had a conversation with staff #88 about missing [MEDICATION NAME] and [MEDICATION NAME] medications. She stated that she reported it to the previous DON. Staff #63 further stated that she and staff #88 had talked about the suspected missing medications an additional 3-4 times in August, but did not say anything to anyone, because it was just a suspicion. Staff #63 denied taking any medications. The facility's policy and procedures titled Resident abuse and neglect revealed the facility has adopted a zero tolerance policy related to resident abuse. Any incident or suspected incident of resident abuse will be reported promptly to the appropriate agencies/individuals, Director of Nursing, and the Administrator. Per policy the facility will not condone abuse by anyone including but not limited to staff. In addition, to assist staff in recognizing incidents of abuse the following definition was provided: Misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent.",2020-09-01
913,RIM COUNTRY HEALTH & RETIREMENT COMMUNITY,35134,807 WEST LONGHORN ROAD,PAYSON,AZ,85541,2018-09-25,607,D,0,1,P4TT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility documentation, clinical record review, staff interviews, and policy, the facility failed to implement their abuse policy for two allegations of abuse that involved 4 residents (#s 243, 10, 52, and 57). Findings include: -Review of the facility's investigation revealed that on (MONTH) 11, (YEAR) at 4:45 p.m. a male resident (#243) was sitting beside a female resident (#10) in the television room of the secured memory care unit when resident #243 reached over and touched her lap area outside her clothing. The investigation included that resident #243 was redirected by the activity assistant (staff #8) who remained in the area to monitor the residents until nursing staff returned. Staff #8 then witnessed resident #243 touch resident #10's thigh a few minutes later and she again re-directed resident #243. The investigation identified the incident as a resident to resident event. Per the investigation the Director of Nursing (DON/staff #37) stated that on (MONTH) 12, (YEAR) at 8:10 a.m., she received the report that resident #243 had inappropriately touched a female resident. However, the State Agency was not notified of the allegation until (MONTH) 12, (YEAR) at 3:05 p.m. and no documentation was found that Adult Protective Services were notified. An interview was conducted with the Director of Nursing (DON/staff #37) on (MONTH) 20, (YEAR) at 10:20 a.m. She stated that the sexual abuse allegation was not reported immediately to the DON by the charge nurse on (MONTH) 11, (YEAR). The DON stated the nurse did not report the allegation to administration until the next morning (September 12, (YEAR)). -Resident #52 was admitted on (MONTH) 10, (YEAR), with [DIAGNOSES REDACTED]. -Resident #57 was admitted on (MONTH) 3, (YEAR), with [DIAGNOSES REDACTED]. During an observation conducted on (MONTH) 17, (YEAR) at 11:17 [NAME]M. in the hallway on the Pony unit, resident #52 was observed sitting in a Geri chair in the hallway and resident #57 was observed ambulating in the hallway. Resident #57 was observed to strike resident #52 on the right forearm with her open right hand as she walked by resident #52. Resident #52 was then observed to strike resident #57 on the right buttock with her open right hand. No verbal exchange was observed between the residents preceding the physical exchange. Resident #57 was observed to continue to walk down the hallway away from resident #52. The incident was immediately reported to the administrator (staff #128). However, review of the Reportable Event Record/Report revealed the incident was not reported to the State Agency and Adult Protective Services (APS) until (MONTH) 18, (YEAR) at 10:20 AM. During an interview conducted with the Assistant Director of Nursing (ADON/staff #3) on (MONTH) 18, (YEAR) at 11:45 AM, the ADON stated that she made the report to the State Agency on (MONTH) 18, (YEAR). The facility's policy titled Resident Abuse and Neglect revealed the administrator will be immediately alerted to every potential abuse incident. The policy included that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made if the events involve abuse to the administrator of the facility and to other officials as appropriate.",2020-09-01
914,RIM COUNTRY HEALTH & RETIREMENT COMMUNITY,35134,807 WEST LONGHORN ROAD,PAYSON,AZ,85541,2018-09-25,609,D,1,1,P4TT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility documentation, clinical record review, staff interviews, and policy, the facility failed to ensure that two allegations of abuse were reported to the State Agency and Adult Protective Services within the required time frame. Findings include: -Review of the facility's investigation revealed that on (MONTH) 11, (YEAR) at 4:45 p.m. a male resident (#243) was sitting beside a female resident (#10) in the television room of the secured memory care unit when resident #243 reached over and touched her lap area outside her clothing. The investigation included that resident #243 was redirected by the activity assistant (staff #8) who remained in the area to monitor the residents until nursing staff returned. Staff #8 then witnessed resident #243 touch resident #10's thigh a few minutes later and she again re-directed resident #243. The investigation identified the incident as a resident to resident event. Per the investigation the Director of Nursing (DON/staff #37) stated that on (MONTH) 12, (YEAR) at 8:10 a.m., she received the report that resident #243 had inappropriately touched a female resident. However, the State Agency was not notified of the allegation until (MONTH) 12, (YEAR) at 3:05 p.m. and no documentation was found that Adult Protective Services were notified. An interview was conducted with staff #8 on (MONTH) 19, (YEAR) at 11:40 a.m. She stated that on (MONTH) 11, 1018 at 4:45 p.m., she was standing with the residents during an evening activity. She stated that she saw resident #243 push his hand between the legs of resident #10. She stated that she walked over and moved his hand off of resident #10 and talked with him. She stated that is when she noticed that he was holding a pair of glasses in the hand that was between resident's #10 legs. She stated that she then hung his glasses on his shirt where he usually keeps them and asked him to please not do that to resident #10. She stated that she started to walk away, but then saw resident #243 again put his hand between the legs of resident #10. Staff #8 stated that she moved his hand away and told him to please keep his hands to himself. She stated that she then walked behind them and looked at both residents, and saw resident #243 with his hand just above the knee of resident #10. Staff #8 stated that she told resident #243 to keep his hands to himself and not to be touching other people. She stated that at that point resident #10 got up and went into the dining room. An interview was conducted with the Director of Nursing (DON/staff #37) on (MONTH) 20, (YEAR) at 10:20 a.m. She stated that the sexual abuse allegation was not reported immediately to the DON by the charge nurse on (MONTH) 11, (YEAR). The DON stated the nurse did not report the allegation to administration until the next morning (September 12, (YEAR)). -Resident #52 was admitted on (MONTH) 10, (YEAR), with [DIAGNOSES REDACTED]. -Resident #57 was admitted on (MONTH) 3, (YEAR), with [DIAGNOSES REDACTED]. During an observation conducted on (MONTH) 17, (YEAR) at 11:17 [NAME]M. in the hallway on the Pony unit, resident #52 was observed sitting in a Geri chair in the hallway and resident #57 was observed ambulating in the hallway. Resident #57 was observed to strike resident #52 on the right forearm with her open right hand as she walked by resident #52. Resident #52 was then observed to strike resident #57 on the right buttock with her open right hand. No verbal exchange was observed between the residents preceding the physical exchange. Resident #57 was observed to continue to walk down the hallway away from resident #52. The incident was immediately reported to the administrator (staff #128). However, review of the Reportable Event Record/Report revealed the incident was not reported to the State Agency and Adult Protective Services (APS) until (MONTH) 18, (YEAR) at 10:20 AM. During an interview conducted with the Assistant Director of Nursing (ADON/staff #3) on (MONTH) 18, (YEAR) at 11:45 AM, the ADON stated that she faxed the report to the State Agency that morning (September 18, (YEAR)). The facility's policy titled Resident Abuse and Neglect revealed the administrator will be immediately alerted to every potential abuse incident. The policy included that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made if the events involve abuse to the administrator of the facility and to other officials as appropriate.",2020-09-01
915,RIM COUNTRY HEALTH & RETIREMENT COMMUNITY,35134,807 WEST LONGHORN ROAD,PAYSON,AZ,85541,2018-09-25,645,D,0,1,P4TT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of policy, the facility failed to complete the Preadmission Screening and Resident Review (PASARR) process for two residents (#10 and #29). Findings include: -Resident #10 was admitted to the facility on (MONTH) 15, 2006, with [DIAGNOSES REDACTED]. Review of the PASARR level 1 screening document for resident #10 dated (MONTH) 31, (YEAR) revealed a PASARR level 2 evaluation needed to be completed for a [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated (MONTH) 17, (YEAR) revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident's cognition was moderately impaired. The MDS also included [DIAGNOSES REDACTED]. Review of the clinical records did not reveal any documentation of a level 2 evaluation. An interview was conducted with social services (staff #115) on (MONTH) 21, (YEAR) at 10:14 a.m. She stated that the PASARR assessment is received prior to admission. An interview was conducted with the admission director (staff #127) on (MONTH) 21, (YEAR) at 10:20 a.m. She stated that within 30 days of a resident being recommended for a PASARR level 2, the facility will send a packet to the appropriate office which contains hospital records, two weeks of observations of the resident's signs and symptoms, and an evaluation from the physician and the psychiatrist. Staff #127 stated that a report will be returned to the facility that will indicate if the resident is appropriate for the facility. She stated that the facility would then continue to monitor for changes in the resident's status and that a resident with a level 2 status would be on the psychiatry providers list each month until stable. Staff #127 stated that she was unable to find the documentation that the level 2 recommendation was followed through for resident #10. An interview was conducted with the Director of Nursing (DON/staff #37) on (MONTH) 21, (YEAR) at 10:17 a.m. She stated that when the resident comes from the hospital, the medical record staff will check for the PASARR screenings. She stated that if a level 2 evaluation is needed, social services will submit this to the State and that once the level 2 evaluation is completed it will be incorporated into the resident's clinical record. -Resident #29 was readmitted to the facility on (MONTH) 12, 2011 with [DIAGNOSES REDACTED]. Review of the PASARR level I screening document dated (MONTH) 10, 2011, revealed that an exemption was selected due to the resident's expected stay in the nursing facility was to be 30 days or less. The screening document included that a PASARR level II referral was not necessary. Review of the clinical record revealed that the resident remained in the facility which is more than 30 days. The care plan dated (MONTH) 6, (YEAR), revealed the resident was a PASARR level I. The care plan stated that all care and services for the resident would be provided by the facility, and that the resident did not require specialized services. The care plan did not address that the resident's level I PASARR dated May, 10, 2011, included an exemption due to the expectation that the resident's nursing facility stay would be 30 days or less. Review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 8, (YEAR) revealed a Brief Interview for Mental Status (BIMS) score of 0 which indicated the resident's cognition was severely impaired. The MDS also included [DIAGNOSES REDACTED]. An interview was conducted with the admissions director (staff #127) on (MONTH) 18, (YEAR) at 2:01 PM. She stated the facility did not conduct another PASARR screening for resident #29. She stated the facility relied on the screening dated (MONTH) 10, 2011. Another interview was conducted with staff #127 on (MONTH) 19, (YEAR) at 10:33 AM. She stated that she and the social services director (staff #115) shared responsibility for conducting PASARR level I screenings for residents. She stated that level I screenings were conducted as needed, and that she sends referrals to the State to conduct level II evaluations. The facility's policy regarding PASARR Evaluation revealed that the medical records department was responsible for reviewing each new admission to ensure a PASARR was completed. If a PASARR was not completed, social services would review the resident's diagnoses. If the resident has a [DIAGNOSES REDACTED].",2020-09-01
916,RIM COUNTRY HEALTH & RETIREMENT COMMUNITY,35134,807 WEST LONGHORN ROAD,PAYSON,AZ,85541,2018-09-25,655,D,0,1,P4TT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interviews, and policy, the facility failed to ensure two residents (#143 and #65) and their representatives were provided with a summary of their baseline care plans. Findings include: -Resident #65 was admitted on (MONTH) 14, (YEAR) with [DIAGNOSES REDACTED]. Review of the admission physician's orders [REDACTED]. A care plan dated (MONTH) 14, (YEAR), included problems, goals, and interventions related to hospice services, [MEDICAL CONDITION] medications, pain, requiring assistance with activities of daily living, cognitive loss, and risk for injury. Review of the clinical record revealed no documentation that the care plan summary had been provided the resident and her representative. The facility was unable to provide any documentation that a summary of the baseline care plan had been provided to resident and her representative. During an interview conducted on (MONTH) 21, (YEAR) at 9:12 AM with a Registered Nurse (RN/staff #57), the RN stated that a baseline care plan is completed on admission while she is doing the full assessment. Staff #57 stated there are other disciplines that also contribute to the baseline care plan and that when they completed their parts, they will notify the nurse. She further stated that the nurse will provide the summary to the resident and/or responsible party and obtain their signature. An interview was conducted with the Director of Nursing (DON/staff#37) on (MONTH) 21, (YEAR) at 9:36 AM. The DON stated that the baseline care plan process is initiated by the admission assessment nurse and that other entities are notified to enter their input. Staff #37 stated the admitting nurse will review the plan with the resident or the resident's representative and have them sign the care plan. The DON stated the signed care plan is then scanned into the electronic record. The DON stated the only signed baseline care plan for resident #65 is dated (MONTH) 22, (YEAR). -Resident #143 was admitted to the facility on (MONTH) 11, (YEAR) with [DIAGNOSES REDACTED]. Per an admission baseline care plan assessment dated (MONTH) 11, (YEAR), the resident was assessed to be alert and cognitively intact. Continued review of the admission baseline care plan documented the resident problem areas as follows: -High risk for falls. -Skin integrity issues of [MEDICAL CONDITION]. -Obstructive sleep apnea. -[MEDICAL CONDITION]. -Use of indwelling urinary catheter. -Need for skilled therapy services. The baseline care plan also included the resident needed education regarding orientation to the facility and his routine. Although the baseline care plan was signed by several staff members the section for the resident's signature was blank and there was no evidence the resident had been given a copy of the baseline care plan or had been told of his plan of care. During a resident interview conducted on (MONTH) 17, (YEAR) at 2:33 p.m., he stated that he was not aware of any plan of care and that he had not received anything verbally or in writing about how the staff would care for him and meet his needs. An interview was conducted with a Licensed Practical Nurse (staff #38) on (MONTH) 21, (YEAR) at 9:55 a.m. She stated that the procedure is to have the resident or representative sign and date the baseline care plan. Staff #38 stated the reason the resident is at the facility, what the resident care needs are, and which staff will provided the care is on the baseline care plan and reviewed with the resident. She stated the resident's signature is missing from the baseline care plan form and therefore was probably not reviewed with him. An interview was conducted with the Director of Nursing (DON/staff#37) on (MONTH) 21, (YEAR) at 9:36 AM. The DON stated that the baseline care plan process is initiated by the admission assessment nurse and that other entities are notified to enter their input. Staff #37 stated the admitting nurse will review the plan with the resident or the resident's representative and have them sign the care plan. The DON stated the signed care plan is then scanned into the electronic record. The facility's policy regarding Care Plans and Weekly Care Plan Meetings revealed each resident would have an individualized care plan written after assessment and completed by a licensed nurse upon admission. The policy included the baseline care plan would be reviewed with the resident and family upon completion and signatures would be obtained.",2020-09-01
917,RIM COUNTRY HEALTH & RETIREMENT COMMUNITY,35134,807 WEST LONGHORN ROAD,PAYSON,AZ,85541,2018-09-25,658,E,0,1,P4TT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of clinical records, staff interviews, pharmacy and facility documents, and policy, the facility failed to ensure 6 residents (#25, #62, #41, #246, #47, and 74) had medications documented as per standard on the Medication Administration Record (MAR)/Controlled Substance Records (CSR) and failed to ensure medications were not left on the dining table for two residents (#20 and #66). Findings include: During a review of the MARs for 6 residents, the following was identified: -Resident #25 was admitted to the facility on [DATE], and then readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. The frequency ranged from every 4 hours as needed initially to every 8 hours as needed. A comparison of the MARs and the CSR used to sign out narcotics from the secured storage drawer revealed the following: July (YEAR): 112 doses of [MEDICATION NAME] were documented on the MAR as administered and 121 doses of [MEDICATION NAME] were signed on out the CSR. August (YEAR): 94 doses of [MEDICATION NAME] were documented on the MAR as administered and 85 doses of [MEDICATION NAME] were signed on out the CSR. One of the two CSR sheets, page 2 of 2 from 08/18/18, was missing per the DON. September (YEAR): 50 doses of [MEDICATION NAME] were documented on the MAR as administered and 57 doses were signed out on the CSR. -Resident #62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A comparison of the MAR with the CSR sheets revealed the following: August (YEAR): 29 doses of [MEDICATION NAME] were documented on the MAR as administered and 2 doses were refused. 28 doses of [MEDICATION NAME] were signed out on the CSR. 1 dose of [MEDICATION NAME] was documented on the MAR as administered but there was no correlating dose signed out on the CSR. -Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A comparison of the MAR and the CSR sheets revealed the following: August (YEAR): Review of the MAR from 08/01/18 through 08/20/18 revealed documentation that 11 doses of [MEDICATION NAME] was administered for a total of 18 tablets. No CSR was found to correspond with these administrations. Review of the MAR from 08/21/18 through 08/31/18 revealed documentation that 7 doses of [MEDICATION NAME] was administered for a total of 12 tablets. However, the corresponding CSR revealed 16 doses were signed out on the CSR for a total of 30 tablets. -Resident #246 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. dated 08/23/18 for [MEDICATION NAME] 5 mg one tablet every 6 hours as needed for pain. A comparison of the MARs and the CSR sheets revealed the following: July (YEAR): 30 doses of [MEDICATION NAME] were documented as administered on the MAR and no CSR was found to correspond with these administrations. 12 doses of [MEDICATION NAME] 0.5 mg were documented as administered on the MAR and 15 doses were signed out on the CSR. August (YEAR): 12 doses of [MEDICATION NAME] 0.5 mg were documented as administered on the MAR and 15 doses were signed out on the CSR. 44 doses of [MEDICATION NAME] were documented as administered on the MAR and 37 doses were signed out on the CSR. September (YEAR): 8 doses of [MEDICATION NAME] were documented as administered on the MAR and 11 doses were signed out on the CSR. -Resident #74 was admitted to the facility on [DATE] and discharged home on[DATE]. [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. 6 hours as needed for pain. Review of the (MONTH) (YEAR) MAR revealed documentation that 11 doses of [MEDICATION NAME] was administered. There was no corresponding CSR. -Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. -an order dated 03/27/18 for [MEDICATION NAME] 1 mg one tablet two times a day for anxiety -an order dated 04/20/18 for [MEDICATION NAME] 5 mg one tablet every 4 hours as needed for pain -an order dated 07/23/18 for [MEDICATION NAME] 1 mg tablet one time a day on Monday, Wednesday, and Friday for anxiety related to [MEDICAL TREATMENT] -two orders dated 08/12/18 for [MEDICATION NAME] 1 mg one tablet on Monday, Wednesday, and Friday for anxiety related to [MEDICAL TREATMENT] and another order on the same date for [MEDICATION NAME] 1 mg tablet two times a day for anxiety -an order dated 08/13/18 for [MEDICATION NAME] 5mg one tablet every 4 hours as needed for pain A comparison of the MARs and the CSR sheets revealed the following: July (YEAR): A total of 60 doses of [MEDICATION NAME] for [MEDICAL TREATMENT] anxiety or twice daily anxiety were documented on the MAR (6 additional doses were refused). The CSRs revealed 50 doses of [MEDICATION NAME] were signed out. 7 doses of [MEDICATION NAME] was documented as administered on the MAR. There was no corresponding CSR. August (YEAR): A total of 73 doses of [MEDICATION NAME] was documented as administered on the MAR (3 doses refused) and the CSRs revealed documentation that 72 doses of [MEDICATION NAME] were signed out. 6 doses of [MEDICATION NAME] was administered on the MAR. There was no corresponding CSR. A telephone interview was conducted on 09/20/18 at 10:58 AM with a Registered Nurse (RN/staff #88), who stated that the process for administration of a controlled medication included the following steps: resident pain is assessed; open the narcotic drawer and retrieve the medication; open the narcotic book and sign out the medication on the CSR at the time it is removed; administer the medication; document the medication on the MAR and on the E-MAR progress note. A telephone interview was conducted on 09/20/18 at 11:26 AM with a LPN (staff #67) who stated that he administers a narcotic, he signs the CSR at the time he gets the medication out of the drawer and signs the MAR when the medication is administered. An interview was conducted on 09/20/18 at 11:45 with the Registered Nurse/Director of Nursing (DON/staff #37) who stated that the nurses should sign the narcotic out on the CSR at the time they remove it from the locked narcotic drawer and sign the medication on the MAR at the time it is administered. The facility's policy titled Medication Administration revealed the facility will adopt a non-punitive policy to assure the ability to obtain and track data regarding administration concerns and tracking of controlled drugs. The policy included the facility is committed to staff education to assure the safe practice of medication administration. The policy also revealed the nursing staff will observe the '6 Rights' which included right documentation when administering medication. -Resident #20 was admitted on (MONTH) 28, (YEAR) with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 7, (YEAR) revealed the resident had a Brief Interview for Mental Status score of 11, which indicated moderate cognitive impairment. The assessment also revealed that the resident received an antidepressant on all days of the 7-day assessment period. The resident's care plan included a problem of cognitive loss due to dementia with a goal to have all needs met through staff observation and assistance. Interventions which included segmenting tasks, cue as needed, and orient as needed to person, place, and situation. A review of the physician's orders [REDACTED]. A review of the (MONTH) (YEAR) Medication Administration Record revealed that the resident had medications to be administered at 8:00 AM daily that included [MEDICATION NAME] Oxalate tablet 10 milligrams (mg) for major [MEDICAL CONDITION], [MEDICATION NAME] tablet 20 mg for [MEDICAL CONDITION], and [MEDICATION NAME] tablet 80 mg for essential hypertension. The above medications were signed off as administered on (MONTH) 19, (YEAR) at 8:00 AM by a Licensed Practical Nurse (LPN /staff #42). During a dining observation conducted on (MONTH) 19, (YEAR) at 8:02 AM, the LPN (staff #42) was observed checking the arm band of resident #20 and then setting a small cup on the table in front of the resident. The nurse was heard to direct the resident to take her medications and then walked out of the dining room. Approximately one to two minutes later the resident was observed to take the medications. -Resident #66 was admitted on (MONTH) 6, (YEAR) with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment dated (MONTH) 24, (YEAR) revealed a Brief Interview for Mental Status score of 14 which indicated the resident was cognitively intact. The assessment also revealed that the resident received an antidepressant on all days of the 7-day assessment period. A review of the (MONTH) (YEAR) Medication Administration Record revealed that the resident had medications to be administered at 8:00 AM daily that included Aspirin tablet 81 mg for [MEDICATION NAME], Folic acid tablet 1 mg (supplement), [MEDICATION NAME] tablet 10 mg for depression, [MEDICATION NAME] tablet 25 mg for hypertension, Renal multivitamin formula tablet for supplement and healing, Vitamin C tablet 500 mg for supplement and healing, Zinc tablet 220 mg for supplement and healing, NAME] tablet delayed release 40 mg for severe [MEDICAL CONDITION] reflux disease, and Tums tablet 500 mg for high [MEDICATION NAME]. The above medications were signed off as administered on (MONTH) 19, (YEAR) at 8:00 AM by LPN #42. A review of the physician's orders [REDACTED]. During a dining observation conducted on (MONTH) 19, (YEAR) at 8:11 AM, the LPN (staff #42) was observed checking the arm band of resident #66 and then setting a small cup on the table in front of the resident. The nurse was heard to direct the resident to take his medications and then walked out of the dining room. Approximately one to two minutes later the resident was observed to take the medications. During an interview conducted on (MONTH) 21, (YEAR) at 9:12 AM with a Registered Nurse (RN/staff #57), she stated that she would administer medications in the dining room if there's a physician's orders [REDACTED]. She further stated that she had been told that it is ok to leave medications with the resident if they are alert and oriented. During an interview conducted on (MONTH) 21, (YEAR) at 9:29 AM with the Director of Nursing (DON/staff #37), the DON stated that for every resident with a physician's orders [REDACTED]. She further stated that the nurse may leave the medications with the resident if the resident is alert and oriented enough to know the medications are there and to take them. The DON stated that the nurse needs to keep an eye on that resident to visualize them taking the medication. A review of the facility's policy titled Medication Administration revealed the nursing staff will observe the 6 rights (right drug, right dose, right route, right time, right resident, right documentation) when administering medication. No medication should be given without checking the resident's identifiers. The policy included no medications will be left unattended at the bedside for any reason.",2020-09-01
918,RIM COUNTRY HEALTH & RETIREMENT COMMUNITY,35134,807 WEST LONGHORN ROAD,PAYSON,AZ,85541,2018-09-25,684,D,1,1,P4TT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, facility's report, resident and staff interviews, and review of policy and procedure, the facility failed to ensure one resident (#12) was provided incontinent care in accordance with professional standards of practice. Findings include: Resident #12 was admitted to the facility on (MONTH) 24, (YEAR) with [DIAGNOSES REDACTED]. Per the annual Minimum Data Set assessment dated (MONTH) 19, (YEAR) revealed the brief interview for mental status score was 15, which indicated no cognitive impairment. In addition, the resident was assessed to always be incontinent of urine and frequently incontinent of bowel. The assessment included the resident was totally dependent on staff for toileting. A care plan with a revision date of (MONTH) 24, (YEAR) revealed the resident was at high risk for skin breakdown related to immobility and incontinence. The goal was to have no further skin breakdown. Interventions included: -Address any incontinence care as needed. -Encourage or assist the resident in shifting or changing position every hour when up in the chair. -Observe skin daily during routine care and report changes. -Provide preventative skin care per protocol. A care plan with a revision date (MONTH) 5, (YEAR) revealed the resident had altered elimination as exhibited by bowel and bladder incontinence. The goal was for the resident to participate in incontinence care. Interventions included: -Utilize barrier cream with incontinence care to prevent skin breakdown. -Resident will be assisted to the commode/toilet every 2 hours to assist with elimination. -Resident will be checked for incontinence every 2 hours and care provided if needed. -Perform thorough pericare after each incontinent episode. A review of the weekly skin assessments dated (MONTH) 4, 11, 19, and 26, (YEAR) revealed the resident's skin was intact. A review of a facility's report revealed the resident reported to staff on (MONTH) 30, (YEAR) a Certified Nursing Assistant (CNA/staff #129) had not provided her timely incontinence care and that she felt like she was getting a sore. The report further included staff #129 observed a small opening on the resident's bottom. The facility's report revealed documentation staff #129 was counseled regarding the lack of providing timely incontinence care to resident #12 and that because of the lack of care, the resident now has skin breakdown identified as moisture associated skin damage to the coccyx area. A skin assessment dated (MONTH) 1, (YEAR) revealed the resident had moisture associated skin damage on her coccyx area. The area was 100% pink and blancheable and there was no odor or drainage. The area was superficial and the periwound was blancheable. Treatments were provided per physician orders. The assessment included the area healed on (MONTH) 9, (YEAR). An interview was conducted with the Assistant Director of Nursing (ADON/staff #3) on (MONTH) 20, (YEAR) at 11:09 a.m. She stated that the resident had made an allegation that incontinence care was not provided to her timely and as a result the resident had moisture associated skin breakdown. The ADON stated the physician was notified; treatment orders were obtained and provided. During an interview conducted with a Registered Nurse (staff #57) on (MONTH) 20, (YEAR) at 12:35 p.m., she stated any resident who is incontinent must be checked every 2 hours or more frequently if needed and that incontinence care needs to be provided right away. An interview was conducted with a CNA (staff #81) on (MONTH) 20, (YEAR) at 12:50 p.m. She stated that it is the policy of the facility that all residents who were incontinent be checked at least every 2 hours or more often if necessary. She stated that if the resident needed a brief change, the resident needs to be changed as soon as possible to prevent skin breakdown. An interview was conducted with a CNA (staff #53) on (MONTH) 20, (YEAR) at 1:39 p.m. She stated that any resident who is incontinent must be provided care as soon as possible. The facility's policy regarding resident rights included the facility shall care for its residents in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life.",2020-09-01
919,RIM COUNTRY HEALTH & RETIREMENT COMMUNITY,35134,807 WEST LONGHORN ROAD,PAYSON,AZ,85541,2018-09-25,686,D,0,1,P4TT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff and family interviews, and policy, the facility failed to ensure the necessary treatment and services were provided to one resident (#81) with pressure ulcers. Findings include: Resident #81 was admitted to the facility on (MONTH) 20, (YEAR), with [DIAGNOSES REDACTED]. The nursing admission assessment dated (MONTH) 20, (YEAR) revealed the resident was alert and oriented to person and place. The assessment also included the resident had a skin tear to the right elbow. No pressure ulcers were documented. Review of a Braden scale dated (MONTH) 20, (YEAR), revealed the resident was at a low risk for developing skin breakdown. Review of the care plan initiated (MONTH) 21, (YEAR), revealed the resident was at risk for skin breakdown related to impaired mobility and incontinence. The interventions included a pressure redistributing mattress to the bed, a pad in the chair, and observing the skin during routine care and reporting any changes and to provide preventative skin care per protocol (which included floating heels and heel protectors if needed). The admission Minimum Data Set (MDS) assessment dated (MONTH) 27, (YEAR), revealed a Brief Interview for Mental Status (BIMS) score of 0 which indicated the resident had severely impaired cognition. The assessment also included the resident did not have any pressure ulcers but was at risk for developing pressure ulcers. A Braden scale dated (MONTH) 27, (YEAR), revealed the resident was at moderate risk for developing skin breakdown. Review of the nurse progress note dated (MONTH) 30, (YEAR), revealed that heel protectors were in place while the resident was in bed. A Braden scale dated (MONTH) 3, (YEAR), revealed the resident was at low risk for developing skin breakdown. Review of the weekly skin check record dated (MONTH) 3, (YEAR), revealed the resident had a stage 2 left heel pressure ulcer (an intact clear fluid filled blister) that measured 4.5 centimeters (cm) x 5.0 cm x 0 cm. The weekly skin check also included the resident had a suspected deep tissue injury pressure ulcer (an intact dark purple blister) to the right heel that measured 3.8 cm x 4.2 cm x 0 cm. The record revealed the physician and family were notified and that the heel protectors were changed to large heel boots. The physician's orders [REDACTED]. A significant change Minimum Data Set (MDS) assessment dated (MONTH) 3, (YEAR), revealed the resident had severely impaired cognitive skills for daily decision making and required extensive assistance with bed mobility and transfers. The MDS assessment also included the resident had one stage 2 pressure ulcer and one unstageable pressure ulcer. The skin care plan was updated (MONTH) 3, (YEAR), to include the large heel/foot boots when in bed and to float the heels at all times. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Review of the Treatment Administration Record for (MONTH) (YEAR), revealed documentation these orders were implemented. Further review of the clinical record revealed multiple progress notes that the resident would remove the heel protectors and soft boots. An observation was conducted on (MONTH) 18, (YEAR) at 2:23 p.m. of the resident lying in bed with slippers on both feet. The resident was not observed with her feet elevated and was not observed wearing heel protectors/boots. An interview was conducted on (MONTH) 18, (YEAR) at 2:32 p.m. after this observation with a registered nurse (RN/staff #33). The RN stated that staff would apply the heel protectors, but that the resident would take them off. She also stated that they tried the soft boots but that when they would apply the soft boots; the resident would remove them as well. During an observation conducted on (MONTH) 19, (YEAR) at 9:25 a.m., the resident was observed sitting in her wheelchair just outside of her room. The resident was observed wearing slippers with her feet resting on the floor. No footrests were observed attached to the wheelchair. Another observation was conducted on (MONTH) 19, (YEAR) at 12:58 p.m. Resident #81 was observed sitting in her wheelchair in the hallway by her room. No footrests were observed on the wheelchair and the resident was observed wearing slippers with her feet on the floor. A wound care observation was conducted on (MONTH) 19, (YEAR) at 1:04 p.m. with a registered nurse (RN/staff #84). After the wound treatment, the RN was observed to apply the soft boots but not elevate the resident's heels. During an interview conducted with a certified nursing assistant (CNA/staff #68) on (MONTH) 21, (YEAR) at 8:07 a.m., the CNA stated that he assists the resident to bed, then applies the heel protectors and elevates the resident's feet with a pillow. On (MONTH) 21, (YEAR) at 9:44 a.m., the resident was observed sleeping in bed with no boots on and her feet not elevated. The resident's daughter was in the room and stated that a male CNA had assisted the resident to bed and that he did not elevate the resident's feet or put the soft boots on the resident. The soft boots were observed on the resident's wheelchair. An interview was conducted with the Assistant Director of Nursing/wound nurse (staff #3) on (MONTH) 21, (YEAR) at 9:52 a.m. Staff #3 stated that after providing treatment to the resident's heels, the heel protectors are put on and the heels floated. The facility's policy regarding Prevention and treatment of [REDACTED]. The policy also included residents will receive the appropriate treatment to promote healing and to prevent any other pressure wounds.",2020-09-01
920,RIM COUNTRY HEALTH & RETIREMENT COMMUNITY,35134,807 WEST LONGHORN ROAD,PAYSON,AZ,85541,2018-09-25,697,D,0,1,P4TT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, and policy and procedures, the facility failed to ensure two residents (#246 and #47) received pain medications per the physician orders. Findings include: -Resident #246 was admitted to the facility on (MONTH) 19, 2007 and readmitted on (MONTH) 6, (YEAR), with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. The order included to use the pain scale of 0-10 or the face scale. A physician order [REDACTED]. A review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 13, (YEAR) revealed the resident was rarely or never understood. The Health Condition section included the resident was on a pain management program. Review of the current care plan revealed the resident had the potential for chronic pain related to side effects of [MEDICAL TREATMENT]. The resident's goal was to not have discomfort related to side effects of [MEDICATION NAME]. Interventions included anticipate the need for pain relief and respond immediately to a complaint of pain and evaluate the effectiveness of pain interventions. Review of the medication administration record (MAR) for (MONTH) (YEAR) revealed there were 4 occasions during the scheduled pain assessments (July 17 at 8:00 a.m., (MONTH) 22 at 8:00 p.m., (MONTH) 23 at 8:00 p.m., and (MONTH) 24 at 8:00 a.m.), that the resident's pain was documented to be a 4 or greater. Further review of the MAR revealed the as needed [MEDICATION NAME] pain medication was available to be administered. Review of a pain assessment dated (MONTH) 26, (YEAR) revealed resident's pain frequency was frequent and that the resident stated the pain was moderate. Review of the MAR for (MONTH) (YEAR) revealed one occasion (August 11 at 8:00 p.m.) the scheduled pain assessment was documented to be 4. Further review of the MAR revealed the resident was not administered as needed pain medication for (MONTH) 11, (YEAR) at 8:00 p.m. Review of the MAR for (MONTH) (YEAR) revealed three occasions (September 1 at 8:00 p.m., (MONTH) 11 at 8:00 a.m., and (MONTH) 12 at 8:00 p.m.), that the resident's pain was a 4 or greater. Further review of the MAR revealed the resident was administered an as needed [MEDICATION NAME] at 8:00 a.m. on (MONTH) 1. However, no pain medication was documented as administered at 8:00 p.m. on (MONTH) 1 or (MONTH) 11 at 8:00 a.m. or (MONTH) 12 at 8:00 p.m. Review of the electronic MAR notes and the nursing notes corresponding to the dates listed above revealed no evidence of pain interventions, pain medication administration, or notification to the physician. -Resident #47 was admitted to the facility on (MONTH) 11, 2011 and readmitted (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. The order included to use the pain scale of 0-10 or face scale. A physician's orders [REDACTED]. Review of the MAR for (MONTH) (YEAR) revealed on (MONTH) 1, (YEAR) at 8:00 a.m. the resident's pain was 5 out of 10 on the pain scale. There was no evidence as needed pain medication was administered at or around that time. Later that day at 12:55 p.m., the resident's pain was documented an 8 out of 10 and the resident was administered [MEDICATION NAME] 5-325 mg tablet. On (MONTH) 24, (YEAR) at 8:00 a.m., the resident's pain was documented as 4 out of 10 on the pain scale. There was no evidence as needed pain medication was administered at or around that time. A review the significant change MDS assessment dated (MONTH) 28, (YEAR) revealed a BIMS score of 7, which indicated the resident had severe cognitive impairment. The Health Condition section of the MDS assessment revealed the resident was on a pain management program and received scheduled and as needed pain medications. Review of the current care plan revealed the resident had an alteration in comfort related to end stage [MEDICAL CONDITION] and aging process. The resident's goal included to be comfortable with discomfort within one hour of medication and report to nurse if not relieved. Interventions included administer medications per physician orders, monitor and document pain management. Review of the MAR for (MONTH) (YEAR) revealed on (MONTH) 10, (YEAR) at 8:00 p.m. the resident's pain was 4 out of 10. There was no evidence of as needed pain medication was administered. A physician's orders [REDACTED]. Review of the MAR for (MONTH) (YEAR) revealed on (MONTH) 17 at 8:00 p.m., the resident's pain was 7 out of 10; however, there was no evidence of as needed pain medication administration. Review of the nursing notes and the electronic MAR notes revealed there no evidence of non-pharmacological interventions for pain, pain medication administration, or notification to the physician regarding the resident's pain for the corresponding dates listed above. An interview was conducted on (MONTH) 19, (YEAR) at 12:22 p.m. with a registered nurse (RN/staff #84). Staff #84 stated pain assessments are completed every shift (12 hour shifts) using the numerical pain scale 0-10 for cognitively intact residents and a pain aid chart for cognitively impaired residents. She stated that the pain aid chart monitors for breathing, facial expression, and mood that is based off a point system 0-10. The RN stated pain assessments include the location, characteristics, onset, and the alleviating interventions and identification of a tolerable pain level. Staff #84 stated that if a resident is in pain, staff are to determine if there are scheduled pain medications or as needed pain medications that can be administered. She stated pain medication orders are followed as ordered. The RN stated non-pharmacological interventions for pain can be used to control pain. Staff #84 stated that she is familiar with the order for administering as needed pain medication if the pain is a 4 or greater. She stated that the order should be followed as ordered and that if the pain is uncontrolled, the physician is notified. During an interview conducted on (MONTH) 19, (YEAR) at 10:58 a.m. with a licensed practical nurse (staff #42), she stated that physician's orders [REDACTED]. She further stated that when administering pain medications, it is documented on the MAR and the controlled substance record if the medication is a narcotic. An interview was conducted on (MONTH) 20, (YEAR) at 11:45 a.m. with the Director of Nursing (DON/staff #37). She stated pain assessments are completed each shift or as needed throughout the shift if the resident is verbalizing pain or showing signs of pain. The DON further stated that nurses are to assess the pain and administer the appropriate medications according to the ordered pain scale and reassess the resident's pain after administering the pain medication. She stated the nurses are to use non-pharmacological intervention before or with pain medication administration. The facility's policy and procedures titled Pain Management revealed is it the facility's goal through assessment, interventions, and care planning that all residents' pain be managed to a level that they feel is acceptable and promotes the highest possible level of functioning. The management of pain will include non-drug interventions such as: repositioning, cold or heat packs, mentholated topical creams, massage therapy, as well as the use of non-narcotic and narcotic pain medication administered per the physician orders. The policy included the physician will be notified about any resident who does not receive adequate pain management. Review of the facility's policy and procedures titled Medication Administration revealed the nursing staff will document the date, time, drug, dose, route, and site on the MAR and the resident's response in the medical record when administering a medication. Per policy, any time a medication is refused or omitted, the nurse will document the on the MAR and include a narrative explanation in the nurses' notes as to the reason and any further actions taken as a result.",2020-09-01
921,RIM COUNTRY HEALTH & RETIREMENT COMMUNITY,35134,807 WEST LONGHORN ROAD,PAYSON,AZ,85541,2018-09-25,725,E,0,1,P4TT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the clinical record review, resident and staff interviews, resident council minutes, facility document, and policy and procedure, the facility failed to ensure that there was sufficient nursing staff to meet the needs of multiple residents (#s 12, 17, 54, 58, and 143). Findings include: -Resident #12 was admitted on (MONTH) 24, (YEAR) with [DIAGNOSES REDACTED]. Review of the resident's quarterly MDS (Minimum Data Set) assessment dated (MONTH) 19, (YEAR) revealed a BIMS (Brief Interview for Mental Status) score of 14 indicating the resident was cognitively intact. The current care plan included that the resident was on oxygen therapy related to ineffective gas exchange. It also included that resident had altered elimination as exhibited by bowel and bladder incontinence and required assistance with ADL (Activities of Daily Living) related to a declining condition. Interventions included assistance with bathing, hygiene, dressing, toileting, ambulation, and transfers as needed. During an interview conducted with the resident on (MONTH) 17, (YEAR) at 1:44 p.m., she stated that she was incontinent and needed three people to assist her. She stated that early this morning, she needed to go to the bathroom and had to wait for one hour before she received help. The resident also stated that sometimes the wait is so long, it is embarrassing and hard for her. She stated that last night, she needed a breathing treatment. She further stated that she wanted to see the nurse but that the CNA (certified nurse assistant) brought her the breathing treatment. An interview was conducted with the resident on (MONTH) 21, (YEAR) at 9:00 a.m. The resident stated that since she requires assistance with toileting and transfer and pretty much everything, she uses the call light. She stated she does not remember the longest time she had to wait for staff assistance, but that she has to wait for the staff all the time. -Resident #17 was readmitted on (MONTH) 4, (YEAR) with [DIAGNOSES REDACTED]. The quarterly MDS assessment dated (MONTH) 27, (YEAR), revealed a BIMS score of 12 indicating the resident had moderately impaired cognition. The current care plan included the resident required assistance with ADL related to a declining condition. Interventions included assistance with bathing, hygiene, dressing, toileting, ambulation, and transfers as needed. An interview was conducted with the resident on (MONTH) 17, (YEAR) at 11:53 a.m. The resident stated that last night she had to go to the bathroom and waited for about 30 minutes. She stated that no one came, so she went to the bathroom by herself even though she was not supposed to due to [MEDICAL CONDITION] spells. The resident stated that she went to the bathroom without help because she did not want to have an accident. She stated that the wait for staff assistance can be 30 minutes or longer. -Resident #54 was readmitted on (MONTH) 26, (YEAR) with [DIAGNOSES REDACTED]. The quarterly MDS assessment dated (MONTH) 6, (YEAR) revealed a BIMS score of 15 indicating the resident was cognitively intact. The current care plan included the resident has altered elimination as exhibited by bowel and bladder incontinence. It also included that the resident was totally dependent on staff for toilet use and required two staff for bathing and a sit to stand transfer. During an interview conducted with the resident on (MONTH) 17, (YEAR) at 2:30 p.m., she stated that last night she used the call light twice to request staff change her incontinent brief. The resident stated the first time she used the call light she had to wait 45 minutes for assistance. She stated the second time she used the call light, she waited for 30 minutes before she received assistance. Another interview was conducted with resident #54 on (MONTH) 21, (YEAR) at 8:37 a.m. She stated that because of having to wait 45 minutes to 55 minutes before she receives assistance, she has had accidents. The resident further stated that she is currently waiting for staff to assist her now with her brief and that she has been waiting for 45 minutes to have her brief changed. -Resident #58 was admitted on (MONTH) 16, 2011 with [DIAGNOSES REDACTED]. The significant change MDS assessment dated (MONTH) 9, (YEAR) included a BIMS score of 9 indicating the resident had moderately impaired cognition. The Incontinence Care Plan with a revision date of (MONTH) 20, (YEAR) revealed the resident was incontinent of bowel and bladder related to cerebral vascular disease and limited mobility. Interventions included the use of a brief at night and to continue to go to the bathroom during the day with assistance and that the resident cannot wait a long period to be helped. The current ADL Care Plan included the resident has limited ADL function and limited physical mobility related to contractures and left sided weakness. Interventions included assistance with ADLs and 1-2 person assistance with transfers. An interview was conducted with the resident on (MONTH) 18, (YEAR) at 8:24 a.m. The resident stated she wears pull-ups and needs assistance to the toilet. She stated yesterday she waited two hours for assistance to the toilet. She stated because of the wait, she waits at the nurse's station for the CNA to assist her. -Resident #143 was admitted on (MONTH) 11, (YEAR) with [DIAGNOSES REDACTED]. The admission MDS assessment dated (MONTH) 18, (YEAR) revealed a BIMS score of 14 indicating the resident had intact cognition. The ADL Care Plan dated (MONTH) 11, (YEAR) revealed the resident required assistance related to loss of function and normal routine and declining condition. Interventions included two-person assistance with transfers, assistance with ambulation, bathing, hygiene, dressing, and toileting as needed. During an interview conducted with the resident on (MONTH) 17, (YEAR) at 2:25 p.m., he stated that last night he had to wait 12 hours for his diaper to be changed. He stated that he frequently has long wait times for his call light to be answered. Another interview was conducted with the resident on (MONTH) 21, (YEAR) at 9:08 a.m. The resident stated he had to wait 12 hours before his diaper was changed. He stated a CNA came and asked what he needed and he told the CNA, but did not get changed until 12 hours later. He stated that he does not pay attention to how long he has to wait anymore because it always happens. A review of the Resident Council Minutes of the Meeting for (MONTH) (YEAR) revealed residents voiced concerns related to the need for CNAs. Per the documentation, the DON and administrator's response included staff assignment is according to the facility's census and if there was a call off, facility do their best to get someone to cover. A review of the Resident Council Minutes of the Meeting for (MONTH) (YEAR) revealed that residents voiced concerns related to shortage of CNAs and nurses on the weekends. Per the documentation, the DON and administrator's response included weekends are staffed with the same number of staff as the weekdays and the only staffs missing were the administrative staff. A review of the Staffing Assignment Guideline Sheet revealed staff numbers are calculated based on 3.27 PPD (patient per day) with 8 nurses per day. It also included that the configuration for each shift can be modified, as long as the total number for each census category is met. During an interview conducted with a CNA (staff #122) on (MONTH) 19, (YEAR) at 6:15 a.m., she stated that the CNAs work 12 hour shifts. The CNA stated 6:00 p.m. to 10:00 p.m. can be difficult because it is the time residents are receiving assistance to bed. She further stated it would be better with 5 CNAs instead of 4 CNAs. In a later interview conducted with staff #122 on (MONTH) 19, (YEAR) at 6:34 a.m., she stated that the number of residents under her care is usually not overwhelming; but that the acuity level of the residents can be challenging. She stated a lot of staff members left. An interview was conducted with another CNA (staff #101) on (MONTH) 19, (YEAR) at 6:38 a.m. Staff #101 stated that there is only 1 CNA and 1 nurse on the night shift. During an interview conducted with a CNA (staff #99) on (MONTH) 21, (YEAR) at 8:40 a.m., staff #99 stated that sometimes a resident will have wait for her because she is assisting another resident. She stated that when she finally assist the resident, the resident is upset and that she explains to the resident why her response was delayed. The CNA stated that she has 19 residents assigned to her and that she also covers another hall. During an interview conducted with another CNA (staff #104) on (MONTH) 21, (YEAR) at 9:25 a.m., she stated that she was assigned to 26 residents on one station and 22 residents on another station. She stated that both stations have 2 CNAs on the day shift all the time but that it usually is not enough because the residents on one station have memory problems and requires extensive assistance, frequent turning and changing. She stated that sometimes, a resident has to wait because she cannot leave the resident she is assisting. The CNA stated that sometimes the resident is upset and she has to explain why she could not answer their call light right away. An interview was conducted with the staffing scheduler (staff #34) on (MONTH) 21, (YEAR) at 9:35 a.m. She stated that staffing is based on the total facility census. Staff #34 stated that the average census for the last month ranged from 80 to 90 and that there are a total of 4 halls. She stated that the typical staffing pattern for a census of 90 is two CNAs for each hall and four nurses on the dayshift and five CNAs and four nurses on the night shift. She further stated that this staffing pattern is also for the weekends. During an interview conducted with the Director of Nursing (DON/staff #37) on (MONTH) 21, (YEAR) at 10:17 a.m., she stated that the staffing guideline was changed recently to reflect the facility census and the number of staff needed for the day. The DON further stated that the administrator made the decision to staff according to the census number. The facility's policy regarding Employee Scheduling revealed the facility assures that there is sufficient staff to provide quality care that assists in maintaining the highest practicable physical, mental, and psychosocial well-being of every resident. It also included that because the focus is quality resident care that requires 24/7 direct care, the facility has guidelines that are followed in maintaining sufficient staff to achieve this.",2020-09-01
922,RIM COUNTRY HEALTH & RETIREMENT COMMUNITY,35134,807 WEST LONGHORN ROAD,PAYSON,AZ,85541,2018-09-25,755,E,1,1,P4TT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, facility documents, and policies, the facility failed to establish a system that ensured prompt identified of loss or potential diversion of controlled medications for 6 residents (#25, #62, #41, #246, #47, and #74). Findings include: A facility investigation regarding missing narcotics dated 09/06/18, revealed that on 09/06/18 at approximately 8:30 a.m., staff reported to the Director of Nursing (DON/staff #37) that there were missing narcotics from the Pine Unit for two residents (#41 and #246). The investigation revealed the boxes where papers are placed for shredding on each unit were searched and that Controlled Substance Records (CSR) used to sign out narcotics from the secured drawer on the medication carts for three residents (#47, #74 and #246) were found. The investigation also included an empty dose pack of [MEDICATION NAME] ([MEDICATION NAME]) for resident #246 was found in the shredding box. According to the pieced together CSR's, the facility was able to determined there were 84 narcotic pills missing and unaccounted for. Per the report, it was determined that the shred boxes were last emptied on 08/30/18, so every nurse that had worked since that date was brought in and drug tested . A total of 15 nurses were drug tested and only one tested positive for narcotics, however, that nurse produced a prescription (belonging to a family member) for the medication that she was positive for. Per the report, one nurse's name (licensed practical nurse/staff #63) came up multiple times on the narcotic sheets, but the nurse was unable to provide any information regarding the missing narcotics. The report included statements from 15 nurses and denied taking the medications or having knowledge of what happened to the narcotics. The DON was unable to definitively determine who took the medications or what happened to the medications. Review of the recovered CSRs, retained CSRs, the Medication Administration Records (MARs) for July, August, and (MONTH) (YEAR) for 6 residents (#25, #62, #41, #246, #47, and 74) revealed the following: -Resident #25: July (YEAR): There were 112 doses of [MEDICATION NAME] (narcotic) that were documented on the MAR as being administered, and there were 121 doses of [MEDICATION NAME] which were signed out on the CSR. The MAR reflected that between the dates of 07/24/18 and 0727/18 that 10 doses of [MEDICATION NAME] were administered; however there is no corresponding CSR to validate the medications used or remaining on that CSR. August (YEAR): There were 94 doses of [MEDICATION NAME] that were documented on the MAR as being administered, and there were 85 doses of [MEDICATION NAME] signed out on the CSR. Per the DON, page 2 of the [MEDICATION NAME] CSR was missing. The MAR revealed that between the dates of 08/23/18 and 08/30/18 (before 10:15 AM) there were 19 doses of [MEDICATION NAME] administered. No corresponding CSR was presented to validate the medications used or remaining on that CSR. September (YEAR): There were 50 doses of [MEDICATION NAME] that were documented on the MAR as being administered and 57 doses of [MEDICATION NAME] signed out on the CSR. -Resident #62: August (YEAR): 29 doses of [MEDICATION NAME] (narcotic) were documented on the MAR as administered and 2 doses refused. There were 28 doses of [MEDICATION NAME] signed out on the CSR. 1 dose of [MEDICATION NAME] (narcotic) was documented on the MAR as administered. There was no corresponding CSR to validate the medication used or remaining on the CSR. A full CSR for [MEDICATION NAME] 12 tablets was found in the shredding box but no corresponding medications were located. -Resident #41: July (YEAR): Review of the MAR revealed a dose of [MEDICATION NAME] (antidepressant) 25 mg was administered each morning and 50 mg administered each night. However, no corresponding CSR was found. August (YEAR): Review of the MAR from 08/01/18 through 08/20/18 11 doses of [MEDICATION NAME] was administered for a total of 18 tablets; however, there were no corresponding CSR to validate the use of these medications or the remaining pills. Review of the MAR from 08/01/18 through 08/20/18 revealed 11 doses of [MEDICATION NAME] was administered for a total of 16 tablets; however there is no corresponding CSR to validate the use of the tablets or the remaining quantity. Review of the MAR from 08/21/18 through 08/31/18 revealed documentation that 7 doses of [MEDICATION NAME] was administration for a total of 12 tablets. However, the CSR for the same time frame revealed 16 doses were signed for a total of 30 tablets and that only 1 of the 2 CSR was present. -Resident #74: July (YEAR): The MAR contained documentation that 11 doses of [MEDICATION NAME] were administered. There was no corresponding CSR to validate the number of administrations or remaining tablets. August (YEAR): Review of the MAR revealed 3 doses of [MEDICATION NAME] were administered, however the corresponding CSR revealed 7 doses were signed out. The CSR revealed there were 6 CSR, each with 30 tablets delivered on 6/30/18. CSR 2 of 6 (with 3 doses signed) and CSR 3 of 6 were both found torn up in the shredder box. CSR 1 of 6 was not located, nor were the medications associated with 1 of 6, 2 of 6, or 3 of 6 for a total of 57 missing tablets. -Resident #47: July (YEAR): 60 doses of [MEDICATION NAME] for [MEDICAL TREATMENT] anxiety or twice daily for anxiety were documented on the MAR as administered (6 additional doses were refused). Review of the CSRs revealed 50 doses of [MEDICATION NAME] were signed out. Two different CSRs for [MEDICATION NAME] revealed documentation that nurse #63 removed two tablets at 5:00 PM on 7/14/18 from one CSR and documented one was dropped and replaced, then documented she removed two tablets at 5:18 PM on a different CSR and documented one tablet was dropped and replaced. There were no nurse witness signature on either of the CSRs. Nurse #63 removed 4 tablets of [MEDICATION NAME] within 18 minutes for one resident and documented one dose as administered on the MAR. Review of the MAR revealed 7 doses of [MEDICATION NAME] was administered for pain however, there was no corresponding CSR. Another CSR with 30 tablets of [MEDICATION NAME] remaining was found torn in the shredder box. August (YEAR): Review of the MAR revealed 73 doses of [MEDICATION NAME] was administered for [MEDICAL TREATMENT] anxiety or twice daily anxiety (3 doses refused) and the that 72 doses were signed out on the CSRs documented 72 doses of [MEDICATION NAME] were signed out; 6 doses of [MEDICATION NAME] administered for pain and there was no corresponding CSR to validate the number of administrations; -Resident #246: July (YEAR): 30 doses of [MEDICATION NAME] were documented as administered on the MAR and no CSR was found to correspond with these administrations. 12 doses of [MEDICATION NAME] 0.5 mg were documented as administered on the MAR and 15 doses were signed out on the CSR. August (YEAR): 12 doses of [MEDICATION NAME] 0.5 mg were documented as administered on the MAR and 15 doses were signed out on the CSR. 44 doses of [MEDICATION NAME] were documented as administered on the MAR and 37 doses were signed out on the CSR. September (YEAR): 8 doses of [MEDICATION NAME] were documented as administered on the MAR and 11 doses were signed out on the CSR. Review of the policy titled Delivery and Receipt of Routine Deliveries revealed that upon delivery, a nurse will sign the delivery manifest and note the date and time of delivery, then take responsibility for the receipt, proper storage, and distribution of the medications. The policy included that controlled substances are immediately logged into the facility's controlled medication inventory system and will be stored in compliance with the law. The facility's policy titled Medication Administration included that the nursing staff will document the date, time, drug, dose, route, site on the MAR and the resident's response in the medical record when administering a medication. Review of the facility's policy titled Security of Medications statement included that it is the goal of the facility to ensure the security of all medications in the facility. The policy included that upon arrival of medications to the facility; the accepting nurse will inventory arriving medications and compare the medications to the pharmacy requisition form. The policy included that narcotic medications require the security of a double-locking system and are required to be tracked using the receipt record/disposition form. The policy also included, All narcotics are required to be counted and accounted for at the change of every shift or the change of nurse having access to these drugs; this is to (be) documented on the control drug reconciliation record.",2020-09-01
923,RIM COUNTRY HEALTH & RETIREMENT COMMUNITY,35134,807 WEST LONGHORN ROAD,PAYSON,AZ,85541,2018-09-25,758,E,0,1,P4TT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, clinical record review, and policy, the facility failed to ensure that resident #38 was free from unnecessary psychoactive medication. Findings include: Resident #38 was admitted on (MONTH) 10, (YEAR), with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. The order was discontinued on (MONTH) 23, (YEAR). Review of physician's progress notes from (MONTH) 1, (YEAR) through (MONTH) 24, (YEAR) revealed one psychiatric note dated (MONTH) 17, (YEAR) that included the resident was having an increase in anxiety and depression, however, the documentation did not address the prn of [MEDICATION NAME] Review of the Medication Administration Record [REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 20, (YEAR) revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident's cognition was intact. The assessment also included the resident exhibited verbal behaviors toward others 1 to 3 days in the 7 day lookback period and received antianxiety medication. Review of the pharmacy report dated (MONTH) 27, (YEAR) revealed documentation that prn sedatives, anxiolytics, or antipsychotics may not be used longer than 14 days and if the agent is needed longer than 14 days the medical doctor/nurse practitioner, or physician assistant must write a note that states the benefit versus risk requires such use and a new order must be written. The report included a recommendation to change the prn [MEDICATION NAME] to 14 days or an appropriate number of days: 30, 60 or 90. The physician made a notation on the form to change to 60 days which was signed and dated (MONTH) 23, (YEAR). However, no rationale for continuing the medication was included. Review of the MAR for (MONTH) (YEAR) revealed the [MEDICATION NAME] was administered (MONTH) 20 and 22. Review of the physician's orders [REDACTED]. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. An interview was conducted with the Assistant Director of Nursing (ADON/staff #3) on (MONTH) 25, (YEAR) at 12:31 p.m. She stated that if a [MEDICAL CONDITION] medication is ordered prn, it cannot continue for more than 14 days without a physician's note that states that the medication is to continue, the rationale, and for how long. The ADON stated that the prn [MEDICATION NAME] for resident #38 was not addressed within 14 days of the order as required and the required physician's rationale documentation for continuing the medication was not present in the record. She stated that the prn [MEDICATION NAME] use should have been addressed in (MONTH) (YEAR), but was not addressed until (MONTH) (YEAR). An interview was conducted with the Director of Nursing (DON/staff #37) (MONTH) 25, (YEAR) at 1:34 p.m. She stated that the ADON monitors and tracks the [MEDICAL CONDITION] medications. The DON stated that her expectation is that prn [MEDICAL CONDITION] medications be used for 14 days. She then stated that the physician would re-evaluate the medication use/resident. The facility's policy regarding medication administration included that an unnecessary drug is any drug when used for excessive duration and without adequate indications for it use.",2020-09-01
924,RIM COUNTRY HEALTH & RETIREMENT COMMUNITY,35134,807 WEST LONGHORN ROAD,PAYSON,AZ,85541,2018-09-25,812,D,0,1,P4TT11,"Based on observations, staff interviews, and policies, the facility failed to serve food under sanitary conditions. Findings include: A dining observation was conducted on (MONTH) 17, (YEAR) at 11:40 a.m. in the main dining room. A certified nursing assistant (CNA/staff #1) was pushing a trolley with various drinks in clear pitchers with lids and a container with ice on top of the trolley around to each table and serving drinks to the residents. A glass with ice was knocked off of one of the tables onto the dining room floor. Staff #1 was observed picking up the ice off of the floor and placing the ice on the top of the trolley next to the drinks and the container of ice twice. Staff #1 was not observed to wash her hands. The CNA continued serving drinks to the residents. Another dining observation was conducted on (MONTH) 19, (YEAR) at 7:58 a.m. A CNA (staff #53) was observed serving two bowls of cold cereal. The CNA used her thumb that was extended over the lip of the bowls and partially inside the bowl to grip the rim of the bowls. She used the rest of her fingers to support the bottom of the bowls. During the same dining observation, staff #53 was observed using a pen to take orders from the residents. Staff #53 then began serving food to the residents. The CNA held the plate with her thumb touching the inside of the plate. She served several residents their plate using this technique. Staff #53 was not observed to wash her hands, use hand sanitizer, or wear gloves between using the pen to take orders and serving the residents food. The CNA was also observed to serve a resident a plate of food using the same technique while holding the order form with her thumb on the inside of the plate. During an interview conducted with staff #53 on (MONTH) 21, (YEAR) at 8:34 a.m., staff #53 stated that the dining room policy requires that she wash her hands and put on gloves before serving food and drinks to the residents. Staff #53 also stated that it is policy that staff only touch the bottom of the plates and bowls when serving food to the residents. The CNA stated that she would not serve food to a resident if she had touched the inside of the plate or the inside rim of the bowl. The facility's policy Dining Room Service revealed staff should wash their hands prior to distributing trays. The policy included eating surfaces of plates should not come in contact with staff clothing or hands. The policy also included hands should be washed after physical contact with resident, self, or soiled items before touching a clean item in order to prevent cross contamination. Review of the facility's Hand Washing and Glove policy included that handwashing is a priority for infection control and hands must be washed following contact with any unsanitary surface.",2020-09-01
925,RIM COUNTRY HEALTH & RETIREMENT COMMUNITY,35134,807 WEST LONGHORN ROAD,PAYSON,AZ,85541,2018-09-25,838,D,0,1,P4TT11,"Based on facility documentation and staff interviews, the facility failed to ensure the facility assessment contained the detailed documentation/plan to manage residents, staff, and resources for day to day operations and emergency situations. Findings include: Review of the facility assessment revealed that the assessment did not address: -the overall acuity of the facility, -any ethnic/cultural/or religious factors of the residents, -rehabilitation services, -a facility-based and community-based risk assessment to evaluate the facility's ability to maintain continuity or operations and its ability to secure required supplies and resources during an emergency or natural disaster, -operating budget, -evaluation of training programs and contracts. An interview was conducted with the Owner/acting Administrator (staff #128) on (MONTH) 25, (YEAR) at 1:46 p.m. He stated that the facility Administrator (on leave at the time of the survey) obtained the template used for the facility assessment. He stated that he was sure that there are things that are supposed to be in the assessment that are not. He agreed that the data provided is a collection of information and that the plan to put it into a narrative for action is missing.",2020-09-01
926,RIM COUNTRY HEALTH & RETIREMENT COMMUNITY,35134,807 WEST LONGHORN ROAD,PAYSON,AZ,85541,2018-09-25,880,D,0,1,P4TT11,"Based on observations, staff interviews, and policy, the facility failed to ensure that infection control procedures were followed during a wound care observation for one resident (#81) and failed to ensure a glucose meter was properly cleaned after a resident's use. Findings include: -A wound care observation for resident #81 was conducted on (MONTH) 19, (YEAR) at 1:04 p.m. with a registered nurse (RN/staff #84). The RN was observed to wash her hands and turn the faucet off with her right hand and put on gloves. The RN then touched the garbage can with her gloved hand. Staff #84 and a female CNA transferred the resident from the wheelchair to the bed and the RN removed her gloves. The RN donned another pair of gloves and removed the resident's slippers from both feet and placed the resident's feet on the bedspread. Staff #84 removed her gloves, washed hands, dried her hands with a paper towel, and used the paper towel to turn off the faucet. She laid the 6 individual packets of skin prep on the resident's bedspread without a barrier. She then left the resident's room to get a measuring tool. Staff #84 measured the wound and applied treatment to the right heel. Staff #84 washed her hands, dried them with a paper towel, used the paper towel to turn the faucet off, and donned gloves. Staff #84 measured the wound and applied treatment to the left heel. Staff #84 proceeded to the resident's bathroom and washed her hands, dried her hands with a paper towel, and turned the faucet off with her bare right hand. The RN then put socks on the resident's feet and applied the soft boots. Staff #84 washed her hands, turned off the faucet with her bare hand, and dried her hands with a paper towel. She then left the room. Following the observation an interview was conducted with staff #84 at 1:46 p.m. She stated that she washes her hands with soap and water while singing the ABC song, uses paper towel to dry her hands, and uses another paper towel to turn the faucet off. She stated that she could not recall turning the faucet off with her bare hands. An interview was conducted with the Director of Nursing (DON/staff #37) on (MONTH) 21, (YEAR) at 10:17 a.m. Staff #37 stated that nurses are to check the orders, gather supplies which may or may not include a barrier pad to put supplies on prior to administering wound treatment to a resident. She stated that if the supplies are closed that the supplies do not need to be placed on a barrier pad. The facility's policy regarding Handwashing and Glove use included that hands must be washed following contact with any unsanitary surface but did not include the procedure for turning the faucet off. The policy revealed when gloves are used, handwashing must occur prior to putting on gloves and whenever gloves are changed. -An observation was conducted on (MONTH) 19, (YEAR) at 6:25 AM of a blood glucose test being performed by a registered nurse (RN/staff #84) on a resident in his room. After finishing the test, the RN returned the glucometer to the medication cart without disinfecting the glucometer. An interview was conducted with the RN following the blood glucose test. She stated that the glucometer was for multi-resident use, and that she normally cleans the glucometer after every resident use. The RN stated that she forgot to clean the glucometer before placing it in the medication cart. During an interview conducted with a licensed practical nurse (LPN/staff #42) on (MONTH) 19, (YEAR) at 7:08 AM., she stated that the facility's glucometers are for multi-resident use and should be cleaned after each use before being placed in the medication cart. The facility's policy titled Infection Control Program revealed the blood glucose monitoring equipment will be cleaned between each use using an approved disinfectant wipe.",2020-09-01
927,RIM COUNTRY HEALTH & RETIREMENT COMMUNITY,35134,807 WEST LONGHORN ROAD,PAYSON,AZ,85541,2019-11-25,607,D,0,1,0F1M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, staff interview and policy review, the facility failed to implement their abuse policy for one resident (#63), by failing to report an allegation of neglect to the State agency within the required time frame. The deficient practice could result in neglect allegations not being reported timely. Findings include: Resident #63 was admitted to the facility on (MONTH) 10, (YEAR) with [DIAGNOSES REDACTED]. Review of a nursing note dated (MONTH) 8, 2019 at 11:30 AM, revealed the resident had a fall in the bathroom. The note included the Certified Nursing Assistant (CNA) stated that while transferring the resident from the toilet to the wheelchair, the resident began to slip so she lowered the resident to the floor and called for help. The note included the resident was agitated, complained of pain in her legs and knees, and the nurse was unable to assess for range of motion. The note also included paramedics were called and the resident was transferred to the hospital for evaluation and to rule out a fracture. Review of the facility's investigation regarding the incident on (MONTH) 8, 2019 revealed the resident was care planned for two person assistance with a gait belt. The report also included the CNA neither confirmed nor denied that she knew the resident required two person assistance with a gait belt. However, review of the State complaint system revealed the facility did not notify the State Agency of the allegation of neglect until 4:50 PM on (MONTH) 8, 2019. During an interview conducted with the Director of Nursing (DON/staff #125) on (MONTH) 21, 2019 at 12:15 PM, the DON stated that she has 2 hours to report an allegation of abuse to the State agency. The DON stated that she was not at the facility at the time of the incident and that she spoke to the Assistant Director of Nursing (ADON/staff #69) via telephone and instructed her to notify the State via the online system. In an interview conducted with the ADON on (MONTH) 21, 2019 at 12:25 PM, the ADON stated the incident was not report to her. She stated that she found out about the incident when she saw the paramedics entering the resident's room. The ADON stated that she reported the incident to the DON immediately. Review of the facility's policy titled Resident Abuse and Neglect updated (MONTH) 26, 2019 revealed all alleged violations involving neglect shall be reported to the proper agencies within regulatory guidelines after the allegation is made at the direction of the administrator, DON and/or designee.",2020-09-01
928,RIM COUNTRY HEALTH & RETIREMENT COMMUNITY,35134,807 WEST LONGHORN ROAD,PAYSON,AZ,85541,2019-11-25,609,D,0,1,0F1M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, staff interview and policy review, the facility failed to implement their abuse policy for one resident (#63), by failing to report an allegation of neglect to the State agency within the required time frame. The deficient practice could result in neglect allegations not being reported timely. Findings include: Resident #63 was admitted to the facility on (MONTH) 10, (YEAR) with [DIAGNOSES REDACTED]. Review of a nursing note dated (MONTH) 8, 2019 at 11:30 AM, revealed the resident had a fall in the bathroom. The note included the Certified Nursing Assistant (CNA) stated that while transferring the resident from the toilet to the wheelchair, the resident began to slip so she lowered the resident to the floor and called for help. The resident was agitated and complaining of pain in her legs and knees. The note included paramedics were called and the resident was transferred to the hospital for evaluation and to rule out a fracture. Review of the facility's investigation regarding the incident on (MONTH) 8, 2019 revealed the resident was care planned for two person assistance with a gait belt. The report also included the CNA neither confirmed nor denied that she knew the resident required two person assistance with a gait belt. However, review of the State complaint system revealed the facility did not notify the State Agency of the allegation of neglect until 4:50 PM on (MONTH) 8, 2019. During an interview conducted with the Director of Nursing (DON/staff #125) on (MONTH) 21, 2019 at 12:15 PM, the DON stated that she has 2 hours to report an allegation of abuse to the State agency. Review of the facility's policy titled Resident Abuse and Neglect updated (MONTH) 26, 2019 revealed all alleged violations involving neglect shall be reported to the proper agencies within regulatory guidelines after the allegation is made at the direction of the administrator, DON and/or designee.",2020-09-01
929,RIM COUNTRY HEALTH & RETIREMENT COMMUNITY,35134,807 WEST LONGHORN ROAD,PAYSON,AZ,85541,2019-11-25,641,D,0,1,0F1M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the discharge Minimum Data Set (MDS) assessment was accurate for one resident (#88). The deficient practice could result in inaccurate discharge tracking information. Findings include: Resident #88 was admitted to the facility on (MONTH) 10, 2019 with a [DIAGNOSES REDACTED]. Review of the Discharge Summary dated (MONTH) 26, 2019, revealed the date of discharge was (MONTH) 27, 2019 and that the resident was happy about returning home. The Post Discharge Plan of Care dated (MONTH) 26, 2019 revealed the resident was being discharged to home. Review of a nursing note dated (MONTH) 27, 2019 revealed the resident was discharged home. However, review of the discharge MDS assessment dated (MONTH) 27, 2019 revealed the resident was discharged to an acute hospital. During an interview conducted with the MDS Coordinator (staff #131) on (MONTH) 20, 2019 at 1:35 p.m., she stated that during their IDT (interdisciplinary) morning meeting, they discuss the anticipated dates residents will be discharged and their discharge location. After reviewing the clinical record for resident #88, the MDS Coordinator stated the resident was discharged home and that she did not know why she coded acute hospital as the discharge location The RAI manual instructs to review the clinical record including the discharge plan and discharge orders for documentation of a resident's discharge location and code that location. The RAI manual also included that it is required the assessment accurately reflects the resident's status and that the importance of accurately completing and submitting the MDS assessment cannot be over emphasized.",2020-09-01
930,RIM COUNTRY HEALTH & RETIREMENT COMMUNITY,35134,807 WEST LONGHORN ROAD,PAYSON,AZ,85541,2019-11-25,644,E,0,1,0F1M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure one resident (#52) with a [DIAGNOSES REDACTED]. The deficient practice could result in necessary specialized services not being provided for residents who need it. Findings include: Resident #52 was readmitted to the facility on (MONTH) 3, (YEAR), with diagnoses of [MEDICAL CONDITION], generalized anxiety disorder, major [MEDICAL CONDITION], dysthymic disorder, and unspecified [MEDICAL CONDITION] not due to a substance or known physiological condition. Review of the care plan initiated (MONTH) 18, (YEAR) revealed the resident was a PASARR (Preadmission Screening and Resident Review) level I. The goal was that all care and services the resident needs will be provided. Interventions included all psychosocial, medical, ADL (activities of daily living) services are provided by the facility and that the resident did not require any specialized mental [MEDICAL CONDITION]/mental illness services. Review of the Medication Administration Record [REDACTED]. The MAR for (MONTH) and (MONTH) 2019 revealed the resident was being administered [MEDICATION NAME] 150 mg three times a day by mouth for paranoid [MEDICAL CONDITION] with an initial order date of (MONTH) 30, 2019. However, further review of the clinical record revealed no PASARR level II referral related to the [DIAGNOSES REDACTED]. On (MONTH) 21, 2019 at 1:17 p.m., an interview was conducted with the social services director (staff #27), who stated that if there is not a mental illness diagnoses or if the resident has a [DIAGNOSES REDACTED]. Staff #27 further stated that if the resident has a mental illness and does not have a primary diagnoses of dementia, she would request a PASARR level II. She stated resident #52 should have had a PASARR level II completed because the resident did not have a [DIAGNOSES REDACTED]. During an interview conducted with the Director of Nursing (DON/staff #125) on (MONTH) 22, 2019 at 10:35 a.m., the DON stated that the resident should have been referred for a PASARR level II. The facility's policy regarding PASARR evaluation revised (MONTH) 28, (YEAR), revealed that if a resident has a [DIAGNOSES REDACTED].",2020-09-01
931,RIM COUNTRY HEALTH & RETIREMENT COMMUNITY,35134,807 WEST LONGHORN ROAD,PAYSON,AZ,85541,2019-11-25,645,E,0,1,0F1M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure one resident (#66), who remained in the facility longer than 30 days, level I screening was updated. The deficient practice could result in necessary specialized services not being provided for residents who need it. Findings include: Resident #66 was readmitted to the facility on (MONTH) 19, (YEAR) with [DIAGNOSES REDACTED]. Review of the care plan revised (MONTH) 21, (YEAR) revealed the resident was receiving [MEDICAL CONDITION] medications related to [MEDICAL CONDITION] disorder and [MEDICAL CONDITION] which was helping with the resident's paranoia and restlessness. The quarterly MDS assessment dated (MONTH) 28, (YEAR) included active [DIAGNOSES REDACTED]. Per the MDS assessment, the resident received antipsychotic, antianxiety and antidepressant medications during the 7 day look-back period. Review of the care plan initiated (MONTH) 18, (YEAR) revealed the resident was a PASARR (Preadmission Screening and Resident Review) level I. The goal was that all care and services the resident needs will be provided. Interventions included all psychosocial, medical, ADL (activities of daily living) services are provided by the facility and that the resident did not require any specialized mental [MEDICAL CONDITION]/mental illness services. The discharge MDS assessment dated (MONTH) 17, 2019 revealed the resident was discharged to an acute hospital. Review of the hospital PASARR Level I screening completed on (MONTH) 20, 2019 revealed the resident did not have any serious mental illness (SMI) such as [MEDICAL CONDITIONS] disorder, [MEDICAL CONDITION], psychotic/delusional disorder, [MEDICAL CONDITION] disorder ([MEDICAL CONDITION]) and paranoid disorder. The section regarding the resident having a [DIAGNOSES REDACTED]. The screening included a level II referral was not necessary. The screening also included the resident met the criteria for 30 day convalescent care and that the nursing facility must update the Level 1 at such time that it appears the resident's stay will exceed 30 days. Review of the clinical record revealed the resident was readmitted to the facility on (MONTH) 22, 2019. Further review of the clinical record revealed no evidence the PASARR level 1 was updated once the resident's stay exceeded 30 days. During an interview with the social services director (staff #27) conducted on (MONTH) 21, 2019 at 2:00 p.m., she stated the hospital completes the PASARR level I screening prior to the resident's admission to the facility. She stated the PASARR is completed again when the resident stays longer than 30 days in the facility and/or there is a change in the resident's [DIAGNOSES REDACTED]. She stated the facility has identified issues related to the PASARR screening not being completed or updated. Staff #27 stated for the last 6 months she has been conducting audits of the PASARRs. She stated when she conducts her audits, she reviews the clinical record for new psychiatric diagnosis, new medications to include psychoactive medications, any changes in the resident status and any recommendations made by the psychiatrist. The facility's policy regarding PASARR evaluation revised (MONTH) 28, (YEAR) revealed medical records will audit each new admission to ensure the PASARR is completed. If the resident has a [DIAGNOSES REDACTED]. The policy also included that at the annual or significant change MDS completion, the PASARR will be reviewed for continued accuracy.",2020-09-01
932,RIM COUNTRY HEALTH & RETIREMENT COMMUNITY,35134,807 WEST LONGHORN ROAD,PAYSON,AZ,85541,2019-11-25,657,D,0,1,0F1M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy review, the facility failed to ensure the care plan was revised for one (#52) of twenty-five sampled residents. The deficient practice could result in inaccuracies regarding resident care. Findings include: Resident #52 was readmitted to the facility on (MONTH) 3, (YEAR) with [DIAGNOSES REDACTED]. Review of the Medication Administration Record [REDACTED]. The MAR for (MONTH) and (MONTH) 2019 revealed the resident was being administered [MEDICATION NAME] 150 mg three times a day by mouth for paranoid [MEDICAL CONDITION] with an initial order date of (MONTH) 30, 2019. However, review of the care plan did not reflect the resident was receiving [MEDICATION NAME], an antipsychotic, for paranoid [MEDICAL CONDITION]. On (MONTH) 22, 2019 at 10:35 a.m., an interview was conducted with the Director of Nursing (DON/staff #125). She stated that the care plan meeting attendees include the social worker, MDS (Minimum Data Set) coordinator, case manager/discharge planner, dietary, activities, assistant DON and Quality Assurance nurse, resident and family. She stated that prior to the resident's care plan meeting; a review of the resident's clinical records should be conducted to check for changes. The DON stated anyone can report changes in the resident's condition and bring those changes forward. She also stated the care plan should have been updated. Review of the facility's policy titled Care Plans and Care Plan Meetings revised (MONTH) 28, (YEAR), revealed residents care plans will be reviewed, discussed and updated at the time of the resident's comprehensive assessments per schedule and as needed.",2020-09-01
933,RIM COUNTRY HEALTH & RETIREMENT COMMUNITY,35134,807 WEST LONGHORN ROAD,PAYSON,AZ,85541,2019-11-25,658,D,0,1,0F1M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, clinical record and policy review, the facility failed to ensure services provided met professional standards of quality, by failing to ensure a medication was administered to one resident (#13) in accordance with the physician order. The deficient practice could result in additional medication errors. Findings include: Resident #13 was admitted to the facility on (MONTH) 20, 2019 with [DIAGNOSES REDACTED]. During an observation of medication administration conducted on (MONTH) 20, 2019 at 7:30 AM with a Registered Nurse (RN/staff #11), the RN was observed to administer Calcium/Vitamin D 600 mg (milligrams)/200 units one tablet to resident #13. However, review of the physician's orders [REDACTED]. An interview was conducted with the RN (staff #11) on (MONTH) 20, 2019 at 9:43 AM. The RN stated she administered a Calcium 600 mg/Vitamin D 200 units tablet to the resident. She also stated that the physician order [REDACTED]. The RN stated they only stock Calcium 600mg/Vitamin D 200 units tablets and that the order should have been changed. In an interview conducted with the Director of Nursing (DON/staff #125) on (MONTH) 22, 2019 at 8:38 AM, the DON stated that the nurse could have notified the physician to have the order changed. She also stated that the nurse could have administered an additional 200 units of Vitamin D to make the correct dose, or the nurse could have contacted the central supply person to request they stock Calcium 600 mg with Vitamin D 400 units. Review of the facility's policy regarding Medication Administration revised (MONTH) 21, 2019 revealed a physician order [REDACTED]. The policy also included the nursing staff will observe the 6 rights of medication administration which included the right dose.",2020-09-01
934,RIM COUNTRY HEALTH & RETIREMENT COMMUNITY,35134,807 WEST LONGHORN ROAD,PAYSON,AZ,85541,2019-11-25,684,D,0,1,0F1M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#69) received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan related to positioning. The deficient practice could result in residents not being repositioned as needed. Findings include: Resident #69 was admitted to the facility on (MONTH) 10, (YEAR) with [DIAGNOSES REDACTED]. Review of the clinical record revealed a physician order [REDACTED]. The quarterly Minimum Data Set assessment dated on (MONTH) 31, 2019 revealed the resident's cognitive skills were severely impaired for daily decision making. The assessment included the resident required extensive assistance of two+ staff for bed mobility and transferring. The care plan revised (MONTH) 9, 2019 revealed the resident was at risk for skin breakdown related to disease process, incontinence, immobility, and comorbidities. Interventions included encouraging or assisting the resident in shifting of positions every 1-3 hours and PRN. Review of the Treatment Administration Record (TAR) for (MONTH) 2019 revealed no documentation by the nurses the resident was repositioned every 1-3 hours and PRN on (MONTH) 11 and 14 on the day shift. The TARs for (MONTH) and (MONTH) 2019 revealed documentation the resident was repositioned each shift. Review of the Certified Nursing Assistant (CNA) care flowsheets for the question was the resident repositioned every 2 hours while in bed and every one hour while in chair revealed no documentation on the flowsheet dated (MONTH) 2019 for (MONTH) 5 and 25 on the day shift and (MONTH) 7 on the night shift. The CNA flowsheet for (MONTH) 2019 revealed no documentation for the question on (MONTH) 3 and 31 on the day shift. During an observation conducted of the resident on (MONTH) 19, 2019 at 8:54 a.m., the resident was observed reclined in a Geri chair until 10:52 a.m. when two CNAs took the resident to her room for care. The resident was returned at 11:50a.m. The resident was observed in a semi reclining position in the Geri chair until 2:44 p.m. without being repositioned. Another observation was conducted of the resident at 3:35pm. The resident was observed in the same position. An interview was conducted with a CNA (staff #38) on (MONTH) 22, 2019 at 8:16 a.m. Staff #38 stated the CNAs are responsible for turning and repositioning residents. She stated that she ensures all residents who needs assistance with repositioning are provided that assistance every hour. Staff #38 stated the CNAs document the care that has been provided during their shift in the Electronic Medical Record (EMR). After reviewing the EMR for resident #69, staff #38 stated that if the care area is checked off, the care was provided as ordered for the entire shift. Staff #38 stated she would inform the nurse if there was a reason why care was not provided. An interview was conducted with the Director of Nursing (DON/staff #125) on (MONTH) 22, 2019 at 8:45a.m. She stated residents who require assistance with repositioning are repositioned every 1-3 hours or more often if needed. She stated the CNA will mark the task as completed in the EMR and the nurse will document it on the TAR. After reviewing resident #69's record, the DON stated the checks meant care was provided as ordered for the shift. The DON also stated she expects the documentation to be accurate. The facility's policy titled prevention and treatment of [REDACTED]. The policy also included staff should offload pressure by turning and repositioning every 1-3 hours and PRN.",2020-09-01
935,RIM COUNTRY HEALTH & RETIREMENT COMMUNITY,35134,807 WEST LONGHORN ROAD,PAYSON,AZ,85541,2019-11-25,689,G,1,1,0F1M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, resident and staff interviews and hospital and facility documentation, the facility failed to ensure one resident (#63) was transferred in a safe manner. The deficient practice resulted in a fall with major injury. Findings include: Resident #63 was admitted to the facility on (MONTH) 10, (YEAR), with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment dated (MONTH) 8, 2019 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment. The MDS included the resident required extensive assistance of one for transfers, and had not fallen since admission. The care area for falls had triggered and would be addressed in the care plan. Review of the accident potential care plan dated (MONTH) 1, 2019 revealed a goal that the resident would comply with safety precautions. An intervention included the resident required the assistance of two people with a gait belt for transfers. Review of the Certified Nursing Assistant (CNA) documentation regarding support provided for transfers (excluding transfers on and off the toilet) revealed that 5 of 14 entries included the resident received one person physical assistance from (MONTH) 1-8, 2019. Review of the CNA documentation regarding support provided for toileting assistance including transfers on and off the toilet revealed that 16 of 16 entries included the resident received one person physical assistance between (MONTH) 1-8, 2019. One of the entries was by CNA (staff #129) who had documented that the resident received one person physical assistance with toileting on (MONTH) 8. According to a nurses note dated (MONTH) 8, 2019 at 11:30 a.m., the nurse was called to resident #63's room regarding a fall in the bathroom. Per the note, the resident was agitated and complaining of pain in her legs and knees and the paramedics were called and the resident was transferred to the hospital to rule out a fracture. Review of the hospital x-ray report dated (MONTH) 8, 2019 at 12:07 p.m., revealed the left knee bones were diffusely osteopenic, and the presence of an oblique impacted [MEDICAL CONDITION] aspect of the femur, with overlap of the fracture components. Review of the hospital physician's history and physical exam dated (MONTH) 8, 2019 at 4:16 p.m. revealed the resident presented to the emergency room with left leg and hip pain, after loosing her balance while being assisted to the toilet. The documentation included the resident had stated that she was caught by a staff member, but landed on both knees. The report further included that the x-ray showed an impacted distal femur fracture on the left. The resident had received [MEDICATION NAME] in the emergency department with relief of her pain and that upon arrival to the medical/surgical floor, resident #63 was having excruciating pain. Review of the addendum to the hospital history and physical dated (MONTH) 8, 2019 at 5:56 p.m., revealed the resident was being assisted to the bathroom when the CNA lost her grip and the resident fell to the floor. Review of the facility's investigative report revealed that on (MONTH) 8, 2019 at approximately 11 a.m., a CNA (resident #129) transferred resident #63 by herself to the toilet. The resident started to slide off the toilet and the CNA slid the resident to the ground. Upon the charge nurse's assessment, the resident had an abnormality to her left leg, 911 was called and the resident was transferred to the hospital. Per the report, a hospital xray confirmed that the resident had a left femur fracture. The facility's report also included a written statement from the CNA (staff #129) who stated that she put the resident on the toilet by herself. She reported the resident called her back to take her off and the resident stood up, then when she started pulling up her brief, her legs were giving up and she tried to pull her back on the toilet. She stated the resident sat on the edge, but then started to slide off so she put her down to the floor slowly. Review of the personnel file for staff #129 revealed the CNA completed training on transfers, including two person transfers with a return demonstration on (MONTH) 10, 2019. The file also contained a statement from staff #129 that she knew she should have gotten someone else in regard to the transfer of resident #63. Per the documentation, staff #129 was placed on suspension on (MONTH) 8, 2019 due to transferring the resident alone when the resident was care planned for two person assistance with transfers, which resulted in a major injury. The file also contained a hand-written resignation by staff #129 dated (MONTH) 15, 2019. During an interview with resident #63 conducted on (MONTH) 18, 2019 at 1:52 p.m., the resident stated that she had fallen and broke her leg in two places, when she was transferred to the toilet by a CN[NAME] The resident stated that the CNA did the transfer alone and there should have been two CNA's to assist with transfers. She also stated the CNA had transferred her alone many times and she had told the CNA that she needed two people for transfers. During an interview with a CNA (staff #72) on (MONTH) 19, 2019 at 2:05 p.m., staff #72 said that she knew resident #63's care needs well. She said when resident #63 was admitted to the facility she required only one person assistance with transfers, but after the resident sustained [REDACTED]. She also stated that resident #63 now requires a mechanical lift and two person assistance, because of the broken leg and it is facility policy to use two people when transferring a resident using a mechanical lift. She said that to her knowledge, the resident has not refused two person assistance with transfers. During an interview with a Licensed Practical Nurse (LPN/staff #42) conducted on (MONTH) 19, 2019 at 2:10 p.m., staff #42 stated she was not present on the day the resident fell but she was aware that the resident fell while being transferred in the bathroom by one CNA, and she was aware that the resident's care plan called for two person assistance with transfers at that time. She stated now the resident's care plan requires transfers with a mechanical lift. In an interview with the Director of Nursing (DON/staff #125) conducted on (MONTH) 19, 2019 at 2:15 p.m., the DON stated that the CNA's receive care plan information from the nurses and the Kardex, which displays the interventions required of the CN[NAME] The DON showed that the two person transfer intervention was on resident #63's Kardex beginning on (MONTH) 1, 2019. The DON stated that all CNA's are instructed to access the Kardex when they are in orientation. During an interview with the Assistant Director of Nursing (ADON/staff #69) conducted on (MONTH) 21, 2019 at 12:25 p.m., staff #69 stated that she monitors staff and provides oversight in order to assure care and services are implemented based on the care plan and resident's needs by making rounds throughout the day and by random chart audits. She stated the incident with resident #63 was not reported to her. She said that she was coming out of a meeting and the paramedics were entering resident #63's room. She stated that she found out what happened and called the DON immediately. She said the CNA did not say why she did the transfer alone and she was aware that the other nurses would help if a CNA was not available. During the survey, multiple telephone attempts were made to reach staff #129 including leaving voicemails, with no return call.",2020-09-01
936,RIM COUNTRY HEALTH & RETIREMENT COMMUNITY,35134,807 WEST LONGHORN ROAD,PAYSON,AZ,85541,2019-11-25,690,D,0,1,0F1M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure that one resident (#69) was provided incontinence care in accordance with professional standards of practice. The deficient practice could result in residents' not receiving incontinence care timely. Findings include: Resident #69 was admitted to the facility on (MONTH) 10, (YEAR) with [DIAGNOSES REDACTED]. A care plan included the resident has altered elimination as exhibited by incontinent episodes. The goal was that the resident's incontinence care needs would be met. An intervention was that the resident would be checked for incontinence every 1-3 hours and PRN (as needed), with care provided if needed. Review of the Certified Nursing Assistant (CNA) Care flowsheets for bladder incontinence for (MONTH) and (MONTH) 2019 revealed there was missing documentation that incontinence care was provided on (MONTH) 5 during the day shift, on (MONTH) 7 during the night shift, on (MONTH) 25 during the day shift, on (MONTH) 3 during the day shift, and on (MONTH) 31 during the day shift. The quarterly Minimum Data Set (MDS) assessment dated (MONTH) 31, 2019 noted that the resident has short and long term memory problems and that the resident was always incontinent of bladder and bowel. On (MONTH) 19, 2019 at 8:54 a.m., an observation was conducted of resident #69 sitting in a geri chair in the day room on the secured dementia unit. The resident was observed from 8:54 a.m. until 10:52 a. m. At 10:52 a.m, two CNA's (staff #8 and staff #117) took the resident to her room. At this time, staff #117 stated they were taking the resident to her room to provide care. The two CNA's returned the resident to the day room at 11:50 a. m. The resident was observed continuously and remained in the day room until 2:44 p. m. During this time frame, the resident was not provided any incontinence care, which was approximately 3 hours. Another observation was conducted on (MONTH) 20, 2019 at 7:46 a.m. of the resident in the day room, sitting in a geri chair near the window. The resident was observed continuously, and at 11:02 a.m., there was a noticeable urine odor around the resident. However, the resident was not provided incontinence care at that time. At 11:20 a.m., the resident was taken into the dining room without having incontinence care provided. The resident continued to be observed until 1:03 p.m., when 2 CNA's (staff #8 and staff #117) removed the resident from the dining room and took her to her room. At this time, staff #117 stated the resident would now be receiving incontinence care. Another observation was conducted on (MONTH) 21, 2019 at 8:38 a. m. of the resident sitting in a geri chair in the day room. The resident was taken to her room at 9:22 a.m by a hospice CN[NAME] At this time, the CNA stated that the resident would be receiving incontinence care. At 10:09 a.m., the resident was observed in her bed. The resident remained in bed until 2:03 p.m. During this frame of approximately 4 hours, the resident was not provided any incontinence care. An interview was conducted on (MONTH) 21, 2019 with the CNA (staff #71) who was assigned to resident #69 during this time frame. The CNA stated that resident #69 was not feeling well and has been napping. He stated incontinence care is not provided when residents are asleep. An interview was conducted on (MONTH) 22, 2019 at 8:16 a.m., with a CNA (staff #38). She stated the CNA's are responsible for providing incontinence care and it is documented on the CNA flowsheet for bladder incontinence. She stated incontinence care is provided every two hours or more often if needed. She stated all of the residents should be checked and provided with incontinence care, prior to meals. At this time, the CNA flowsheet for resident #69 was reviewed with staff #38. Staff #38 stated if the bladder continence box is marked by the CNA for the shift, it means that incontinence care was provided according to the resident's care plan. An interview was conducted on (MONTH) 22, 2019 at 8:25 a. m. with a Registered Nurse (staff #130), who stated a resident should not be left longer than two hours between incontinence care, unless the resident is asleep. An interview was conducted with the Director of Nursing (DON/staff #125) on (MONTH) 22, 2019 at 8:45 a. m. She stated that incontinence care should occur following incontinence episodes, but there is not a set schedule for when care should be provided. The DON stated the CNA's are to document when incontinence care is provided on the CNA flowsheet. Resident #69's CNA flowsheet for bladder incontinence was reviewed with the DON, who stated that she expects the documentation to be accurate and reflect the care that was provided to the resident. The facility's policy on urinary catheters and incontinence revealed that residents with incontinence will be assessed for possible causative factors with interventions put into place to decrease episodes of incontinence or maintain current level of functioning.",2020-09-01
937,RIM COUNTRY HEALTH & RETIREMENT COMMUNITY,35134,807 WEST LONGHORN ROAD,PAYSON,AZ,85541,2019-11-25,695,E,0,1,0F1M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, staff interviews and policy review, the facility failed to ensure there were complete physician orders [REDACTED].#47, #70, #85 and #238). The deficient practice could result in oxygen being administered to residents which does not meet their needs. Findings include: -Resident #238 was admitted to the facility on (MONTH) 14, 2019 with [DIAGNOSES REDACTED]. A hospital physician discharge summary dated (MONTH) 13, 2019 included [DIAGNOSES REDACTED]. Per the discharge information, there was no documentation regarding the use of oxygen. A nursing note dated (MONTH) 14, 2019 revealed the resident was readmitted with oxygen on. Review of the clinical admission evaluation dated (MONTH) 14, 2019 revealed the resident was confused, disoriented, lethargic and required cueing. Body system baseline information included lungs clear throughout bilaterally, with no difficulty breathing. The evaluation also included the resident was on 4 LPM (liters per minute) of oxygen via nasal cannula (NC). A baseline care plan dated (MONTH) 14, 2019 included the resident received oxygen therapy. Review of a physician's progress note dated (MONTH) 15, 2019 revealed the resident was calm, and alert and oriented x 1. Physical examination included bilateral lung sounds clear to auscultation, with normal respiratory excursion and no wheezes, rales or rhonchi. A physician's orders [REDACTED]. However, the order did not include how many liters per minute (LPM) to administer the oxygen to the resident and if the oxygen was to be continuous or intermittent. Review of the TAR (treatment administration record) for (MONTH) 2019 revealed the following oxygen saturation readings: -November 15: 90% for day and night shift -November 16: no oxygen saturation reading for the day shift; 90% for night shift -November 17: no oxygen saturation reading for the day shift -November 18: 92% for the day and night shift During multiple observations conducted on (MONTH) 19, 2019 at 12:33 p.m., at 1:33 p.m. and at 2:46 p.m., the resident had oxygen on at 2 LPM via nasal cannula. Further review of the clinical record revealed no evidence that the order was clarified with the physician to include the amount of oxygen to be administered to the resident and whether the oxygen was to be administered PRN or continuous. In an interview with a licensed practical nurse (LPN/staff #118) conducted on (MONTH) 20, 2019, she stated the physician orders [REDACTED]. She stated usually a resident is administered 2 LPM of oxygen, unless the order specifies a different dose. She said in an emergency when a resident has a low oxygen saturation or has shortness of breath but does not have orders for oxygen, she follows the standing orders which includes to administer oxygen at 2 LPM and then she would call the physician. Another observation was conducted on (MONTH) 20, 2019 at 12:11 p.m. of the resident being taken by staff to the outpatient gym. The resident's oxygen was set at 2 LPM via nasal cannula. An interview with a registered nurse (RN/staff #50) was conducted on (MONTH) 20, 2019 at 2:17 p.m. He stated all oxygen use must have an order to include how much oxygen to administer and whether oxygen use is PRN or continuous. During an interview with a registered nurse (staff #74) conducted on (MONTH) 21, 2019 at 11:18 a.m., she stated there must be an order for [REDACTED]. order for oxygen administration, then would call the physician and get orders for oxygen use. During the interview staff #74 presented a document titled, The Physician's Standing Orders which included a list of guidelines to be followed per physician's agreement to meet the needs of the residents. She stated that she uses this guideline, if there are no orders in the resident's clinical record. At this time the Physician Standing Orders were reviewed with staff #74, who stated that they did not include standing orders for oxygen administration. She stated it would be nice if the standing orders included for oxygen therapy. In an interview with a CNA (staff #101) conducted on (MONTH) 22, 2019 at 8:20 a.m., she stated the resident has oxygen on only at night, but needs to have an oxygen tank on the back of the wheelchair for use when the resident goes to the gym. During an interview with the Director of Nursing (DON/staff #125) conducted on (MONTH) 22, 2019, she stated it is their policy that orders for oxygen should include how much oxygen will be administered to the resident and whether it is PRN or continuous. At this time, the clinical record was reviewed with the DON. She stated the order for oxygen use for resident #238 did not include how much oxygen the resident should receive, and whether it is PRN or continuous. -Resident #85 was admitted (MONTH) 1, 2019 with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. However, this order did not include how much oxygen to administer to the resident or if the oxygen was to be continuous or intermittent. A care plan dated (MONTH) 18, 2019 with a focus on antibiotic therapy related to a [DIAGNOSES REDACTED]. An intervention was to administer medication as ordered. Review of the clinical record revealed no evidence that the oxygen order was clarified with the physician to include the amount of oxygen to be administered to the resident and whether it was to be administered continuously or intermittently. An interview was conducted on (MONTH) 20, 2019 at 5:50 p.m. with a Registered Nurse (staff #50), who stated that they have a standard order that gets put in. Staff #50 was shown the order for oxygen and said that the order should have a parameter on it. Staff #50 said that the order should include how many liters and to call the doctor if the patient needs exceeds what is ordered. During an interview conducted on (MONTH) 22, 2019 at 9:40 a.m., the Director of Nursing (staff #125) said the order should have the liters per minute on the order. She said that she will make sure that it's done going forward. -Resident #47 was admitted to the facility on (MONTH) 26, 2019, with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The order included to check oxygen saturation every shift and as needed for low oxygen saturation. However, the order did not include how much oxygen to administer to the resident or if the oxygen was to be administered continuous or intermittent. A care plan for oxygen therapy initiated on (MONTH) 27, 2019, included a goal that the resident would have no signs or symptoms of poor oxygen absorption through the next review. An intervention was to administer oxygen therapy as ordered by the physician. The admission Minimum Data Set (MDS) assessment dated (MONTH) 1, 2019 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The MDS also included that the resident was receiving oxygen therapy. Review of the TAR for (MONTH) 2019 revealed the resident's oxygen saturation level was 85% during the day shift on (MONTH) 4, which was below the parameters in the physician's orders [REDACTED].>There was no evidence in the clinical record that the physician was notified or that the resident's oxygen was adjusted, due to the lower oxygen saturation level. Further review of the TAR's for (MONTH) and (MONTH) 2019 revealed there were missing entries for the resident's oxygen saturation levels on the following dates: October 5, day shift October 11, day shift October 24, day shift November 2, day shift November 17, day shift There was no documentation in the clinical record as to why the oxygen saturations were not done. In addition, there was no evidence that the order was clarified with the physician to include the amount of oxygen to be administered to the resident and if it was to be continuous or intermittent. -Resident #70 was admitted to the facility on (MONTH) 3, (YEAR) with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The order included to check oxygen saturation every shift and as needed for low oxygen saturation. However, the order did not include how much oxygen to administer to the resident, and if the oxygen should be administered continuously or intermittently. A care plan for oxygen therapy included a goal that the resident would have no signs or symptoms of poor oxygen absorption through the next review. The quarterly MDS assessment dated (MONTH) 31, 2019 revealed the resident had a BIMS score of 2, indicating severe cognitive impairment. The MDS also included that the resident was receiving oxygen therapy. Review of the TAR for (MONTH) 2019 revealed there were missing entries for the resident's oxygen saturation levels on the following dates: October 1, day shift October 8, night shift October 21, day shift Review of the (MONTH) 2019 TAR revealed there was no oxygen saturation entry on (MONTH) 4, during the day shift. A nursing note dated (MONTH) 15, 2019 by a Registered Nurse (staff #11) included the resident was having increased respiratory distress and was currently on 2.5 liters of oxygen. The note included that the resident's oxygen was increased to 3.5 liters. Further review of the (MONTH) 2019 TAR revealed the resident's oxygen saturation levels were below 90% on the following dates: November 15: day shift with an oxygen saturation level of 85% and night shift level was 87% November 18: day shift with an oxygen saturation level of 88% November 19: day shift with an oxygen saturation level of 84% Review of the clinical record revealed no evidence that the order was clarified to include the amount of oxygen to be administered to the resident and whether it was to be administered continuous or intermittent. An interview was conducted with a registered nurse (staff #130) on (MONTH) 21, 2019 at 9:10 a.m. She stated that the physician's orders [REDACTED]. She stated if the amount of oxygen is not included in the order, she would increase the resident's oxygen until the resident's oxygen saturation was over 90%. Staff #130 stated she would start a resident on 2 liters of oxygen per minute (LPM) and increase it up to 5 LPM to reach 90% saturation in case of an emergency. An interview was conducted with the Director of Nursing (staff #125) on (MONTH) 22, 2019 at 8:45 a. m. Staff #125 stated she expects nursing staff to monitor residents who are on oxygen and ensure the residents' oxygen saturation is within the parameters of the physician's orders [REDACTED].>During the interview, resident #47's and resident #70's clinical records and the facility's policy on oxygen therapy were reviewed with staff #125. She stated neither resident's orders included the amount of oxygen to be given or whether the oxygen was to be continuous or as needed. She stated it is their policy for the order to include how much oxygen a resident should receive and whether it is continuous or as needed. Review of the policy on Oxygen Therapy revealed the facility is committed to providing all services necessary for resident care, and recognizes residents may need oxygen therapy at times related to medical [DIAGNOSES REDACTED].",2020-09-01
938,RIM COUNTRY HEALTH & RETIREMENT COMMUNITY,35134,807 WEST LONGHORN ROAD,PAYSON,AZ,85541,2019-11-25,758,D,0,1,0F1M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews and policy and procedures, the facility failed to ensure the use of as needed (PRN) psychoactive medications for two residents (#76 and #238) were limited to 14 days, or that there was documentation by the physician/prescriber of the rationale for its continued use and that the duration of treatment was indicated. The deficient practice may result in residents receiving psychoactive medications which are unnecessary. Findings include: -Resident #76 was admitted on (MONTH) 22, 2019 with a [DIAGNOSES REDACTED]. Review of a clinical admission evaluation dated (MONTH) 22, 2019 revealed the resident was alert and oriented x 3 and was admitted for respite stay. A nursing note dated (MONTH) 22, 2019 revealed the resident was admitted for a 5-day hospice respite stay. The psychoactive medication informed consent dated (MONTH) 22, 2019 included the resident was prescribed [MEDICATION NAME] (antianxiety) for anxiety, agitation and restlessness. Review of the physician recapitulation of orders for (MONTH) 2019 included for [MEDICATION NAME] 2 mg/ml (milligrams/milliliter) give 0.25 ml by mouth every 4 hours as needed for agitation and restlessness. However, the order did not include a stop date. According to documentation in the clinical record, the resident was found lying on the floor on (MONTH) 25, 2019 and her left distal femur/knee area was hurting and the resident was sent to the hospital. A nursing note dated (MONTH) 29, 2019 included the resident was readmitted to the facility from the hospital status [REDACTED]. The physician recapitulation of orders for (MONTH) 2019 included for [MEDICATION NAME] 2 mg/ml give 0.25 ml by mouth every 4 hours PRN for agitation and restlessness. However, the order did not include a stop date. Review of the (MONTH) and (MONTH) 2019 Medication Administration Records (MARs) revealed the order for [MEDICATION NAME] PRN was included, however, there was no stop date. Further review of the clinical record revealed there was no documentation by the physician/prescriber of the rationale for the continued use of [MEDICATION NAME] beyond 14 days. -Resident #238 was admitted on (MONTH) 14, 2019 with a [DIAGNOSES REDACTED]. Review of the clinical admission evaluation dated (MONTH) 14, 2019 revealed the resident was confused, disoriented, lethargic and required cueing. Per the documentation, the resident was difficult to arouse and responds to tactile stimulation. It also included the resident had PRN antianxiety medication in place. Review of the PASRR (Pre-Admission Screening and Resident Review) dated (MONTH) 14, 2019 revealed the resident had a serious mental illness of [MEDICAL CONDITION]. The psychoactive medication informed consent form dated (MONTH) 14, 2019 included the resident was prescribed [MEDICATION NAME] (antianxiety medication) for anxiety, with target behaviors of crying and shortness of breath. A physician's orders [REDACTED]. However, the order did not include a stop date. This order was also transcribed onto the MAR for (MONTH) 2019. A care plan for [MEDICAL CONDITION] medication use dated (MONTH) 14, 2019 included the resident was taking [MEDICAL CONDITION] medication related to anxiety. Further review of the clinical record revealed there was no documentation by the physician/prescriber of the rationale for the continued use of [MEDICATION NAME] beyond 14 days. In an interview with a licensed practical nurse (LPN/staff #118) conducted on (MONTH) 20, 2019 at 10:31 a.m., she stated the PRN use of any [MEDICAL CONDITION] medications including antipsychotics, antidepressants, antianxiety and sedative/hypnotics is limited to 15 days, then discontinued. She said if the resident needs the PRN [MEDICAL CONDITION] medication longer, then a new order is written and it will be administered only for another 15 days. An interview with a registered nurse (staff #50) was conducted on (MONTH) 20, 2019 at 12:17 p.m. He stated that a PRN psychoactive medication such as an antianxiety is only prescribed for 14 days, then it is discontinued. He stated if the resident still needs the medication, the physician should assess the resident and a new order would be written. During an interview with the Director of Nursing (DON/staff #125) conducted on (MONTH) 22, 2019 at 8:58 a.m., she stated she continually educates the nurses that when they receive an order for [REDACTED]. She stated that during morning meetings, she and the nursing staff review the admissions and new orders to ensure that PRN orders for [MEDICAL CONDITION] medications are limited to 14 days. During this interview, the clinical records for resident #76 and #238 were reviewed with the DON. She said the orders for [MEDICATION NAME] for resident #76 and [MEDICATION NAME] for resident #238 did not include a 14 day stop date. She stated the orders for these medications should include a stop date for their use. Review of a policy regarding Psychoactive Medication Administration revealed the facility is committed to ensuring that psychoactive medications will only be utilized when medically necessary for the resident. The policy defined [MEDICAL CONDITION] medication as any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to the following drug categories: antipsychotic, antidepressant, antianxiety, hypnotic, as well as medication classes that may affect brain activity. The policy further stated that PRN use of psychoactive medications shall be limited to 14 days. To continue their use, a new order for the PRN medication may be written if the prescribing practitioner directly [MEDICATION NAME] and assesses the resident and documents the clinical rationale. The clinical rationale must include the benefit of the medication for that resident.",2020-09-01
939,MONTECITO POST ACUTE CARE AND REHABILITATION,35135,51 SOUTH 48TH STREET,MESA,AZ,85206,2020-02-07,641,D,0,1,NYBR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure one of two sampled residents (#160) Minimum Data Set (MDS) assessment was coded correctly for discharge status. Findings include: Resident #160 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the discharge MDS assessment dated [DATE] revealed resident #160 was discharged to an acute care hospital. However, review of a progress note dated 11/8/19 revealed the resident was discharged to an assisted living facility. In an Interview conducted with the MDS nurse (staff #184) on 2/6/20 at 1:51 PM, she stated the MDS discharge assessment dated [DATE] should have been coded discharged to the community. An interview was conducted with the Director of Nursing (DON/staff #159) on 2/6/20 at 2:16 PM. After reviewing the discharge MDS assessment dated [DATE] and the progress note dated 11/8/19, she stated the MDS assessment was coded incorrectly. The RAI manual instructs to review the clinical record including the discharge plan and discharge orders for documentation of a resident's discharge location and code that location.",2020-09-01
940,MONTECITO POST ACUTE CARE AND REHABILITATION,35135,51 SOUTH 48TH STREET,MESA,AZ,85206,2020-02-07,658,E,0,1,NYBR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure services provided to three residents (#212, #408, and #6) met professional standards of quality, by failing to administer medications per the physician orders. The deficient practice could result ineffective management of residents' blood pressures. Findings include: Resident #212 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed a physician's orders [REDACTED].>160. Review of the Blood Pressure Summary report for February 2020 revealed the following SBPs: February 4 at 7:01 AM, SBP 171 February 5 at 11:35 AM, SBP 165 February 5 at 3:18 PM, SBP 179 February 5 at 11:06 PM, SBP 172 February 6 at 8:08 AM, SBP 166 However, review of the Medication Administration Record [REDACTED]. An interview was conducted with a Registered Nurse (RN/staff #175) on February 7, 2020 at 9:52 AM. The RN stated the Certified Nursing Assistants (CNAs) are responsible for obtaining residents blood pressures and that the CNAs are expected to notify the nurse if there are variations from the residents' baseline. The RN further stated the electronic MAR indicated [REDACTED]. The RN also stated that he would administer a prn blood pressure medication as ordered and would recheck the resident's blood pressure to assess the effectiveness of the medication. In an interview conducted with the Director of Nursing (DON/staff #159) on February 7, 2020 at 11:40 AM, the DON stated the expectation is that nurses administer medication as ordered and that if the medication was not given, the nurse would notify the physician and document the notification. -Resident #6 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the physician orders [REDACTED]. Review of the MAR indicated [REDACTED]. In an interview conducted with a RN (staff #156) on 2/7/20 at 1:56 PM, she stated the order was confusing and should be clarified. She acknowledged the medication was given before [MEDICAL TREATMENT]. During an interview conducted with the DON (staff #159) on 2/7/20 at 2:00 PM, she stated [MEDICATION NAME] should not have been given at 8:00 am on the days the resident went to [MEDICAL TREATMENT] which were February 3, 5 and 7, 2020. -Resident #408 was admitted on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of the MAR for January 2020 revealed [MEDICATION NAME] was given on 5 occasions when the resident's SBP was less than 110: January 15 at 8:00 PM, SBP 95 January 18 at 8:00 AM, SBP 108 January 19 at 8:00 AM, SBP 93 January 20 at 8:00 AM, SBP 101 January 21at 8:00 AM, SBP 100 Review of the progress notes revealed no documentation why the medication was given outside of the ordered parameter or if the physician was notified. An interview was conducted with a Licensed Practical Nurse (LPN/staff #160) on February 5, 2020 at 11:12 a.m. After reviewing the MAR for January 2020, the LPN stated [MEDICATION NAME] was administered 5 days when the SBP was less than 110. The LPN stated the nurse should have notified the physician the medication was administered outside of the ordered parameter and documented the notification. In an interview conducted with the DON (staff #159) on February 5, 2020 at 11:49 a.m., the DON stated her expectation is that the nurses administer medications as ordered which would include following the ordered parameters. The DON acknowledged [MEDICATION NAME] was given outside of the ordered parameter. The facility's policy regarding administering medication reviewed September 2019; revealed medications shall be administered as prescribed by the physician. The policy also revealed medications must be administered in accordance with the written orders of the attending physician.",2020-09-01
941,MONTECITO POST ACUTE CARE AND REHABILITATION,35135,51 SOUTH 48TH STREET,MESA,AZ,85206,2020-02-07,684,D,0,1,NYBR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#212) was provided care and services in accordance with professional standards regarding changes in pulse rates. The deficient practice could result in delayed care for residents experiencing changes in conditions. Findings include: Resident #212 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed a physician order [REDACTED]. Review of the pulse summary reports for January 2020 revealed the following pulses: January 20, 2020 at 6:12 AM, pulse 64 January 21, 2020 at 6:03 AM, pulse 64 January 22, 2020 at 7:00 AM, pulse 20 low of 60.0 exceeded Review of the clinical record revealed no documentation the resident was assessed, the pulse was retaken, or the physician was notified for the pulse of 20. A Licensed Nurse Daily Skilled Note dated January 22, 2020 at 10:02 PM revealed the resident's pulse was 73 on January 22, 2020 at 11:35 PM. The note included the vital signs showed no fluctuations from baseline that required intervention Review of the pulse summary report dated January 23, 2020 at 6:07 AM revealed the resident's pulse was 170 and included the warning high of 100.0 exceeded. The report also included the resident's blood pressure was 115/73. Review of the clinical record revealed no documentation the resident was assessed, the pulse was retaken, or the physician was notified for the pulse of 170. A Licensed Nurse Daily Skilled Note dated January 23, 2020 at 9:55 PM revealed the resident's pulse was 170 on January 23, 2020 at 6:07 AM and the blood pressure was 115/73 at 6:07 AM. The note included the vital signs showed no fluctuations from baseline that required intervention. The note also included the resident's heart rate and rhythm was recorded within baseline and no cardiovascular changes were observed. Further review of the pulse summary reports revealed no documentation the resident's pulse was obtained for the remainder of January 23 or on January 24, 2020. The resident was discharged to the hospital on January 24, 2020. Review of the Hospital History and Physical (H&P) dated January 24, 2020 revealed the resident had been at a clinic appointment where, upon checking vital signs, the clinic found the resident to be [MEDICAL CONDITION]. The clinic called Emergency Medical Services (EMS) and the resident was taken to the emergency room (ER). At the hospital the resident was given medication which slowed her heart rate to 90-120. The H&P also included the resident's blood pressure returned to normal once the heart rate was controlled. The resident was readmitted to the facility on [DATE] with new [DIAGNOSES REDACTED]. In an interview with a Registered Nurse (RN/staff #175) conducted on February 7, 2020 at 9:52 AM, the RN stated that the Certified Nursing Assistants (CNAs) routinely take vital signs at the beginning of each shift, at 6 AM, 2 PM, and 10 PM. He stated the CNAs are expected to report to the nurse any variations from the resident's baseline pulse. The RN stated that if a CNA reported to him a pulse of 20 or 170 he would immediately assess the resident, retake the pulse, and notify the physician as needed and document it. Staff #175 stated that the pulses must have been typographical errors, and that he did not know why there was no further documentation regarding the pulses. During an interview conducted with the Director of Nursing (DON/staff #159) on February 7, 2020 at 11:40 AM, the DON stated that she would expect the nurse to retake the resident's vital signs for a pulse of 20 and a pulse of 170, assess the resident, and call the physician if needed and document it. Review of the facility's policy titled Vital Signs revised September 2019, revealed the policy of the facility is to record vital signs as ordered by the physician or as frequently as the resident's condition warrants. The facility's policy titled Change of Condition Reporting reviewed September 2019, revealed unusual signs and symptoms will be communicated to the physician promptly and that the nurse in charge is responsible for notification to the physician. The policy also revealed the change of condition and response as well all attempts to reach the physician and responsible party will be documented in the nursing progress notes. The policy included the licensed nurse responsible for the resident will continue to assess and document every shift for at least seventy-two (72) hours or until the condition has stabilized.",2020-09-01
942,MONTECITO POST ACUTE CARE AND REHABILITATION,35135,51 SOUTH 48TH STREET,MESA,AZ,85206,2020-02-07,689,G,0,1,NYBR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure one of nine sampled residents (#30) was properly positioned to prevent an injury. The deficient practice could place residents at increased risk for injuries. Findings include: Resident #30 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a care plan updated on October 9, 2018, revealed the resident had Activities of Daily Living (ADL) self-care performance deficit related to limited mobility, [MEDICAL CONDITIONS] and contractures. Interventions included the resident used a custom reclining wheelchair when out of bed, received splint applications for contracture management and was totally dependent on staff for transfers and for repositioning and turning in bed. A care plan initiated October 10, 2018, for activities included the resident needed transport to and from activity programming. Interventions included assisting the resident to the activity room for group activities because the resident was unable to propel his wheelchair independently. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The assessment also included the resident was totally dependent for bed mobility, transfers and locomotion. Review of a nursing note dated December 13, 2019, revealed the following, this nurse was assisting in taking residents out of dining room following lunch. Upon exiting the door to the hallway, not realizing this resident's legs were hanging over the chair, this nurse accidentally bumped the resident's knee and over hanging left leg on the door frame. A pop was heard. This nurse immediately said, 'oh my gosh are you ok!? I am so sorry!' He looked at nurse un-phased and didn't say anything. Again asked if he was ok, he again did not reply . An assessment of overhanging legs was done. No visible injury to lower extremities was noted. Baseline ROM (range of motion) of contracted lower extremities was done . This nurse got another nurse to ask resident about pain and verify ROM . Resident was continually asked about pain in which he denied. Seen having involuntary movement and left leg was moving with no c/o (complaints of) pain. Review of a nursing note from a different author dated December 13, 2019, revealed another nurse approached the resident to ask if he was in pain and the resident did not answer the question but started to talk about the television show that was playing in the background. The note included that the author assessed the resident legs, found no visible swelling, and observed the resident's left knee to be over the edge of the wheelchair as usual positioning. The note included that the resident denied pain, but displayed grimacing facial expressions when his knee was touched. The note further included the author asked the resident if he felt the incident was intentional on behalf of the nurse and the resident replied no, he accidentally got leg caught on doorway. The provider was notified and an order was obtained for an x-ray. Review of the x-ray results dated December 13, 2019, revealed the resident had a displaced [MEDICAL CONDITION] femur. Review of the clinical record revealed the resident was discharged to the hospital on December 14, 2019. Review of the hospital records revealed an x-ray obtained December 14, 2019, was compared to the resident's previous x-ray dated June 1, 2007, and findings included decreased bone mineralization. The resident was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the care plan for ADL self-care performance deficit revealed an update on January 29, 2020, which included a mobility assessment and a bilateral padded foot box modification to the resident's wheelchair for foot protection. Review of an addendum to a hospital physician's progress note dated February 7, 2020, revealed the resident's case was reviewed. An addendum included the resident's x-ray findings were consistent with bone demineralization which could be [DIAGNOSES REDACTED] and/or [MEDICAL CONDITION]. The note included the bone demineralization would put the resident at high risk of fragile fractures even with activities of daily living with or without any trauma. An interview and observation was conducted with the resident on February 4, 2020 at 10:22 a.m. He stated there was a time recently when the nurse was pushing him in his wheelchair in the dining room and bumped his leg on the door and broke it. He said it did not hurt because he cannot feel his legs. He said it was an accident. At the time of the interview, the resident was observed to be seated in a reclining wheelchair with a padded foot box. Both of the resident's legs were bent at the knee and resting on the wheelchair in a side-lying position. An interview was conducted with a Registered Nurse (RN/staff #156) on February 6, 2020 at 9:01 a.m. She said she remembered the incident occurred when she was helping residents out of the dining room. She said she was pushing the resident's wheelchair and did not realize his leg was off to the side of the chair. She thought she had cleared the door frame because the wheels were clear, then she bumped his leg on the doorway and heard a pop sound. She said she assessed the resident and did not find any injuries. She said he denied pain and did not have feeling in his legs. She said an x-ray was obtained that showed the resident had a fracture. She said she received one-on-one training after the incident to be more aware of a resident's body position when pushing a resident's wheelchair. An interview was conducted with the Director of Nursing (DON/staff #159) on February 6, 2020 at 11:07 a.m. She stated that an investigation was conducted following the resident's fracture. She said the resident was interviewed, and the resident stated that the nurse's actions were not intentional. She said staff members were educated during subsequent mandatory in-service training to be more careful when pushing residents in wheelchairs. She said it took time to update to the resident's care plan following the fracture because a specialist was needed to evaluate the resident for a padded foot box for his wheelchair. Review of the facility's policy for incidents and accidents revealed it is the policy of the facility to implement measures to avoid hazards and accidents. Should an accident/incident occur, the resident would be provided immediate attention by a licensed nurse, who would notify the medical provider, family member and emergency medical services as appropriate. Any staff member witnessing an accident or incident should render immediate assistance and summon help. A licensed nurse shall assess the resident and determine if additional care is needed. The licensed nurse will notify the medical provider for the resident and obtain orders for further treatment or [DIAGNOSES REDACTED].",2020-09-01
943,MONTECITO POST ACUTE CARE AND REHABILITATION,35135,51 SOUTH 48TH STREET,MESA,AZ,85206,2020-02-07,693,D,1,1,NYBR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, and policy and procedure, the facility failed to ensure one resident (#308) fed by enteral means was provided the appropriate treatment and services. The deficient practice could result in residents not receiving enteral nutrition. Findings include: Resident #308 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the admission physician's orders [REDACTED]. The admission orders [REDACTED]. Another physician order [REDACTED]. A care plan dated October 21, 2019, revealed the resident had the potential for nutrition risk related to tube feedings and NPO status. Interventions included to administer tube feedings and water flushes as ordered and to keep the resident NPO as ordered. A nursing note dated October 21, 2019, revealed the resident arrived to the facility at 4:00 p.m., with no signs or symptoms of discomfort. The note included the resident was oriented to person. The noted also included a bolus feeding was administered to the resident at 6:00 p.m.; however the type and volume of formula administered was not included in the note. Review of the Medication Administration Record (MAR) for October 21, 2019, revealed no evidence a bolus or a continuous feeding was administered to the resident. The space for documentation was blank. The MAR also included that the resident's residual was checked and documented as zero on the overnight shift. Review of the resident's blood glucose testing results for October 21, 2019, revealed that at 5:14 p.m. the resident's blood glucose was 110 milligrams per deciliter (mg/dl), and at 7:30 p.m. his blood glucose was 111 mg/dl. Review of the physician's orders [REDACTED]. Review of the MAR for October 22, 2019, revealed no evidence that a bolus or a continuous feeding was administered to the resident. The space for documentation was blank. The MAR also included the resident's residuals were checked and documented as zero on the morning and afternoon shifts. A nursing note dated October 22, 2019, included the resident was on continuous enteral feedings and tolerating well. The note did not include the type of formula, the rate of administration or the total volume of the feeding. A physician's admission note dated October 22, 2019, included the resident was NPO and on continuous tube feedings. The note did not include the type or volume of the feeding. Review of the resident's blood glucose results for October 22, 2019, revealed the following results: 132 mg/dl at 6:57 a.m. 125 mg/dl at 11:00 a.m. 177 mg/dl at 3:06 p.m. Review of the clinical record revealed that at the request of the resident's representative, the resident was discharged to the hospital on October 22, 2019. An interview was conducted on February 5, 2019 at 12:12 p.m., with a Licensed Practical Nurse (LPN/staff #145). She said she took care of the resident when he arrived to the facility, and remembered documenting specific times in her progress note of when the resident arrived and when she administered the bolus feeding. She said the resident's medications and supplements had not yet been delivered from the pharmacy, but the resident had tube feeding supplements in the belongings he brought from the hospital. She said she administered a feeding bolus using the supplements from the hospital. She said another nurse was training her that day and helping her with documentation. She said if the bolus feeding was not documented on the MAR, the reason may have been because she was training and receiving assistance from her training nurse with the documentation. An interview was conducted on February 5, 2020 at 12:20 p.m. with a Registered Nurse (RN/staff #32). She stated she was training staff #145 when the resident arrived to the facility. She said she noticed the resident had a feeding tube and bolus supplies when he arrived. She said she checked the MAR to find out the resident's feeding orders, but there were no orders entered yet. She said she called the admission nurse to ask if the resident received a bolus, the admission nurse said yes, and she administered the bolus using the hospital supplements. She said later the resident's representative arrived and asked why the resident did not have a tube feeding set up on a pole. She said she told the representative that the reason there was no tube feeding pole was because the resident was receiving bolus feedings. She said she did not remember how the bolus feeding had been documented. A follow up interview was conducted with the Assistant Director of Nursing (staff #157) and staff #32 on February 5, 2020 at 12:54 p.m. Staff #157 stated she was working as an admission nurse during the time the resident was admitted to the facility. She said normally the admission and/or charge nurse would have a copy of the resident's hospital discharge orders and would review the discharge orders to initiate and verify admission orders [REDACTED]. She said the bedside nurse would not normally have a copy of the resident's hospital orders, but would rely on the MAR to see the resident's admission orders [REDACTED]. She said the bedside nurse would not have quick access to the printed hospital orders because the nursing unit was upstairs and the admission/charge nurse was downstairs. She said the bedside nurse would rely on the orders entered into the MAR to provide care for the resident, and the bedside nurse would have to contact the admission/charge nurse if there were no orders in the MAR. An interview was conducted on February 5, 2020 at 3:03 p.m. with an LPN (staff #158). She stated she was the resident's nurse during the overnight shift. She said she remembered hanging a tube feeding for the resident, but did not remember the type of formula or volume administered. She said she did not remember if there were orders on the MAR or if she had to ask the admission/charge nurse to find out the resident's feeding orders. An interview was conducted with the Director of Nursing (DON/staff #159) on February 6, 2020 at 11:07 a.m. She stated that for residents receiving tube feedings, her expectation is that the nurse would follow the physician's orders [REDACTED]. She said nurses are able to view the orders on the MAR. She said if the resident is a new admission, the orders might not be on the MAR yet, but they could be found in the hospital orders. She said sometimes residents have arrived earlier than expected from the hospital, and sometimes they have arrived with orders for both bolus feedings and continuous feedings. She said the charge nurse is to clarify the orders with the physician, enter the orders into the electronic record for viewing on the MAR, and inform the bedside nurse of the orders if needed. She said if the orders were not yet on the MAR for documentation, she would still expect the nurse to document tube feedings in a progress note. She said ideally the orders would be available in the electronic charting system, but if needed she would expect the charge nurse and the bedside nurse to review the resident's printed hospital orders together. She said regarding this resident, the resident arrived from the hospital with bolus and continuous feeding orders and that the nursing staff clarified the orders with the physician. She said the resident's representative had been informed that the resident had received a bolus feeding soon after arrival. She said she had interviewed nursing staff and confirmed that the resident had also received continuous tube feedings, but that she did not asked staff to document the details of the feedings as late entries on the MAR. Review of the facility's policy for tube feeding revealed: -Tube feedings shall be prepared according to physician's orders [REDACTED].>-Feeding containers will be labeled with the time started with each new feeding -The feeding container, tubing and syringe will be changed every 24 hours -The feeding shall be documented on the tube feeding record -The head of the resident's bed will be elevated 30-45 degrees at all times",2020-09-01
944,MONTECITO POST ACUTE CARE AND REHABILITATION,35135,51 SOUTH 48TH STREET,MESA,AZ,85206,2020-02-07,880,E,0,1,NYBR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, clinical record review, personnel file record review, policy and procedure and the Center for Disease Control (CDC) guidelines, the facility failed to ensure that one of four sampled residents (#310) received PICC (peripherally inserted central catheter) line dressing changes in accordance with professional standards of practice, transmission based precautions were followed for one resident (#311), and that two staff members (#13 and #182) had evidence of freedom from infectious [MEDICAL CONDITION]. The deficient practice could place residents at increased risk for exposure to infectious microorganisms. Findings include: -Resident #310 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the admission physician's orders [REDACTED]. A care plan initiated January 29, 2020, included the resident had a PICC line for intravenous (IV) antibiotic administration with a goal that the resident would remain free from signs and symptoms of infection. Interventions included changing the dressing as ordered and as needed and flushing the tubing with normal saline water before and after IV medication administration. Review of the Medication Administration Record [REDACTED]. However, an observation and interview was conducted with the resident on February 3, 2020 at 11:00 a.m. The resident's PICC line dressing was observed to be dated January 26, 2020. The dressing, which normally would have contained sections that were transparent and sections that were white, was soiled and the overall color of the dressing was tan. The dressing was peeling away from the resident's skin all around the edges. The resident said he did not remember the last time the dressing was changed. An interview was conducted on February 6, 2020 at 11:07 a.m., with the Director of Nursing (DON/staff #159). She stated that for residents with central lines and PICC lines, infection control precautions would include cleaning the port before and after accessing the line and checking every shift to see if the dressing was intact or soiled, and if there were any signs or symptoms of infection at the insertion site. She stated her expectation is that the dressing should be changed every 7 days or as needed if soiled. Review of the facility's policy for PICC line dressing changes revealed that transparent dressings would be changed every 7 days or sooner if they became loosened to the point of compromising sterility or presented a risk of accidental dislodgement of the catheter. An accumulation of moisture, fluid, blood or exudate could also be criteria for a dressing change. If a dressing is changed, the new dressing will be labeled and the procedure charted. -Resident #311 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the admission physician's orders [REDACTED]. Review of the clinical record revealed a stool sample was collected from the resident on February 2, 2020, due to multiple loose stools. Review of the physician's orders [REDACTED]. The order was discontinued the same day. An observation was conducted on February 3, 2020 at 11:54 a.m., outside of resident #311's room. A yellow sign announcing isolation precautions was posted outside the room. A Certified Nursing Assistant (CNA/staff #75) was observed inside the resident's room wearing a gown and gloves to deliver the resident's meal tray. Staff #75 delivered the tray, answered the resident's questions, moved to exit the room, removed her gown and gloves, washed her hands and moved to the threshold of the doorway. Another staff member standing outside the room told staff #75 that the resident's call light had not been turned off. Staff #75 stopped before exiting the room, put a glove on one hand, walked across the room and turned the call light off with her gloved hand. She then removed the glove, applied hand sanitizer and exited the room. Staff #75 then went directly to deliver beverages and meal trays to residents in three other rooms. Review of the clinical record revealed the resident's stool sample results were received February 3, 2020, which included the negative results for [MEDICAL CONDITION]. An interview was conducted on February 6, 2020 at 11:07 a.m., with the Director of Nursing (DON/staff #159). She stated her expectation is that staff would follow the posted signs for isolation precautions outside specified residents' rooms. She said a yellow isolation sign would be for [MEDICAL CONDITION], and she would expect staff to wear a gown and gloves when entering the room and wash their hands when leaving the room. She said wearing a mask was optional in a room with a yellow isolation sign, but hand washing was not optional. She said if a staff member needed to go back into an isolation room after removing gown and gloves and washing hands, she would expect them to apply a new gown and gloves before going back in to take care of the resident. She said staff should wash their hands again when exiting the room. An interview was conducted with staff #75 on February 6, 2020 at 1:22 p.m. She stated as soon as she left the isolation room she realized she should have done things differently. She said she should have put on a gown and gloves to turn off the resident's call light and she should have washed her hands, not used hand sanitizer, before exiting the room. Review of the facility's policy for transmission-based precautions and isolation revealed that hand washing before and after resident contact and after removing gloves was the single most effective infection control measure known to reduce the potential for transmission of microorganisms. Disposable gowns should be worn when entering a room and it was anticipated that clothing would become soiled or come in contact with soiled surfaces (such as siderails or bed linens of an infected resident). Gloves should be applied prior to anticipated contact, and hands should be washed immediately after removing gloves. Staff would be educated concerning the role they played in reducing the potential for transmission of microorganisms. The facility would implement a system to alert staff, residents and visitors that a resident was on transmission based precautions. Review of the CDC guidelines revealed that [MEDICAL CONDITION] is a spore-forming bacterium that causes inflammation of the colon known as [MEDICAL CONDITION]. [MEDICAL CONDITION] spores are shed in feces and transferred to patients mainly via the hands of people who have touched a contaminated surface or item. For the prevention of transmission of [MEDICAL CONDITION] in healthcare settings, use contact precautions for patients with known or suspected [MEDICAL CONDITION]. The guidelines include using gloves and gowns when entering patient rooms and during care and for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. The guidelines also state that before exiting the patient's room, discard gowns and gloves, and wash hands with soap and water to contain the [MEDICAL CONDITION] pathogens. -Review of a Certified Nursing Assistant (CNA/staff #13) personnel file revealed a hire date of July 22, 2019 for full time employment. Additional review of staff #13's personnel file revealed a [MEDICATION NAME] skin test was administered on November 25, 2019 and that the date the result was read was on November 28, 2019. However, the area designated for the results of the skin test did not contain documentation of the results. It was blank. -Review of the personnel file for a Licensed Practical Nurse (LPN/staff #182) revealed a hire date of September 21, 2019 for full time employment. Continued review of the LPN's personnel file revealed a [MEDICATION NAME] skin test was administered on September 19, 2019 and that the date the result was read was on September 21, 2019. However, the area designated for the results of the skin test did not contain documentation of the results. It was blank. An interview was conducted with the Human Resource/Payroll director (staff #295) on February 5, 2020 at 8:40 a.m. Staff #295 stated staff will have evidence of freedom from [MEDICAL CONDITION] upon hire and every year after. Staff #295 stated the staff that the read the results of the [MEDICATION NAME] skin test for staff #13 and staff #182 should have written negative on the line designated for the results. In an interview conducted with the Director of Nursing (staff #159) on February 5, 2020 at 9:11 a.m., the DON stated that staff are screened annually for freedom from [MEDICAL CONDITION]. The DON further stated that the staff that read the results of the [MEDICATION NAME] skin test for staff #13 and staff #182 did not document negative in the results area of the form. Review of the facility's policy regarding staff screening for [MEDICAL CONDITION] (TB) reviewed September 2019, revealed each employee hired by this facility shall be screened for TB, and receive screening at least annually. The policy also included that every 12 months after the date of testing; a staff member submits documentation of a negative [MEDICATION NAME] skin test that includes the date and the type of test, administered within 30 days before the anniversary date of the most recent test.",2020-09-01
945,MONTECITO POST ACUTE CARE AND REHABILITATION,35135,51 SOUTH 48TH STREET,MESA,AZ,85206,2017-08-25,166,D,0,1,MHW311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, and policy review, the facility failed to ensure that one resident's (#192) grievance regarding sound levels was acted upon. Findings include: Observations were conducted on (MONTH) 24, (YEAR) at 9:18 a.m. on the second floor Papago Unit. A radio in the hall was [MEDICATION NAME] loudly and could be heard while approaching the Papago Unit. While approaching resident #192's room on the same hall. Staff #107,a certified nurses' assistant (CNA), entered the room [MEDICATION NAME] the radio and attempted to lower the radio and closed the door. The resident with the radio began to bang on the door and increased the volume at 9: 25 a.m. Resident #192 was admitted on (MONTH) 10, (YEAR), with [DIAGNOSES REDACTED]. Review of the Minimum Data Set quarterly assessment dated (MONTH) 17, (YEAR). Revealed resident #192's brief interview of mental status score was fifteen, indicating the resident was connectively intact. Review of the activities care plan for resident #192 stated that it is important for resident #192 to do her favorite activities, such as watching television and music. An interview with resident #192 was conducted on (MONTH) 24, (YEAR) at 9:26 a.m. She stated the resident with the radio across the hall has blasted the radio and television since she moved to the unit a month ago and has complained about the noise level to CNAs and nurses. Resident #192 stated the radio or television can be heard at all hours of the day and she is unable to hear her television. An interview with a CNA (Staff #107) was conducted on (MONTH) 24, (YEAR) at 9:45 a.m. Staff #107 stated that the resident with the radio on the Papago Unit turns the radio or television on around breakfast and will increase the volume after it is lowered by staff. Staff #107 stated that resident #192 has previously complained about the resident [MEDICATION NAME] the radio. On (MONTH) 24, (YEAR) at 1:00 p.m., an interview was conducted with staff #17 (Social Services). She stated the expectation is for all staff to file a grievance form and notify Social Services. Staff #17 was unaware of the complaint reported to staff by resident #192 and there had not been a grievance filled since admission on (MONTH) 10, (YEAR). The grievance process policy states the facility is to allow residents, families, guests, and employees to voice concerns and make timely efforts to resolve such concerns. The purpose is to assure that concerns are quickly and thoroughly evaluated and acted upon to resolve issues which affect the quality of life and care for residents in the facility.",2020-09-01
946,MONTECITO POST ACUTE CARE AND REHABILITATION,35135,51 SOUTH 48TH STREET,MESA,AZ,85206,2017-08-25,278,D,0,1,MHW311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and review of the facility policy and procedures, the facility failed to ensure that Minimum Data Set (MDS) assessments were accurate for two residents (#79 and #312). Findings include: Resident #79 was admitted to the facility on (MONTH) 6, (YEAR) with [DIAGNOSES REDACTED]. Review of a quarterly MDS assessment dated (MONTH) 28, (YEAR) revealed that the resident was coded as to have not received an antidepressant medication during the seven day look-back of the assessment. Review of the resident's care plan revealed that the resident was receiving a [MEDICAL CONDITION] medication related to depression as evidenced by self isolation. The goal was to have fewer episodes of self isolation. One of the interventions included to administer the medications as ordered. Two active physician's orders were noted for antidepressant medications: -[MEDICATION NAME] (an antidepressant) 50 milligrams (mg) per day -[MEDICATION NAME] 10 mg every 12 hours Both of these orders were originally ordered (MONTH) 5, (YEAR). The Medication Administration Record (MAR) for (MONTH) (YEAR) showed that the resident received the medications as ordered. An interview was conducted with the MDS coordinator (staff #176) at 11:50 a.m. on (MONTH) 24, (YEAR). She said that when she is coding the MDS for medications, she looks at the physician's orders and the MAR to see which medications the resident has received during the look back period of the MDS assessment which is 7 days from the assessment date. She reviewed this resident's MAR and said she can see that the resident received antidepressant medication and that the MDS should have been coded to show that the resident received it 7 days and not 0. Review of the facility's resident assessment policy and procedure revealed a policy statement that the facility is to ensure that the assessment accurately reflects the resident's status. The purpose of the policy included to assure that each resident receives an accurate assessment by staff that are qualified to assess relevant care areas and knowledge about the resident's status. The procedure included that a registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals and that each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment. Resident #312 was admitted to the facility on (MONTH) 1, (YEAR) with [DIAGNOSES REDACTED]. A Pre Admission Screening Resident Review (PASRR) Level II evaluation was completed for this resident on (MONTH) 10, (YEAR) (done at a previous facility). The evaluation revealed that the resident had a serious mental illness qualifying diagnoses. A care plan was developed on (MONTH) 30, (YEAR), which revealed the resident had a potential for behavior problem related to [MEDICAL CONDITION] Disorder. Further it included that the resident was a PASSR level II. However, an annual Minimum Data Set (MDS) assessment dated (MONTH) 20, (YEAR) coded the resident as not currently being considered by the state level II PASRR process to have a serious mental illness. In an interview with the MDS coordinator (staff #176) on (MONTH) 24, (YEAR) at 11:51 a.m., she stated that yes the PASSR Level II should have been marked as yes on the annual assessment. Additionally, she stated that it was a data entry error. Review of the facility's resident assessment policy and procedure revealed a policy statement that the facility is to ensure that the assessment accurately reflects the resident's status. The purpose of the policy is to ensure that each resident receives an accurate assessment by staff that are qualified to assess relevant care areas and knowledge about the resident's status. The procedure included that a registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals and that each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment.",2020-09-01
947,MONTECITO POST ACUTE CARE AND REHABILITATION,35135,51 SOUTH 48TH STREET,MESA,AZ,85206,2017-08-25,318,D,0,1,MHW311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, policy review, and resident and staff interviews, the facility failed to ensure one resident (#242) with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Findings include: Resident #242 was readmitted on (MONTH) 7, (YEAR), with [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment, dated (MONTH) 19, (YEAR), assessed the resident to have a BIMS (brief interview for mental status) score of 13 out of 15, which indicated the resident was cognitively intact. The MDS indicated mood and no behavioral symptoms for the resident. Resident #242 needed extensive assistance of one staff for bed mobility, transfer, locomotion, dressing, toilet use and personal hygiene. The MDS revealed the resident was non-ambulatory and needed supervision with eating. The MDS further indicated the resident was not steady and only able to stabilize with staff assistance with moving on and off of the toilet. The MDS also indicated resident #242 was not steady, only able to stabilize with staff assistance with surface-to-surface transfer (transfer between bed and chair or wheelchair). The MDS indicated the resident had functional range of motion (ROM) impairment on one side of his upper extremity and functional ROM impairment on one side of his lower extremity. The MDS revealed he used an electric wheelchair for mobility. The MDS revealed no Physical Therapy (PT) and no Occupational Therapy (OT) for the resident. Review of the most recent care plan revealed no care plan related to restorative services. Review of Rehabilitation service screening dated (MONTH) 21, (YEAR), indicated the resident was recommended for Restorative Nursing Assistances (RNA). Review of physician orders [REDACTED]. Review of medical record revealed no documentation that indicated the resident received restorative nursing, as recommenced by PT and ordered by the physician. On (MONTH) 22, (YEAR) at 09:58 a.m., the resident was observed sitting on his bed and he had contractures to his right hand fingers and contractures to his left leg, but was able to move the left lower extremity on command. The resident stated that he could not use his right hand but was able to move his right upper extremity. On (MONTH) 24, (YEAR) at 10:56 a.m., an interview was conducted with the Restorative Nursing Assistant (RNA/ staff #34). She stated that she was familiar with resident #242. Staff #34 stated that she believed resident #242 was on her workload at sometime for restorative nursing services. Staff #34 then reviewed her documentation and she stated that there were current orders for restorative nursing, however, resident #242 was not showing up on her workload documentation for receiving restorative nursing. Staff #34 stated that normally, when residents received restorative nursing, she documented when they received restorative therapy and she documented any refusal. The RNA stated that if a resident refused RNA, she would notified the director of therapy. On (MONTH) 25, (YEAR) at 9:13 a.m., in an interview with the Physical Therapist (Director of Rehabilitation Services) (PT/staff #156) stated that on (MONTH) 21, (YEAR), an Occupational Therapist (OT/staff #185) screened the resident and recommended RNA for the resident. Staff #156 further stated that after recommending the resident for RNA, the OT forgot to update the electronic system for initiation of RN[NAME] The PT stated that because the electronic system was not updated for provision of RNA/RNA care planning, no RNA was initiated for the resident. The PT further stated that the only way for the RNA to know who was on RNA workload, would be the initiation of a RNA care plan in the electronic system and that was missed for resident # 242. The PT stated that the RNA order was missed and that was why there was no documentation for indication that resident #242 received restorative therapy as ordered. On (MONTH) 25, (YEAR) at 9:28 a.m., the Director of Nursing (DON/staff #224) was interviewed and stated, RNA (staff #34) documented no provision of restorative services. The DON further stated that the facility process indicated PT/OT wrote orders for provision of restorative therapy, then Director of Rehabilitation Therapy opens a care plan in the resident's electronic medical record. Once the care plan was opened in the electronic record, restorative therapy would be prompted by the system to initiate RNA for the resident. The DON further stated that nursing staff would confirm the PT/OT order. The DON stated that in regards to resident #242, OT did not open or initiate a care plan in the electronic record, therefore no restorative nursing was prompted or initiated as there was no care plan for resident #242. The DON further stated that there was a break in the process, no RNA was initiated, there was no documentation for initiation of RNA, the resident received no RNA as ordered, it was missed. Review of a policy regarding restorative care indicated, restorative care would be provided to each resident according to his/his individual needs and desires as determined by assessment and care planning. The policy indicted that the resident would receive services to attain and maintain the highest possible mental/physical functional status and physical and psychosocial well-being defined by the comprehensive assessment and care plan. The policy indicated that residents would be screened by therapy for referral to Restorative Nursing and restorative services. The policy indicated residents' restorative care required close intervention and follow-through by a licensed nursing staff designee. Restorative services were defined as any and all means used to stimulate, motivate, support, encourage and assist residents to grow and develop physically, mentally and emotionally beyond their capabilities, or aid residents in adopting to their current health status.",2020-09-01
948,MONTECITO POST ACUTE CARE AND REHABILITATION,35135,51 SOUTH 48TH STREET,MESA,AZ,85206,2017-08-25,371,E,0,1,MHW311,"Based on observations, staff interviews, and review of the facility policy and procedure, the facility failed to ensure that refrigerated foods were labeled properly and failed to ensure that a measuring cup was not stored in dry food. Findings include: Regarding food labeling During an observation of the kitchen at 11:00 a.m. on (MONTH) 21, (YEAR) multiple refrigerated foods were noted to either have been expired or did not have a date on them: -Taco meat prepared date of (MONTH) 16 and a use by date of (MONTH) 20 -Deli meat prepared date of (MONTH) 16 and a use by date of (MONTH) 20 -Chicken noodle soup date of (MONTH) 16 and a use by date of (MONTH) 20 -Feta cheese date of (MONTH) 16 and a use by date of (MONTH) 20 -Diced meat did not have a label on it at all -Bag of baby carrots had a single date of (MONTH) 19 and a name on it An interview was conducted with the dietary manager (staff #109) at 11:10 a.m. on (MONTH) 21, (YEAR). She said that the carrots must have been saved for a staff member (the name on it was a staff member's) and she threw them away. She said that regarding labeling and dating food, the staff label leftover items with four days from the prepared date as the use by date. She said that technically, they have 6 days, but they use 4 to have some extra time to be sure that foods are not kept too long. She said that the diced meat was diced turkey and that she would throw it out since it did not get labeled. In an interview with the consulting dietitian (#230) at 10:45 a.m. on (MONTH) 23, (YEAR) she said that she follows the food code which requires that leftover food be thrown out after 6 days. She said that at this facility, they label with 4 days in case staff forgets to toss the food out. During an interview with a cook (staff #148) at 11:00 a.m. on (MONTH) 23, (YEAR), he said that everyone in the kitchen is responsible for labeling leftover food. He said that they have 4 days to use the food and after the 4th day, the food needs to be discarded and they do not keep anything for longer than 4 days. A second interview was conducted with the consulting dietitian at 1:20 p.m. on (MONTH) 23, (YEAR). She said that it could be a bit confusing that they facility labels for 4 days instead of 6 as someone could label something again after 4 days and it could go past 6 days. She said that the diced turkey was not labeled and it had been leftovers from lunch on (MONTH) 20 and was not in the fridge for 24 hours and the policy does not require foods that are to be stored for less than 24 hours to be labeled. Review of the facility's food storage policy and procedure revealed that the policy statement included that food storage facilities are provided to keep foods safe. Food is stored in an area that is free from contaminants. Food is stored by methods designed to prevent contamination or cross contamination. The procedure included that leftover food is stored in covered containers or wrapped carefully and secured. Each item is clearly labeled and dated if stored for over 24 hours. Leftover food is used within 7 days or discarded. The policy noted that preparation is day 1, leaving 6 days after. The policy further noted that time and temperature controlled food (TCS) should be covered, labeled and dated is stored and not for immediate use. All foods will be checked to assure that foods (including leftovers) will be consumed by their use by dates, frozen, or discharged at the end of the day. Regarding the measuring cup stored in dry food During an observation of the kitchen conducted at 11:00 a.m. on (MONTH) 21, (YEAR) a large container of dry powdered milk was observed to have a large measuring cup stored inside of the powder. The measuring cup had dry milk covering it and when it was removed, the product was seen falling off of the entire measuring cup including the handle. An interview was conducted with the dietary manager (staff #109) at 11:10 a.m. on (MONTH) 21, (YEAR). She said that the measuring cup should not have been stored in the dry milk and should have been stored outside of the milk. She removed the scoop and discarded the dry milk. In an interview with the corporate dietitian (#230) at 10:45 a.m. on (MONTH) 23, (YEAR), she said that the best practice for scoops is to keep them out of the dry food or to ensure that the handle of the scoop does not touch the food. Review of the facility's food storage policy and procedure revealed that the policy statement included that food storage facilities are provided to keep foods safe. Food is stored in an area that is free from contaminants. Food is stored by methods designed to prevent contamination or cross contamination. The procedure included that scoops must be provided for bulk foods such as sugar, flour, and spices. Scoops may be stored in food as long as the handles do not touch the food, an alternate is to keep scoops covered in a protected area near the containers.",2020-09-01
949,MONTECITO POST ACUTE CARE AND REHABILITATION,35135,51 SOUTH 48TH STREET,MESA,AZ,85206,2017-08-25,425,E,0,1,MHW311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure that one resident (#43) received her antianxiety medication as ordered. Findings include: Resident #43 was admitted to the facility on (MONTH) 6, (YEAR) with [DIAGNOSES REDACTED]. Review of an admission Minimum Data Set (MDS) assessment dated (MONTH) 13, (YEAR) revealed that the resident scored an 8 on her Brief Interview for Mental Status (BIMS) indicating cognitive impairment. The resident's care plan indicated that she had psychotropic medications in use related to her anxiety. An intervention included administration of the medication as ordered. The physician's orders [REDACTED]. The Medication Administration Record (MAR) was reviewed for (MONTH) (YEAR). The resident did not receive the lorazepam as ordered. There were multiple missing doses from (MONTH) 1 through 11. The resident received the medication one time on (MONTH) 1, one time on (MONTH) 10 and one time on (MONTH) 11. On (MONTH) 8, one time the medication was coded as being refused by the resident. The resident did not receive the medication any other time from the 1 through the 11. The MAR indicated to review the nursing notes for the reason why the medication was not given. Review of the nursing notes from (MONTH) 1 through 11 revealed that the resident did not get the lorazepam medication because the medication was not available from the pharmacy. There was no indication that any action had been taken to obtain the medication or that the physician had been notified. An interview was conducted with a Registered Nurse (RN/staff #22) at 11:30 a.m. on (MONTH) 24, (YEAR). He stated that when he is getting low on a medication, he will contact the pharmacy via fax and order more. He said that the pharmacy comes to the building several times per day and that the medication is usually available pretty quickly. He said that if he happened to be out of a medication, he would send the fax and would also call the pharmacy because he does not want to be out of a medication that the resident needs. He said that if for some reason a day or two goes by and a medication is not available, he would definitely want to know why the medication is not available and would be addressing it quickly. He reviewed this resident's MAR and stated that he could see that the resident missed several doses of the medication near the beginning of the month of August. He said that he did not know why this happened and that it should not have happened for so long because the medication is not difficult to obtain and the facility should have that medication available in the emergency kit. He said that it could have been a pharmacy issue or it could be that the nurses could not locate the card with the medication on it; there was no way to tell for sure. He said that the medication was to be administered by the night shift as it was given later at night and early in the morning. In an interview with the Director of Nursing (DON/staff #224) at 1:30 p.m. on (MONTH) 24, (YEAR), she said that she was not aware that this resident did not get the medication for several days and that she would expect that if the medication was out, the nurse would call the pharmacy and if they could not get the medication quickly, she would get the okay to get the medication from the emergency kit because lorazepam should be available. She said that the facility changed pharmacies on (MONTH) 1, (YEAR) and that this may have been the reason for the delay. She said that she provided education to all the nursing staff regarding the change and the new requirements. She said she was unable to contact the new pharmacy regarding this issue. During an interview with a pharmacy resource pharmacy tech (staff #228) at 2:50 p.m. on (MONTH) 25, (YEAR), he said that he had a large role in the pharmacy change to make it as smooth as possible. He said that one of the things that changed was that controlled substances, such as narcotic and medications like lorazepam now required a new signed script from the doctor as the older ones would not be accepted. He said that prior to the new pharmacy taking over, he printed out all the prescriptions from all the residents in the facility and put them in a folder for the physicians to sign to make sure there would be no problems. He said that this should have covered this resident's lorazepam and so he did not know why this happened. A second interview was conducted with the RN (staff #22) at 12:20 p.m. on (MONTH) 25, (YEAR). He said that he did receive some education from the facility about the new pharmacy. He said the biggest change is that the new pharmacy wants a physical copy of the prescription signed by the physician and so now the nurses have to provide this up front which is a bit more difficult than it was prior. He said that the emergency kit policy changed as well as the nurse has to have the physical copy of the prescription signed by the physician to get medication from the emergency kit. He said that the older system was a bit easier and so this may have contributed to this resident not getting her medications, but he did not know for sure. A second interview was conducted with the DON (staff #224) at 12:40 p.m. on (MONTH) 25, (YEAR). She said that she had anticipated issues with the pharmacy and so she had put an action plan into the Quality Assurance (QA) committee regarding this. She said she educated staff members and then did audits of all resident's medication to ensure that any issues were caught and fixed quickly. She said that this resident should have been included in this audit, but the nurse responsible for auditing her chart did not realize that the audits needed to be saved and instead she threw them out. She also said the audits were day to day and did not look at trends, so the person auditing would not know that the medication had not been given for multiple days. Review of the facility's medication administration policy and procedure revealed that the policy statement was that medications shall be administered as prescribed by the attending physician. The procedures included that medications must be administered in accordance with the written orders of the attending physician and all current drugs and dosage schedules must be recorded on the MAR. The policy further noted that if a medication is not available and is not administered at the scheduled time, the documentation will be reflected in the clinical record and physician notification and other information regarding unavailable medication will be documented accordingly. A second policy and procedure regarding pharmaceutical services noted that the policy of the facility is to provide pharmaceutical services including the accurate acquiring, receiving, dispensing, and administration of all drugs and biologicals to meet the needs of each resident. The procedure included that the pharmacists, in collaboration with the facility and medical director helps develop and evaluate the implementation of pharmaceutical services that address the needs of the resident, are consistent with state and federal requirements, and reflect current standards of practice.",2020-09-01
950,MONTECITO POST ACUTE CARE AND REHABILITATION,35135,51 SOUTH 48TH STREET,MESA,AZ,85206,2017-08-25,441,D,0,1,MHW311,"Based on observations, staff interviews and review of the facility policy, the facility failed to maintain infection control practices during a medication observation. Findings include: A medication administration observation was conducted on (MONTH) 23, (YEAR) between 8:21 a.m. and 8:56 a.m., with a Licensed Practical Nurse (LPN/staff #14) on the locked unit. Staff #14 was observed preparing medications for a resident. The resident was observed with a Band-Aid applied between his nose and mouth, and the band-aid was stained with red drainage. Staff #14 handed the resident the plastic medication cup containing his medications. The resident raised the medication cup to his mouth and the cup touched the soiled Band-Aid. After taking his medications, resident #272 handed the used medication cup back to staff #14. Staff #14 discarded the used medication cup into the trash bin attached to the medication cart. The LPN did not wash her hands or use hand sanitizer after administering the resident's medications. She then proceeded to prepare medications for another resident. Immediately following, staff #14 then proceeded to prepare medications for a second resident. Staff #14 handed the resident her medications in a plastic medication cup and the resident raised the medication cup to her mouth. After the resident took her medications, the resident handed the dirty cup to staff #14. Staff #14 discarded the dirty cup in the trash can attached to the medication cart. She then used her bare right hand to wipe the top of the medication cart. Staff #14 was not observed to wash her hands or use hand sanitizer. Staff #14 then began to prepare medications for a third resident. Staff #14 handed the resident a medication cup and the resident raised the medication cup to his mouth. The resident then handed the dirty cup back to staff #14. Staff #14 discarded the dirty cup into the trash can at the medication cart. Staff #14 was not observed to wash her hands or use hand sanitizer. Immediately following, staff #14 then prepared medications for a fourth resident. She handed the medication cup to the resident and the resident raised the medication cup to his mouth. Staff #14 discarded the dirty cup into the trash can at the medication cart. Staff #14 was not observed to wash her hands or use hand sanitizer. At 8:56, an interview was conducted with staff #14. Staff #14 stated that she usually uses hand sanitizer in between two residents and after the second she will wash her hands. She stated that she did not wash her hands or use hand sanitizer in between these residents during the medication administration. On (MONTH) 23, (YEAR) at 9:00 a.m., the Quality Assurance Registered Nurse (QARN/staff #226) was interviewed. She stated that she expected for staff to wash their hands or use hand sanitizer between residents, when administering medications. Review of the hand washing policy dated (MONTH) (YEAR) revealed the following: Hand washing is generally considered the most important single procedure for preventing nosocomial infections. The policy included to cleanse hands to prevent transmission of possible infectious material and to provide clean, healthy environment for residents and staff. The policy also stated to wash hands before and after each resident contact, after touching a resident or handling his/her belongings and after handling any contaminated items (linens, garbage etc.)",2020-09-01
951,MONTECITO POST ACUTE CARE AND REHABILITATION,35135,51 SOUTH 48TH STREET,MESA,AZ,85206,2018-12-07,609,D,0,1,RZN111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff and resident interviews, and facility documentation, the facility failed to ensure one allegation of misappropriation of resident property was reported to the State Agency (SA) in a timely manner. Findings include: Resident #51 was admitted to the facility on (MONTH) 21, (YEAR), with [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS) assessment dated (MONTH) 8, (YEAR), revealed a Brief Interview for Mental Status score of 15 which indicated the resident was cognitively intact. Review of the facility's Grievance Resolution Form dated (MONTH) 26, (YEAR) revealed resident #51 reported that she went to the shower room and when she came back her wallet was missing. The documentation revealed 2 credit cards, a debit card, and $120 were missing. The unit manager/assistant director of nursing (ADON/staff #201) was assigned to investigate. During an interview conducted with resident #51 on (MONTH) 3, (YEAR) at 9:35 a.m., she stated that her wallet was stolen last week. The resident stated that the wallet had $120, 2 credit cards, a debit card, her ID card, health insurance card, social security card, and a check book in it. She stated that she made staff aware and that the staff #201 spoke to her about it. During an interview conducted with the Director of Nursing (DON/staff #216) on (MONTH) 3, (YEAR) at 10:36 a.m., she stated they were aware of the resident's concerns and a grievance form had been started. An interview was conducted with staff #201 and staff #216 on (MONTH) 5, (YEAR) at 11:45 p.m. Staff #201 stated resident #51 reported on (MONTH) 26, (YEAR) that she was missing a coral color wallet that contained a credit card and $120. Staff #216 stated that this concern would have been reported to the State Agency if the resident would have stated that the wallet and the items inside had been stolen. Review of the State Agency data base did not reveal the allegation had been reported.",2020-09-01
952,MONTECITO POST ACUTE CARE AND REHABILITATION,35135,51 SOUTH 48TH STREET,MESA,AZ,85206,2018-12-07,641,E,0,1,RZN111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interviews, and policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for three residents (#39, #51, and #145). Findings include: -Resident #39 was readmitted on (MONTH) 13, (YEAR) with [DIAGNOSES REDACTED]. Review of the clinical record revealed an admission assessment dated (MONTH) 13, (YEAR) that included the resident had an open wound to the left ankle. A wound physician note dated (MONTH) 14 and 28, (YEAR) revealed the resident had a left lateral ankle stage 3 pressure ulcer. The note also included the resident had the ulcer for several years. Weekly pressure ulcer assessments dated (MONTH) 18 and 25, (YEAR) included a stage 3 pressure ulcer to the resident's left outer ankle. However, an annual Minimum Data Set assessment dated (MONTH) 1, (YEAR) included the resident had a stage 3 pressure ulcer but that it was not present upon admission. During an interview conducted with the wound nurse (staff # 248) on (MONTH) 4, (YEAR) at 1:32 p.m., she stated the resident was admitted with the pressure ulcer to his left ankle. -Resident #51 was admitted to the facility on (MONTH) 21, (YEAR), with [DIAGNOSES REDACTED]. A care plan regarding [MEDICAL CONDITION] medication revised on (MONTH) 23, (YEAR), revealed the resident required the level two Preadmission Screening and Resident Review (PASRR) process due to serious mental illness (SMI) with an axis 2 [DIAGNOSES REDACTED]. Interventions included psych follow up to monitor symptoms and to adjust psych medications and to contact the PASRR Coordinator if the resident is transferred or discharged to another facility or lower level of care. Review of the clinical record revealed a letter dated (MONTH) 30, (YEAR) that the resident had a level two PASRR screening done on (MONTH) 23, (YEAR). The letter included the resident had SMI but was able to have needs met at the nursing facility level of care. However, an annual MDS assessment dated (MONTH) 8, (YEAR), revealed the resident was not considered by the state level two PASRR process to have a serious mental illness. During an interview conducted with the MDS Registered Nurse (RN/staff # 244) on (MONTH) 6, (YEAR) at 10:12 a.m., she stated that the MDS assessment should have been coded yes because the resident was considered by the level two PASRR process to have a SMI at the time of the assessment. -Resident #145 was admitted to the facility on (MONTH) 30, (YEAR) with [DIAGNOSES REDACTED]. The resident was discharged on (MONTH) 7, (YEAR). Review of the clinical record revealed a physician's orders [REDACTED]. A discharge summary dated (MONTH) 7, (YEAR) included the resident had returned to functional baseline and that the resident's health had improved sufficiently that the resident no longer needed the services of the facility. Nursing notes dated (MONTH) 7, (YEAR) revealed the resident was discharged home with home health services around 6:30 p.m. However, review of a discharge return not anticipated MDS assessment dated (MONTH) 7, (YEAR), revealed the resident had an unplanned discharged to an acute hospital. An interview was conducted with the MDS coordinator (staff #38) on (MONTH) 6, (YEAR) at 10:12 a.m. She stated physician orders, wound notes, social services notes, dietary notes, activity notes, nursing notes, and therapy notes are reviewed to complete MDS assessments. After reviewing the clinical record for this resident, she stated that the resident did discharge home and that the discharge MDS assessment coding was a mistake. During an interview conducted with the Director of Nursing (DON/staff #216) on (MONTH) 6, (YEAR) at 12:49 p.m., she stated that her expectation is that the MDS assessments be complete and accurate. Review of a facility policy titled, Resident Assessment: Accuracy of Assessment included, It is the policy of this facility to ensure that the assessment accurately reflect the resident's status.",2020-09-01
953,MONTECITO POST ACUTE CARE AND REHABILITATION,35135,51 SOUTH 48TH STREET,MESA,AZ,85206,2018-12-07,657,D,0,1,RZN111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, review of the clinical record, and policy review, the facility failed to ensure a care plan was revised for one resident (#106). Findings include: Resident #106 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A fall risk care plan initiated on 11/08/18 related to the resident gait/balance problems included a goal that the resident will not sustain serious injury through the review date. A review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 15 which indicated the resident was cognitively intact. The MDS assessment also included the resident was totally dependent and required 2 or more staff for transfers. The fall risk care plan was revised on 11/30/18 to include the resident had an assisted fall with no injuries. A Nursing Progress note dated 11/30/2018 at 2:17 PM revealed the nurse was alerted to the room where the nurse found the resident on the floor, sitting on her butt. The note included the CNA stated that the patient fell to the floor due to the mechanical lift tipping over and that the resident was slowly assisted to the floor. The note also included the resident complained of side pain from the fall and that she sustained a little abrasion to the right inner arm. The patient had pain, but no swelling, tenderness, or bruising on the fall side. The note included the resident was assisted to bed by 5 staff members. During an initial interview conducted with resident #106 on 12/03/18 at 10:37 AM, the resident communicated, through writing, that the staff were transferring her between the wheel chair and bed when the mechanical lift caught on the bed and the resident fell to the floor with the lift almost tipping over on her. The resident included in the statement that no injuries were suffered and the staff were able to lower her slowly to the floor as the lift was tipping. The resident also included there were three Certified Nursing Assistants (CNAs) helping with the transfer. The fall care plan was revised on 12/03/18. Interventions included the following: anticipate and meet needs; avoid rearranging furniture; be sure the call light is within reach and encourage the resident to use it to call for assistance as needed; educate the resident/family/caregivers about safety reminders and what to do if a fall occurs; encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility; and therapy evaluation and treatment per physician orders. However, additional review of the care plans did not reveal any information regarding the type of transfer required, any special equipment needed for transfer, or the number of staff that may be required to safely transfer the resident. An interview was conducted on 12/06/18 at 1:45 PM with CNA (staff#116) who stated that it took 5 people to get the resident back to bed from the fall that occurred on 11/30/18, and that in the future they may have to have 4-5 staff to transfer the resident. During an interview conducted on 12/06/18 at 02:13 PM with the Director of Nursing (DON/staff #216), the DON stated that because of the resident's weight, the resident may require more than 3 people to assist with her transfers. An interview was conducted with the Assistant Director of Nursing (ADON/staff #201) on 12/06/18, who stated that she updated the Care Guidelines, but not the care plan to include using 4-5 people for transfers for this resident. Staff #201 stated that the Care Guidelines is an updated daily list of residents that contains some of the care requirements that CNAs can refer to. The ADON stated that the nurses refer to the care plan. Review of the facility's policy titled Fall Management System included that the resident's existing care plan will be updated and the interventions will address those elements determined by investigation as probable causal factors that contributed to the fall.",2020-09-01
954,MONTECITO POST ACUTE CARE AND REHABILITATION,35135,51 SOUTH 48TH STREET,MESA,AZ,85206,2018-12-07,679,E,0,1,RZN111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, and policy review, the facility failed to ensure that individualized activities were consistently offered to one resident (#29). Findings include: Resident #29 was admitted on (MONTH) 23, (YEAR) with [DIAGNOSES REDACTED]. Review of the annual MDS (Minimum Data Set assessment dated (MONTH) 3, (YEAR), revealed the resident prefers listening to music. A care plan regarding activities dated (MONTH) 22, (YEAR), included interventions for the resident to have Sensory Stimulation Program for 3-4 times weekly in her room. Interventions also included activities such as reading, music, smell, touch, etc. and that it is very important for the resident to listen to music. The quarterly MDS (Minimum Data Set) assessment dated (MONTH) 24, (YEAR), revealed the resident was rarely/never understood and had severely impaired cognitive skills for daily decision making. Review of the activity participation log for the resident revealed the following: September (YEAR): September 1-8: tactile stimulation on the 4th. September 9-15: tactile stimulation on the 10th and 13th. September 16-22: tactile stimulation on the 18th and on the 19th. September 23-30: tactile stimulation of reading on the 26th. Review of activities for (MONTH) (YEAR) did not reveal music was provided to the resident. October (YEAR): October 1-6: lotion and music on the 2nd and singing and television on the 5th. October 7-13: tactile stimulation on the 8th, lotion applied/television on the 11th, and lotion applied on the 12th. October 14-20: lotion applied/television on the 16th. October 21-27: reading/poem on the 22nd and nails/television on the 26th. October 28-31: talking about Halloween TV movie on the 30th and Halloween decorations on the 31st. Review of activities for (MONTH) (YEAR) revealed music was provided to the resident on the 2nd and on the 5th. November (YEAR): November 1-7: reading on the 1st and reading/tactile stimulation on the 5th. November 8-14: reading on the 14th. November 22-30: one on one activity on the 28th. Review of the activities for (MONTH) (YEAR) revealed no music was provided to the resident. December (YEAR): November 29th to (MONTH) 5th: one on one activity on (MONTH) 3rd and 4th. During an observation conducted on (MONTH) 3, (YEAR) at 3:08 PM, the resident was observed in bed with her eyes open. No music was on. An observation of the resident was conducted on (MONTH) 4, (YEAR) at 8:31 AM. The resident was observed in bed sleeping. No music was on. During an observation conducted on (MONTH) 4, (YEAR) at 11:45 AM, the resident was observed sleeping in bed. No music was on. An interview was conducted with a Certified Nursing Assistant (CNA/staff# 111) on (MONTH) 4, (YEAR) at 1:58 PM who stated that if a resident's family tells them that the resident likes to watch television or listen to music, they will turn on the television and music for the resident. During an interview conducted with a CNA (staff# 233) on (MONTH) 4, (YEAR) at 2:05 PM, the CNA stated that activities come in every day to work with the resident. An interview was conducted with a Licensed Practical Nurse (LPN/staff #241) on (MONTH) 4, (YEAR), at 2:11 PM. The nurse stated that music and the television is on all day and that the activities staff provides one on one activity to the resident almost daily. He stated that the resident's daughter told them that resident likes to watch the game shows and to listen to music. The LPN stated the daughter brought an iPod to leave at the resident's bedside for music and instructed the staff on the specific channels to play. However, the nurse was unable to find the iPod. An interview was conducted with the Activities Supervisor (staff #252) on (MONTH) 4, (YEAR) at 2:21 PM. Staff #252 stated that they provide activities for non-verbal resident at least 2-3 times a week and more if the resident is restless or having a bad day. She stated the type of activities provided for resident #29 includes reading, singing, and tactile stimulation. Staff #252 stated that their book is the only documentation of activities provided to the resident. She stated that for day to day activities it is a team effort with the CNAs and the activities staff. During an interview conducted with the Director of Nursing (DON/staff# 216) on (MONTH) 6, (YEAR), at 1:51 PM, the DON stated that the families of non-verbal residents tell the staff about the resident's likes and dislikes. She stated that the care plan is developed according to the resident's needs and that her expectation is that staff follow the care plan. The DON also stated that any care or activity provided to a resident needs to be documented. The facility's policy regarding Activity revealed that activities, social events, and schedules are developed in conjunction with the resident's interests, assessments, and plan of care. The policy also included activities can be adapted to accommodate a resident's change in functioning due to physical or cognitive limitations.",2020-09-01
955,MONTECITO POST ACUTE CARE AND REHABILITATION,35135,51 SOUTH 48TH STREET,MESA,AZ,85206,2018-12-07,761,D,0,1,RZN111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, and policy review, the facility failed to ensure controlled medications were not returned to the broken seal card and secured with tape. Findings include: A medication storage observation was conducted on (MONTH) 3, (YEAR) at 3:15 PM with a Registered Nurse (RN/staff #226). A medication card for [MEDICATION NAME] (antianxiety) 0.5 mg (milligrams) was observed with the seal broken with the medication secured with a strip of tape over the seal. A medication card for [MEDICATION NAME]-[MEDICATION NAME] (narcotic [MEDICATION NAME]) 5/325 mg was also observed with the seal broken with the medication secured with a strip of tape over the seal. An interview was immediately conducted with staff #226 who stated that if a narcotic is refused, the narcotic is supposed to be wasted with two nurses. The RN stated that they are not to tape the pill back in the card and that this was done on the night shift. An interview was conducted with the Director of Nursing (DON/staff #216) on (MONTH) 6, (YEAR) at 1:23 PM. The DON stated that the nurse is expected to waste a narcotic with another nurse not tape the narcotic back in the card. Staff #216 stated that nurses are not pharmacists, therefore they cannot repackage medications. The DON also stated that the night shift nurse repackaged the pill because she did not have another nurse to waste the pill with. The facility's policy regarding Medication Access and Storage revealed the provider pharmacy dispenses medication in containers that meet legal requirements and that medications are kept and stored in these containers. The policy included that transfer of medications from one container to another is done only by a pharmacist. The policy also included reconciliation of controlled medications are done at least every shift by the incoming and outgoing Licensed Nurses at the change of shifts.",2020-09-01
956,MONTECITO POST ACUTE CARE AND REHABILITATION,35135,51 SOUTH 48TH STREET,MESA,AZ,85206,2018-12-07,880,D,0,1,RZN111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, clinical record review, and policy review, the facility failed to ensure transmission based precautions were implemented for one resident (#24). Findings include: Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. A nurse practitioner note dated 12/4/2018 included the resident had [MEDICAL CONDITION] with a generalized rash with macules and that the treatment was completed on 11/2/18. The note also included a plan for Dermatology to biopsy the recurrent rash. A physician's orders [REDACTED]. Review of the dermatology consult note dated 12/06/18 revealed the dermatologist believed this was a case of classic scabies rash around the waist, rib cage, and arms and recommended following scabies protocol in the facility. An observation conducted on 12/07/18 at 09:15 AM of the resident's room revealed no indication that transmission precautions should be used when entering and caring for the resident. An interview was conducted on 12/07/18 at 09:15 AM with Licensed Practical Nurse (LPN/staff #77) who stated that she applied cream to the resident that morning but did not notice the resident was not on isolation precaution. She stated that she washed her hands after applying the cream. During an interview conducted on 12/07/18 at 09:20 AM with a LPN (staff #124), the LPN stated that she did not see the part of the dermatologist note that indicated the resident had scabies, so the resident was not placed on transmission based precautions. An interview was conducted on 12/07/18 at 09:22 AM with the Registered Nurse/Infection Control Nurse (staff #183), who stated this resident should have been placed in isolation. Staff #183 stated that she was not told about the dermatologist note that indicated the resident had classic scabies. Review of the facility's policy titled Transmission Based Precautions and Isolation included in the policy statement that, It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions . Review of the facility's policy titled Infection and Prevention Control Program included Prevention of spread of infections is accomplished by use of Standard Precautions and/or other transmission based precautions .",2020-09-01
957,LIFE CARE CENTER OF SIERRA VISTA,35136,2305 EAST WILCOX DRIVE,SIERRA VISTA,AZ,85635,2019-02-07,623,D,0,1,G2WT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and policy review, the facility failed to notify the Office of the State Long Term Care Ombudsman when one resident (#95) was discharged to the hospital. Findings include: Resident #95 was readmitted to the facility on (MONTH) 7, (YEAR) with [DIAGNOSES REDACTED]. The resident was discharged (MONTH) 11, (YEAR). Review of a Nursing Progress Note dated (MONTH) 11, (YEAR) revealed Upon checking resident fingerstick, noted that skin was hot to touch. Vital signs checked and temperature was 103.8. Blood sugar checked and was 355. Resident coughing, lungs crackles. Pulse 126 .Paramedics called and arrived and transported resident to hospital . Further review of the clinical record revealed no evidence that the Office of the State Long Term Care Ombudsman was notified of the resident's discharge to the hospital. An interview was conducted with a Registered Nurse case manager(staff #113) on (MONTH) 6, 2019 at 12:57 p.m. Staff #113 stated that she notifies the ombudsman weekly of residents who are discharged to the hospital. Staff #113 stated that she retains copies of weekly ombudsman notifications but was unable to locate the week this resident was discharged to the hospital. Review of the facility's policy Transfers and Discharges revealed .A copy of the notice of transfer/discharge will be sent to a representative of the Office of the State Long Term Care Ombudsman for all facility-initiated transfers or discharges .",2020-09-01
958,LIFE CARE CENTER OF SIERRA VISTA,35136,2305 EAST WILCOX DRIVE,SIERRA VISTA,AZ,85635,2019-02-07,645,E,0,1,G2WT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and policy review, the facility failed to ensure two residents (#45 and #66) had a Pre-admission Screening and Resident Review (PASARR) Level I completed. Findings include: -Resident #45 was admitted to the facility from another nursing facility on (MONTH) 4, (YEAR), with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 12, (YEAR) revealed a Brief Interview for Mental Status (BIMS) score of 4 which indicated the resident was cognitively impaired. -Resident #66 was admitted to the facility on (MONTH) 4, (YEAR) from an acute hospital, with [DIAGNOSES REDACTED]. The quarterly MDS assessment dated (MONTH) 11, (YEAR) revealed a BIMS score of 6 which indicated the resident was cognitively impaired. Review of the clinical record did not reveal any documentation that a PASARR Level I had been conducted for either resident. An interview was conducted on (MONTH) 7, 2019 at 10:15 a.m. with the Director of Nursing (DON/staff #42). She stated that a PASARR Level I is usually completed prior to the resident admitting to the facility. The DON stated that when a resident is admitted from a hospital or another skilled nursing facility a PASARR Level I should be completed. She stated that if a resident is admitted to the facility without a PASARR Level I, they are obligated to ensure it is completed. The DON stated that regarding resident #45 and #66, she did not know why the PASARR level I was not completed for them. The facility's policy titled Pre-admission Screening revealed PASRR is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. The PASARR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for serious mental illness and/or intellectual disability; 2) be offered the most appropriate and least restrictive setting for their needs (in the community, a nursing facility, or acute care setting); and receive the services they need in those settings. The policy also included the facility is to ensure a Level I PASARR screening is completed on all potential admissions.",2020-09-01
959,LIFE CARE CENTER OF SIERRA VISTA,35136,2305 EAST WILCOX DRIVE,SIERRA VISTA,AZ,85635,2019-02-07,684,D,1,1,G2WT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on closed clinical record review, staff interviews, and review of policies, the facility failed to ensure treatments were provided as ordered for surgical wounds for one resident (#294). Findings include: Resident #294 was admitted to the facility (MONTH) 7, (YEAR) with [DIAGNOSES REDACTED]. The resident was discharged (MONTH) 11, (YEAR). Review of the care plan initiated (MONTH) 7, (YEAR) revealed that the resident had a break in skin integrity. Interventions included skin treatment as ordered. -Regarding the Left index finger amputation site: Review of a physician's orders [REDACTED]. Review of the Treatment Assessment Record (TAR) for (MONTH) (YEAR) revealed no documentation that the dressing to the amputation site on the left index finger was completed or checked on (MONTH) 10, (YEAR). The TAR also revealed no documentation that the treatment or dressing checks to the amputation site was provided after (MONTH) 12, (YEAR). The TAR included documentation that the wound was left open to air (OTA) on (MONTH) 13 and 14, (YEAR). Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 14, (YEAR) revealed a BIMS score of 15 which indicated the resident had intact cognition and included the resident had surgical wound(s). Review of the clinical record did not reveal a discontinuation of the treatment order or an order to leave the site open to air. The recapitulation of physician's orders [REDACTED]. -Regarding the left foot wound located on the plantar aspect of the first metatarsal: A physician's orders [REDACTED]. Review of the TAR for (MONTH) (YEAR) and (MONTH) (YEAR) revealed no documentation that the treatment to the left foot wound was provided on (MONTH) 18, 21, 25, and 26, (YEAR) and (MONTH) 4 and 11, (YEAR). A physician's orders [REDACTED]. The order also included to check the dressing to the bottom of the left foot each shift. The physician's orders [REDACTED]. Review of the (MONTH) (YEAR) TAR revealed no documentation that the treatment to the left foot wound was provided on (MONTH) 23, (YEAR) and no documentation that the dressing was checked on (MONTH) 29, (YEAR). The TAR for (MONTH) (YEAR) revealed documentation that the treatment to the left foot was provided on (MONTH) 3, (YEAR) and not again until (MONTH) 6, (YEAR), and then not again until (MONTH) 10, (YEAR). The TAR did not reveal documentation that the placement of the left foot dressing was checked on (MONTH) 5, (YEAR) on the 6 a.m. to 6 p.m. shift. An interview was conducted with a Licensed Practical Nurse (LPN/staff#144) on (MONTH) 7, 2019 at 2:56 p.m. He stated that the staff provides treatment to a resident's wounds as ordered by the doctor and documents it on the TAR. The LPN stated that if there is no documentation on the TAR that the treatment was done, it would mean the treatment was not provided. He stated that the expectation is that the TAR should be free of holes. The LPN also stated that if wound treatments were not provided, it could cause infection and decline in wound healing. An interview was conducted with a Registered Nurse (RN/staff #29) on (MONTH) 7, 2019 at 2:32 p.m. She stated that when a resident is admitted with a surgical wound that staff would watch for signs and symptoms of infection, make sure the dressing was in place, and re-enforce the dressing as needed. The RN stated that if the TAR does not contained documentation that the treatment was provided, then the nurse would not be able to prove that the treatment was done. She stated that if the wound treatment was not done, it could increase the risk for infection and decline in the wound. The RN stated that the expectation is that the nurse would document on the TAR right after the treatment was provided. During an interview conducted with the Director of Nursing (DON/staff #41) on (MONTH) 7, 2019 at 3:17 p.m., she stated that the nurses are expected to change dressings to surgical wounds according to the physician's orders [REDACTED]. The DON stated that if the nurse does not document that the treatment was provided, she would be unable to prove that the care was given. She also stated that the resident would be at risk for infection or wound deterioration if the treatments were not provided as ordered. The facility's policy titled treatment of [REDACTED]. The facility's policy regarding Resident Rights revealed the resident has the right to receive the services included in the plan of care.",2020-09-01
960,LIFE CARE CENTER OF SIERRA VISTA,35136,2305 EAST WILCOX DRIVE,SIERRA VISTA,AZ,85635,2019-02-07,686,D,1,1,G2WT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on closed clinical record review, staff interviews, and review of policies, the facility failed to ensure treatment and services were provided to prevent and treat pressure ulcers for one resident (#294). Findings include: Resident #294 was admitted to the facility on (MONTH) 7, (YEAR) with [DIAGNOSES REDACTED]. The resident was discharged (MONTH) 11, (YEAR). Review of the care plan initiated (MONTH) 7, (YEAR) revealed that the resident had a break in skin integrity. Interventions included skin treatment as ordered and moon boots to the bilateral lower extremities. A Braden Scale assessment dated (MONTH) 7, (YEAR) revealed a risk score of 15 which indicated the resident was at mild risk of developing a pressure ulcer. The admission Minimum Data Set (MDS) assessment dated (MONTH) 14, (YEAR) revealed a BIMS score of 15 which indicated that the resident had intact cognition. The assessment included the resident had 2 unstageable deep tissue injuries and a pressure reducing device on the bed. Review of the physician's orders [REDACTED]. -an order for [REDACTED]. -an order for [REDACTED]. -an order to clean the deep tissue injury to the right and left heel with normal saline, pat dry, cover with a border foam and change every other day and as needed and to check the dressing each shift dated (MONTH) 17, (YEAR). Review of the Treatment Administration Record (TAR) for (MONTH) (YEAR) revealed the dressing changes were provided on (MONTH) 17, (YEAR) and not again until (MONTH) 20, (YEAR) and revealed the dressings were done (MONTH) 22, (YEAR) and not again until (MONTH) 26, (YEAR). There was no documentation that the dressings to the right and left heel were checked on the 6 p.m. to 6 a.m. shift on (MONTH) 24, (YEAR). A physician's orders [REDACTED]. The physician's orders [REDACTED]. Review of the TAR for (MONTH) (YEAR) revealed the following: -no documentation that the moon boots were checked for placement on (MONTH) 16, (YEAR). -no documentation that the bilateral heel protectors were on and checked for placement on the 6 p.m. to 6 a.m. shift on (MONTH) 1, 2, 28, and 29, (YEAR). -no documentation that the heels were kept offloaded at all times on (MONTH) 29, (YEAR). -documentation that the treatment was done to the left and right heels on (MONTH) 3, (YEAR) and not again until (MONTH) 7, (YEAR) and documentation that the treatment was provided on (MONTH) 21, (YEAR) and not again until (MONTH) 23, (YEAR). -no documentation that the heel dressings were checked on (MONTH) 29, (YEAR). Review of the TAR for (MONTH) (YEAR) revealed the following: -no documentation that the bilateral heel protectors were on or the placement was checked on the 6 p.m. to 6 a.m. shift on (MONTH) 10, (YEAR). -documentation that the left and right heel treatment was provided on (MONTH) 3, (YEAR) and not again until (MONTH) 6, (YEAR) and then not again until (MONTH) 10. (YEAR). -no documentation that the dressings were checked on (MONTH) 5, (YEAR) on the 6 a.m. to 6 p.m. shift. An interview was conducted with a Licensed Practical Nurse (LPN/staff#144) on (MONTH) 7, 2019 at 2:56 p.m. He stated that the staff provides treatment to a resident's wounds as ordered by the doctor and documents it on the TAR. The LPN stated that if there is no documentation on the TAR that the treatment was done, it would mean the treatment was not provided. He stated that the expectation is that the TAR should be free of holes. The LPN also stated that if wound treatments were not provided, it could cause infection and decline in wound healing. He stated that if heel protection was not in place, it could cause a pressure ulcer or worsening of an existing pressure ulcer. During an interview conducted with a Registered Nurse (RN/staff #29) on (MONTH) 7, 2019 at 2:32 p.m., she stated that the wound nurse is responsible for staging wounds. The RN stated that if the TAR does not contained documentation that a treatment was provided to a wound, then the nurse would not be able to prove that the treatment was done. She stated that if the treatment was not done, it could increase the risk for infection and decline in the wound. The RN stated that the expectation is that the nurse would document on the TAR right after the treatment was provided. An interview was conducted with the Director of Nursing (DON/staff #41) on (MONTH) 7, 2019 at 3:17 p.m. She stated that the wound nurse assess pressure ulcers, obtain physician orders [REDACTED]. The DON stated that her expectation is that the nurses follow the physician's orders [REDACTED]. The DON stated that if the nurse does not document that the treatment was provided, she would be unable to prove that the care was given. She also stated that the resident would be at risk for infection or wound deterioration if the treatments were not provided as ordered. The DON stated that if heel protection was not implemented as ordered the pressure ulcer risk would increase for the resident. The facility's policy titled treatment of [REDACTED]. Review of the facility's policy for Pressure Ulcer/Injury Prevention and Management revealed measures to protect the resident against the adverse effects of external mechanical forces, such as pressure, friction, and shear are to be implemented and included heel protection/suspension while the resident is in bed. The facility's policy regarding Resident Rights revealed the resident has the right to receive the services included in the plan of care.",2020-09-01
961,LIFE CARE CENTER OF SIERRA VISTA,35136,2305 EAST WILCOX DRIVE,SIERRA VISTA,AZ,85635,2019-02-07,757,D,1,1,G2WT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on closed clinical record review, staff interviews, and policy review, the facility failed to ensure that medication was administered as ordered for one resident (#294). Findings include: Resident #294 was admitted to the facility on (MONTH) 7, (YEAR) with [DIAGNOSES REDACTED]. The resident was discharged (MONTH) 11, (YEAR). Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 14, (YEAR) revealed a BIMS score of 15 which indicated the resident had intact cognition. A physician's orders [REDACTED]. Review of the Medication Administration Record (MAR) for (MONTH) (YEAR) revealed no documentation the patch was removed on (MONTH) 30 and 31, (YEAR). Review of the MAR dated (MONTH) (YEAR) revealed no documentation that the patch was removed as ordered on (MONTH) 6 and 27, (YEAR). An interview was conducted with a Registered Nurse (RN/staff #29) on (MONTH) 7, 2019 at 2:32 p.m. She stated that if the [MEDICATION NAME] was not removed the resident could receive too much of the medication, experience adverse side effects from the medication, and could experience skin breakdown at the site. She stated that the expectation is that the nurse document on the MAR as soon as the care is administered. The RN stated that if the documentation is not on the MAR, the nurse is unable to prove the care was provided. During an interview conducted with a Licensed Practical Nurse (LPN/staff #144) on (MONTH) 7, 2019 at 2:56 p.m., he stated that if the MAR is not signed off it would mean that the care was not provided. The LPN stated that if the nurse did not sign for the removal of the [MEDICATION NAME], it would mean the patch was not removed. He stated that the expectation is that there will be no holes on the MAR. An interview was conducted with the Director of Nursing (DON/staff#41) on (MONTH) 7, 2019 at 3:17 p.m. She stated that the expectation is that staff follow physician's orders [REDACTED]. She stated that the expectation is that there should be no holes on the MAR. The DON stated that if the [MEDICATION NAME] was not removed the resident could absorb more than the intended dose and it could lead to [MEDICAL CONDITION]. The facility's policy on Physician order [REDACTED]. follow physician orders [REDACTED].",2020-09-01
962,LIFE CARE CENTER OF SIERRA VISTA,35136,2305 EAST WILCOX DRIVE,SIERRA VISTA,AZ,85635,2017-11-02,441,E,1,1,PYO411,"> Based on a review of the infection control program documentation, staff interviews and policy review, the facility failed to establish a water management program which addressed the risk of growth and spread of Legionella and other waterborne pathogens. Findings include: A review of the facility's infection control program revealed no documented evidence of the following: -A risk assessment to identify where Legionella and other waterborne pathogens could grow and spread. -The implementation of a water management program that included control measures for pathogens. -Testing protocols and documentation of the results and corrective action taken. Although the facility had obtained a quote for services from an outside resource on (MONTH) 12, (YEAR), which included a Legionella risk assessment and water management testing and monitoring, it was not approved and signed by the facility until (MONTH) 31, (YEAR). An interview was conducted on (MONTH) 1, (YEAR) at 1:30 p.m., with the Administrator (staff #145). He stated that prior to the date of the submitted quote for services to address Legionella, he had identified some potential areas of concern, however, he did not document the findings. Staff #145 acknowledged that the facility should have implemented plans sooner. Another interview was conducted on (MONTH) 2, (YEAR) at 8:00 a.m., with staff #145. He stated that the outside resource company was in the facility and would now conduct the Legionella risk assessment and that plans for testing would be implemented based on their recommendations. On (MONTH) 2, (YEAR) at 8:45 a.m., staff #145 stated that the formal assessment was completed and the testing and treatment would be conducted within the next several weeks. A facility policy titled, Water Management Program dated (MONTH) 30, (YEAR) included the purpose was to protect the health and safety of residents, visitors, and associates by formulating a water management plan that identifies and controls hazardous conditions that support the growth and spread of bacterial organisms, such as Legionella. The policy also included the following: Procedure: 1. Identify building water systems for which bacterial (i.e., Legionella) control measures are needed. 2. Assess how much risk is posed by the hazardous condition in those water systems. 3. Apply control measures to reduce the hazardous conditions, whenever possible, to prevent bacterial growth and spread (such as Legionella). 4. Ensure the program running as designed and is effective. 5. Document and communicate all the activities of the water management program.",2020-09-01
963,LIFE CARE CENTER OF SIERRA VISTA,35136,2305 EAST WILCOX DRIVE,SIERRA VISTA,AZ,85635,2016-12-02,225,D,0,1,WDCK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to investigate and report an injury of unknown origin to the State agency (SA) involving one resident (#81). Findings include: Resident #81 was admitted to the facility on (MONTH) 15, 2014, with [DIAGNOSES REDACTED]. According to an annual Minimum Data Set assessment dated (MONTH) 22, (YEAR), the resident was identified to have severe cognitive impairment and required extensive assistance with activities of daily living. A nursing note dated (MONTH) 13, (YEAR) included the resident had a shower and several bruises were observed on her left leg. Per the documentation, the resident did not know where the bruises came from. Review of the facility's Follow-up and Recommendation Form dated (MONTH) 14, (YEAR), revealed the resident had bruises to the underside of her left knee down to the calf, which measured 27 centimeter (cm) x 10 cm and had a bruise to the left outer thigh, which measured 15 cm x 16 cm. A physician's orders [REDACTED]. A late entry nursing note dated (MONTH) 15, (YEAR) (for (MONTH) 14) for the 6 a.m. to 6 p.m. shift included that a certified nursing assistant (CNA) reported to the nurse that the resident had bruises to the back of her left knee/calf area and outer left thigh. Per the clinical record documentation, the X-rays were completed on (MONTH) 16, (YEAR). Review of the final X-ray report revealed the resident had a distal femoral [MEDICAL CONDITION] leg, with [MEDICAL CONDITION] suggested. Further review of the Follow-up Recommendation Form revealed additional documentation dated (MONTH) 11, (YEAR), which included that the X-ray results were unable to determine if the fracture was new or old and that the facility had determined that no abuse or neglect had occurred. Per this note, the facility determined that the bruising may have occurred during a Hoyer lift transfer. On the section of the form which indicated that the SA was notified, this area was left blank. The facility was unable to provide any documentation that the injury of unknown origin was reported to the SA within 24 hours as required, nor any documentation that it was thoroughly investigated. An interview with the Director of Nursing (DON/staff #134) and the Administrator (staff #151) was conducted on (MONTH) 30, (YEAR) at 2:30 p.m. They both stated that they were not employed at the facility at the time of the incident, and they did not know if this was reported to the SA, nor if an investigation was completed. An interview with the regional nurse (staff #152) was conducted on (MONTH) 2, (YEAR) at 8:26 a.m. She stated that the facility did not investigate the incident and did not report the incident to the SA, as the resident had brittle bones and the physician documented [MEDICAL CONDITION] and fragile bones, as the cause of the fracture. Although, the facility was unable to provide documentation of this. In an interview with the physician (staff #153) conducted on (MONTH) 2, (YEAR) at 9:30 a.m., he stated that the resident had history of multiple fractures to the lower extremities and had very fragile bones. He said that based on the X-ray results, the left knee was osteopenic, but not osteoporotic. He stated that this could be the cause of the fracture, but could not state that this was the actual cause of the fracture. Another interview was conducted with staff #152 on (MONTH) 2, (YEAR) at 9:45 a.m. She stated this incident was not reported to the SA, because abuse was not considered and the resident's bruising was not considered suspicious based on the location of the bruise and the resident's contributing factors, such as [MEDICAL CONDITION] and fragile bones. Further, she stated that if a similar incident happens again, she will not report it to the S[NAME] Review of the facility's Abuse policy revealed that all alleged or suspected violations involving mistreatment, abuse, neglect and injuries of unknown origin (e.g. bruising, skin tears) will be promptly reported to the Administrator and/or DON. The policy further included that the facility must satisfy the immediate reporting requirement, by notifying the appropriate State agency and that immediate reports should be submitted as soon as possible, but no later than 24 hours of the facility learning of the allegation. Per the policy, failure to do so will mean that the facility is not in compliance with the Federal regulations. The Abuse policy further included that all reports of abuse will be promptly and thoroughly investigated. The investigation will include interviews with staff members on all shifts having contact with the resident at the time of the incident, interviews with any witnesses, interview with the resident if appropriate, review of the incident report and review of the resident's medical record. The policy also included that the facility must satisfy the Federal requirement to report the results of the investigation within 5 working days from the date of the incident or knowledge of the incident.",2020-09-01
964,LIFE CARE CENTER OF SIERRA VISTA,35136,2305 EAST WILCOX DRIVE,SIERRA VISTA,AZ,85635,2016-12-02,226,D,0,1,WDCK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to implement their abuse policy, by failing to investigate and report an injury of unknown origin to the State agency (SA) involving one resident (#81). Findings include: Resident #81 was admitted to the facility on (MONTH) 15, 2014, with [DIAGNOSES REDACTED]. A nursing note dated (MONTH) 13, (YEAR) included the resident had a shower and several bruises were observed on her left leg. Per the documentation, the resident did not know where the bruises came from. Review of the facility's Follow-up and Recommendation Form dated (MONTH) 14, (YEAR), revealed the resident had bruises to the underside of her left knee down to the calf measuring 27 centimeter (cm) x 10 cm and a bruise to the left outer thigh measuring 15 cm x 16 cm. Review of the final X-report revealed the resident had a distal femoral [MEDICAL CONDITION] leg, with [MEDICAL CONDITION] suggested. Further review of the Follow-up Recommendation Form revealed that additional documentation dated (MONTH) 11, (YEAR) included that the X-ray results were unable to determine if the fracture was new or old and that the facility had determined that no abuse or neglect had occurred. Per this note, the facility determined that the bruising may have occurred during a Hoyer lift transfer. On the section of the form which indicated that the SA was notified, this area was left blank. The facility was unable to provide any documentation that the injury of unknown origin was reported to the SA within 24 hours as required, nor any documentation that it was thoroughly investigated. An interview with the Director of Nursing (DON/staff #134) and the Administrator (staff #151) was conducted on (MONTH) 30, (YEAR) at 2:30 p.m. They both stated that they were not employed at the facility at the time of the incident, and they did not know if this was reported to the SA, nor if an investigation was completed. An interview with the regional nurse (staff #152) was conducted on (MONTH) 2, (YEAR) at 8:26 a.m. She stated that the facility did not investigate the incident and did not report the incident to the SA, as the resident had brittle bones and the physician documented [MEDICAL CONDITION] and fragile bones, as the cause of the fracture. Although, the facility was unable to provide documentation of this. In an interview with the physician (staff #153) conducted on (MONTH) 2, (YEAR) at 9:30 a.m., he stated that the resident had history of multiple fractures to the lower extremities and had very fragile bones. He said that based on the x-ray results, the left knee was osteopenic, but not osteoporotic. He stated that this could be the cause of the fracture, but could not state that this was the actual cause of the fracture. Another interview was conducted with staff #152 on (MONTH) 2, (YEAR) at 9:45 a.m. She stated this incident was not reported to the SA, because abuse was not considered and the resident's bruising was not considered suspicious based on the location of the bruise and the resident's contributing factors, such as [MEDICAL CONDITION] and fragile bones. Further, she stated that if a similar incident happens again, she will not report it to the S[NAME] Review of the facility's Abuse policy revealed that all alleged or suspected violations involving mistreatment, abuse, neglect and injuries of unknown origin (e.g. bruising, skin tears) will be promptly reported to the Administrator and/or DON. The policy further included that the facility must satisfy the immediate reporting requirement, by notifying the appropriate State agency and that immediate reports should be submitted as soon as possible, but no later than 24 hours of the facility learning of the allegation. Per the policy, failure to do so will mean that the facility is not in compliance with the Federal regulations. The Abuse policy further included that all reports of abuse will be promptly and thoroughly investigated. The investigation will include interviews with staff members on all shifts having contact with the resident at the time of the incident, interviews with any witnesses, interview with the resident if appropriate, review of the incident report and review of the resident's medical record. The policy also included that the facility must satisfy the Federal requirement to report the results of the investigation within 5 working days from the date of the incident or knowledge of the incident.",2020-09-01
965,LIFE CARE CENTER OF SIERRA VISTA,35136,2305 EAST WILCOX DRIVE,SIERRA VISTA,AZ,85635,2016-12-02,278,B,0,1,WDCK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for one resident (#278) regarding Hospice services. Findings include: Resident #278 was admitted to the facility on (MONTH) 26, (YEAR), with a [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of the clinical record revealed Hospice nurses notes which documented that the resident continued to receive Hospice services through (MONTH) and (MONTH) (YEAR). However, review of the MDS assessment dated (MONTH) 26, (YEAR) in Section O, Special Treatments, Procedures and Programs, revealed that Hospice services was not checked. An interview was conducted with the MDS nurse (staff #129) on (MONTH) 22, (YEAR) at at 9:06 a.m. The MDS nurse stated the MDS was incorrectly coded. She stated the information is obtained from the physician's orders [REDACTED]. Review of the RAI Manual for the MDS included .the importance of accurately completing and submitting the MDS cannot be over-emphasized. The MDS is the basis for the development of an individualized care plan .Federal regulations require that the assessment accurately reflects the resident's status.",2020-09-01
966,LIFE CARE CENTER OF SIERRA VISTA,35136,2305 EAST WILCOX DRIVE,SIERRA VISTA,AZ,85635,2016-12-02,280,D,0,1,WDCK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy review, the facility failed to ensure that one resident's (#81) care plan was revised to address the presence of a new pressure ulcer. Findings include: Resident #81 was admitted at the facility on (MONTH) 15, 2014, with [DIAGNOSES REDACTED]. A pressure ulcer status record dated (MONTH) 16, (YEAR), included that a stage II pressure ulcer to the coccyx was identified, which measured 1.1 centimeters (cm) x 0.8 cm x 0.1 cm depth. A physician's orders [REDACTED]. A weekly skin integrity data collection note dated (MONTH) 18, (YEAR) included the resident had a stage II pressure ulcer. On the body diagram section of the form, the sacrococcygeal and gluteal fold area was circled with a written note which stated stage II. A Significant Change Minimum Data Set (MDS) assessment dated (MONTH) 22, (YEAR) included a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS also included the resident had a stage II pressure ulcer to the sacral region. In Section V. Care Area Assessment Summary, the care area regarding pressure ulcers triggered and would be addressed in care planning. However, review of the resident's care plans including the skin care plan revealed there was no evidence that the care plans were revised to reflect the development of a new pressure ulcer. In an interview with a licensed practical nurse (LPN/staff #135) conducted on (MONTH) 1, (YEAR) at 1:29 p.m., she stated that when a resident develops a new pressure ulcer or when a healed pressure ulcer reopens, the care plan should be revised to reflect this and the revised care plan will include new treatments and interventions in place. An interview with the regional nurse (staff #152) was conducted on (MONTH) 2, (YEAR) at 8:26 a.m. She stated that any nurse who observes a new pressure ulcer is expected to update the resident's care plan. She further stated that the wound nurse is also expected to review and update the care plans as needed to reflect the resident's current status. The facility policy on Resident Care Plan stated that Review of the care plan is done at least quarterly and as needed to reflect the resident's current needs, problems, goals, care, treatment and services. The facility policy on Pressure Ulcer Prevention stated that When skin breakdown occurs, it requires attention and a change in the plan of care to appropriately treat the patient.",2020-09-01
967,LIFE CARE CENTER OF SIERRA VISTA,35136,2305 EAST WILCOX DRIVE,SIERRA VISTA,AZ,85635,2016-12-02,314,D,0,1,WDCK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the clinical record, staff interviews and policy review, the facility failed to provide treatments as ordered for one resident (#81), with a pressure ulcer. Findings include: Resident #81 was admitted to the facility on (MONTH) 15, 2014, with [DIAGNOSES REDACTED]. A pressure ulcer status record dated (MONTH) 16, (YEAR) included the resident had a stage II pressure ulcer to the coccyx area, which measured 1.1 centimeters (cm) x 0.8 cm x 0.1 cm depth. A physician's orders [REDACTED]. The order also included to check placement of the dressing every shift. Review of the (MONTH) (YEAR) Treatment Administration Record (TAR) revealed the above orders had been transcribed. However, further review of the TAR revealed that the wound treatment had not been completed on (MONTH) 22, 28 and 30. In addition, there were multiple shifts with no documentation that the dressing placement had been checked, as ordered. Review of the clinical record including the nurses notes revealed no documentation that the above wound treatments had been done or that the dressing placement had been checked for the missing shifts. There was also no documentation that the resident refused the pressure ulcer treatment. In an interview with a licensed practical nurse (LPN/staff #35) conducted on (MONTH) 1, (YEAR) 12:01 p.m., he stated that pressure ulcer treatments are provided by the wound nurse. He said that all wound treatment provided should be documented on the TAR. He further stated that if the TAR is not initialed by the nurse, either the nurse forgot to sign it or the treatment was not done. In an interview with the wound nurse (staff #139) conducted on (MONTH) 1, (YEAR) at 12:33 p.m., she stated that she documents pressure ulcer treatment on the TAR and on her weekly note. In an interview with another LPN (staff #135) conducted on (MONTH) 1, (YEAR) at 1:29 p.m., she stated that when she administers treatments, she initials the TAR and if she could not administer the treatment, she will circle the appropriate box on the TAR and document the reason why it was not administered on the back of the TAR. An interview with the Director of Nursing (DON/staff #134) was conducted on (MONTH) 1, (YEAR) at 12:36 p.m. She stated that documentation of the pressure ulcer treatment administered by the nurse is documented on the TAR. Further, she stated that if the TAR is not initialed, she expects nurses to document it in the nurse's notes. A facility policy regarding Pressure Ulcer Prevention included that pressure ulcers which are present, or which develop after admission, are treated according to medical orders.",2020-09-01
968,LIFE CARE CENTER OF SIERRA VISTA,35136,2305 EAST WILCOX DRIVE,SIERRA VISTA,AZ,85635,2016-12-02,508,D,0,1,WDCK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and facility documentation, the facility failed to provide timely diagnostic services for one resident (#81). Findings include: Resident #81 was admitted to the facility on (MONTH) 15, 2014, with [DIAGNOSES REDACTED]. According to an annual Minimum Data Set assessment dated (MONTH) 22, (YEAR), the resident was identified to have severe cognitive impairment and required extensive assistance with activities of daily living. A care plan included that the resident had a [DIAGNOSES REDACTED]. The goal was for the resident to have no injuries. Interventions included for labs and X-rays to be done as ordered. A nursing note dated (MONTH) 13, (YEAR) revealed that the resident had a shower and there were several bruises on her left leg. Per the documentation, the resident did not know where the bruises came from. Review of the facility's Follow-up and Recommendation Form dated (MONTH) 14, (YEAR), revealed the resident had bruises to the underside of her left knee down to the calf, which measured 27 centimeters (cm) x 10 cm and had a bruise to the left outer thigh, which measured 15 cm x 16 cm. A physician's orders [REDACTED]. A late entry nursing note dated (MONTH) 15, (YEAR) (for (MONTH) 14, the 6 a.m. to 6 p.m. shift) revealed that a certified nursing assistant (CNA) reported to this nurse that the resident had bruises to the back of her left knee/calf and outer left thigh. The physician was notified and an order for [REDACTED]. The nursing note dated (MONTH) 15, (YEAR) included that the script for the left leg X-ray was faxed to the physician's office five times today. The note further included Awaiting physician's signature for X-ray script, MD is aware . A nursing note dated (MONTH) 16, (YEAR) at 3:28 p.m. included the physician was at the facility and signed the script for the X-ray, a call was placed and the X-ray was ordered STAT. A nursing note dated (MONTH) 16, (YEAR) at 6:32 p.m. included the X-ray tech was in the facility to do the X-ray and that the preliminary report showed a [MEDICAL CONDITION] knee. The result of the final X-ray report dated (MONTH) 16, (YEAR) included the resident had a distal femoral [MEDICAL CONDITION] leg, with [MEDICAL CONDITION] suggested. In an interview with a licensed practical nurse (LPN/staff #35) conducted on (MONTH) 1, (YEAR) at 12:01 p.m., he stated that when he receives an order for [REDACTED]. He also stated that there is no problem having the X-rays done, because the facility is contracted with an imaging vendor that comes to the facility whenever they are ordered. An interview with a registered nurse (RN/staff #100) was conducted on (MONTH) 1, (YEAR) at 12:18 p.m. She stated that when she receives an order for [REDACTED]. Further, she stated that she would not wait for days for the physician to sign the order, especially when the order is related to ruling out a fracture. During an interview with the Director of Nursing (DON/staff #134) conducted on (MONTH) 1, (YEAR) at 12:33 p.m., she stated that if the X-ray is ordered STAT, then it would be done immediately; but if it's not ordered STAT, it would be done the next day. An interview with another LPN (staff #135) was conducted on (MONTH) 1, (YEAR) at 1:29 p.m. She stated that when she receives an order to do an X-ray, especially when there is an injury involved (e.g., bruising to affected area), she will process the order right away and will not wait for the physician to sign the order. During an interview conducted on (MONTH) 2, (YEAR) at 8:26 a.m., the regional nurse (staff #152) stated that the facility's mobile imaging vendor required that scripts are signed before an X-ray is done.",2020-09-01
969,LIFESTREAM AT COOK HEALTH CARE,35137,11527 WEST PEORIA AVE,YOUNGTOWN,AZ,85363,2017-01-06,223,D,0,1,Y40X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure one resident (#105) was free from abuse. Findings include: Resident #105 was admitted to the facility on (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated (MONTH) 19, (YEAR) documented a BIMS (Brief Interview for Mental Status) score of five, which indicated the resident had severe cognitive impairment. The MDS also included that the resident needed extensive assistance with eating. Review of the facility's investigative report revealed that on (MONTH) 1, (YEAR), a Certified Nursing Assistant (CNA/staff #171) was assisting the resident during the lunch meal. During the meal, the resident started displaying behaviors in the dining room and was observed throwing juice and silverware at staff #171. Per the report, staff #171 responded by cursing at the resident and throwing juice on the resident. Two CNA's (staff #172 and #173) who were in the dining room witnessed the incident. Further review of the facility's investigative report revealed a statement by staff #171. The statement included that the resident was pushing the table while residents were eating and she was banging her utensils on the table. She stated that she tried to explain to the resident not to do those things. At one point, staff #171 reported that she was cutting up the resident's food and the resident grabbed her wrist, but eventually let go. Per the statement, the resident threw juice and utensils at her. Staff #171 then reported the incident. The statement did not include that staff #171 had cursed at the resident or had thrown juice at the resident. Continued review of the facility's investigative report revealed that the allegation of abuse was substantiated and staff #171 was terminated. An interview was conducted on (MONTH) 4, (YEAR) at 2 p.m., with a licensed practical nurse (LPN/staff #38) who was working at the time of the incident. She stated that two CNA's told her that staff #171 threw a glass of juice on the resident and used profanity directed at the resident. An interview was conducted on (MONTH) 4, (YEAR) at 2:15 p.m., with the Administrator (staff #170) who stated that two staff had witnessed the incident and abuse was substantiated. She further stated that the police were notified. On (MONTH) 4, (YEAR) at 2:30 p.m., an interview was conducted with staff #172. He stated on the day of the incident, staff #171 was working with the resident at the assisted dining table. He stated resident #105 was not wanting to eat anymore and staff #171 kept trying to get the resident to eat. He stated resident #105 started throwing juice and silverware at staff #171. He stated at that point staff #171 then threw juice on the resident and cursed at the resident. Staff #172 stated he reported this to a licensed practical nurse (staff #38). During the survey, staff #171 and #173 were unable to be reached for an interview. Review of the facility's Abuse policy and procedures revealed residents have the right to be free from abuse and neglect. The purpose was to prohibit and prevent abuse and neglect from occurring. The policy further included that abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment resulting in physical harm, pain or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Instances of abuse, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse.",2020-09-01
970,LIFESTREAM AT COOK HEALTH CARE,35137,11527 WEST PEORIA AVE,YOUNGTOWN,AZ,85363,2018-03-16,641,D,0,1,XQK011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, policies and procedures, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that MDS (Minimum Data Set) assessments were accurate for two residents (#60 and #84). Findings include: -Resident #60 was admitted on (MONTH) 1, (YEAR) and readmitted on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed an admission nurses note dated (MONTH) 9, (YEAR), which documented the resident was admitted from an assisted living facility. However, review of an admission MDS assessment dated (MONTH) 16, (YEAR) revealed the resident was admitted from an acute hospital. Review of a Significant Change of Condition MDS assessment dated (MONTH) 8, (YEAR), included the resident was admitted from an acute hospital on (MONTH) 9, (YEAR). The MDS also included the resident had an unstageable pressure ulcer, which was not present upon admission. However, review of the clinical record and the resident's skin assessments through (MONTH) 8, (YEAR), did not reveal any documentation that the resident had an unstageable pressure which had developed. An interview was conduced on (MONTH) 14, (YEAR) at 12:56 p.m., with the MDS coordinator (staff #48). Staff #48 reviewed the (MONTH) 16, (YEAR) admission MDS assessment and the nurses' notes and stated the documentation regarding that the resident was admitted from the hospital was incorrect, and the MDS should have been coded to reflect that the resident came from an assisted living facility. An interview was conducted on (MONTH) 14, (YEAR) at 1:34 p.m., with a Registered Nurse (staff #117). Staff #117 stated she was the wound nurse who had been providing care and documentating the wounds for resident #60. Staff #117 stated that during the time of the MDS completion from (MONTH) 1-8, (YEAR), the resident did not have nor did she develop an unstageable pressure ulcer. On (MONTH) 15, (YEAR) at 8:17 a.m., another interview was conducted with staff #48, who stated that the documentation on the Significant Change of Condition MDS dated (MONTH) 8, regarding the pressure ulcer was incorrect. Staff #48 stated that she had seen documentation of an unstageable pressure ulcer, but the resident had not developed it until (MONTH) 16, after the MDS assessment date. Staff #48 stated that the Significant Change of Condition MDS was also incorrect regarding where the resident was admitted from and should have been corrected to reflect that the resident was admitted from an assisted living facility. -Resident #84 was admitted on (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. The social services note dated (MONTH) 1, (YEAR) revealed the resident chose to be discharged from the facility AMA (against medical advice). A health status note dated (MONTH) 1, (YEAR) included the resident left the facility AMA at approximately after 4:00 p.m. The Against Medical Advice Release of Responsibility for discharge date d (MONTH) 1, (YEAR) which was signed by the resident included that the resident was being discharged against the advice of the attending physician. It also included that the resident wanted to go home. However, the Discharge MDS assessment dated (MONTH) 1, (YEAR) included the resident had an unplanned discharge with return not anticipated and that the resident was discharged to an acute hospital. In an interview with staff #48 conducted on (MONTH) 16, (YEAR) at 2:51 p.m., she stated that she uses the RAI Manual for instructions with coding items in the MDS. She also stated that she conducts rounds every morning and attends morning meetings to receive information related to changes in the residents status. She stated that if she has questions on the information in the clinical record, she goes out on the floor and talks to staff regarding issues identified during her review. She said that resident #84 had an unplanned discharge to home and left the facility AM[NAME] At this time, a review of the Discharge MDS assessment was conducted by staff #48. She stated that the Discharge MDS indicated that the resident was discharged to an acute hospital and that it should have been coded to indicate the resident was discharged to home. According to the facility's policy and the Resident Assessment Instrument (RAI) Version 3.0. Manual for the MDS, staff are to review the medical record including transfer, admission and discharge plans and orders, and enter the correct code which corresponds to the location that the resident was admitted from and the discharge location. The documentation further included that if no unstageable ulcers were present on admission, then code 0.",2020-09-01
971,LIFESTREAM AT COOK HEALTH CARE,35137,11527 WEST PEORIA AVE,YOUNGTOWN,AZ,85363,2018-03-16,656,E,1,1,XQK011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews, review of the Resident Assessment Instrument (RAI) manual and policy and procedures, the facility failed to ensure that comprehensive care plans were developed for one resident regarding pain (#33) and regarding falls for one resident (#382). Findings include: -Resident #33 was readmitted to the facility on (MONTH) 11, (YEAR), with [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment dated (MONTH) 18, (YEAR) did not reflect that the resident had pain. Review of the physician's orders [REDACTED]. The order also included for the resident's pain to be assessed every shift. Review of the Medication Administration Record [REDACTED]. Review of the resident's care plans revealed no evidence that a care plan had been developed to address the resident's pain. An interview was conducted with a Certified Nursing Assistant (CNA/staff #153) on (MONTH) 16, (YEAR) at 8:56 a.m. She stated that the resident had a lot of complaints of pain and she would tell the nurse and the resident would receive pain medications. An interview was conducted with the MDS nurse (staff #48) on (MONTH) 16, (YEAR) at 10:20 a.m. She stated the resident has a [DIAGNOSES REDACTED]. Staff #48 stated that the resident needed to have a care plan for pain. She stated that without a care plan, there are no non-pharmacological interventions listed on the MAR indicated [REDACTED]. She also stated the current care plan needed to reflect the current status of the resident's pain. -Resident #382 was admitted on (MONTH) 30, (YEAR) and discharged on (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. Review of the Morse Fall Risk Scale dated (MONTH) 31, (YEAR), revealed the resident had impaired gait and was at moderate risk for falls. Review of a physical therapy plan of care dated (MONTH) 31, (YEAR) revealed the resident had altered strength and balance, had unsafe functional mobility and had impaired safety awareness. The documentation included the resident was a high fall risk. The evaluation also included that the resident required moderate assistance of two staff for bed mobility and was dependent on staff for transfers. Review of the Occupational Therapy Plan of Care dated (MONTH) 3, (YEAR) revealed the resident had fair to poor balance and was a high fall risk. The evaluation noted that the resident needed cues and redirection for safety. Review of a MDS assessment dated (MONTH) 6, (YEAR) revealed the resident had short and long term memory problems and was severely impaired with decision making. The MDS assessed the resident to require extensive assistance with bed mobility and transfers. Review of the Care Area Assessment (CAA) for falls revealed the resident was a fall risk related to needing staff assistance with transfers and antidepressant use. In the CAA section regarding falls, it included to proceed to care planning with an overall objective to minimize risks, and that the resident would remain free of falls and fall related injuries. Review of a progress note dated (MONTH) 21, (YEAR) revealed the resident slid onto the floor on his bottom, as witnessed by a CN[NAME] Review of the clinical record revealed that no care plan had been developed to address the resident's fall risk, nor did the resident's current care plans address that the resident had sustained an actual fall. An interview was conducted with the MDS coordinator (registered nurse/staff #48) on (MONTH) 15, (YEAR) at 12:20 p.m. She stated that if a resident triggers for falls in the CAA section and it indicated to proceed to care planning, or if a resident had an actual fall, then she would develop a falls care plan. After reviewing the clinical record, staff #48 was unable to locate a care plan for falls. Staff #48 stated that the resident had a fall on (MONTH) 21, (YEAR) and that a fall care plan should have been developed. An interview was conducted with the Director of Nursing (DON/staff #107) on (MONTH) 16, (YEAR) at 8:30 a.m. She stated that the facility follows the RAI manual and MDS process for care plan development. She stated that if the Fall CAA area indicated to proceed to care planning, then a care plan should have been developed. She also stated that if the resident had an actual fall in the facility, she would expect a fall care plan to be developed. Review of the RAI manual revealed that after completing the MDS and CAA portions of the comprehensive assessment, the next step is to evaluate the information gained through both assessment processes, in order to identify problems, causes, contributing factors, and risk factors related to the problems. Subsequently, the inter-disciplinary team must evaluate the information gained to develop a care plan that addresses those findings in the context of the resident's strengths and problems. The RAI manual also included that a comprehensive care plan needed to be developed within seven days after completing the comprehensive assessment. Review of the policy for care plans revealed that the comprehensive, person-centered care plan will incorporate identified problem areas, incorporate risk factors associated with the identified problem areas and reflect treatment goals, timetables and objectives in measurable outcomes.",2020-09-01
972,LIFESTREAM AT COOK HEALTH CARE,35137,11527 WEST PEORIA AVE,YOUNGTOWN,AZ,85363,2018-03-16,657,E,0,1,XQK011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews and staff interviews, the facility failed to ensure care plans were revised for one resident (#4) regarding incontinence and regarding falls for one resident (#37). Findings include: -Resident #4 was admitted to the facility on (MONTH) 5, (YEAR), with a [DIAGNOSES REDACTED]. Per an admission Minimum Data Set (MDS) assessment dated (MONTH) 12, (YEAR), the resident had a score of 5 on the Brief Interview for Mental Status, which indicated severe cognitive impairment. In addition, the resident was assessed to be occasionally incontinent of urine. A care plan dated (MONTH) 18, (YEAR) documented the resident required assistance with activities of daily living. An intervention included the resident required assistance from one staff for toileting. An interview was conducted with a Certified Nursing Assistant (CNA/staff #105) on (MONTH) 15, (YEAR) at 12:47 p.m. She stated that she takes care of the resident on a regular basis and knows her well. She stated the resident is always incontinent of urine and cannot use the call light or let staff know when she has to go to the bathroom. Staff #104 stated the resident wears briefs, so staff have to check on her at least every 2 hours or more often to see if she needs to be changed. An interview was conducted with a Licensed Practical Nurse (LPN/staff #104) on (MONTH) 15, (YEAR). She stated she knows and cares for the resident on a routine basis and the resident is always incontinent of urine and that the CNAs check on her regularly and change her brief as necessary. At this time, the Director of Nursing (DON/staff#107) and the MDS nurse (staff #48) joined the interview. Staff #48 stated the current care plan does not reflect the resident's current status of always being incontinent. Staff #48 further stated that the care plan needed to address urinary incontinence and include appropriate nursing interventions, such as the need for the resident to be checked at least every 2 hours. -Resident #37 was admitted on (MONTH) 25, (YEAR), with [DIAGNOSES REDACTED]. Review of a care plan revealed the resident was at risk for falls, related to poor safety awareness. A goal included the resident would not sustain serious injuries. Interventions included anticipating and meeting the resident's needs, low bed, ensure the resident was wearing appropriate footwear when ambulating or mobilizing in wheelchair, and staff were to provide assistance to maintain safety and encourage independence. A nurse's note dated (MONTH) 6, (YEAR) included the resident sustained [REDACTED]. Clinical record documentation included the resident returned to the facility on (MONTH) 7, with stitches to her forehead. Further review of the fall care plan revealed that it was not revised to reflect that the resdient sustained an actual fall with injury or indicate any additional interventions that were implemented after the fall. A nurses note dated (MONTH) 14, (YEAR) at 5:11 p.m. revealed resident #37 was sitting in her wheelchair in front of the nurses station after lunch, when a crash was heard. The resident was found on the floor and no injuries were noted. Review of the Incident Committee Meeting documentation dated (MONTH) 14, (YEAR), revealed that PT was to screen and evaluate the resident for positioning in the wheelchair. A PT evaluation dated (MONTH) 14, (YEAR) included that resident #37 had more than one incident of falling forward out of a standard wheelchair. The PT evaluation recommended for a geri-chair over a high-back reclining chair. The note indicated that the geri-chair would recline for comfort and the resident could sit up more erect for proper posture at meals. The fall care plan was not revised to reflect that the resident had another fall or indicate any additional interventions which were implemented after the fall. An Occupational Therapy plan of care evaluation dated (MONTH) 8, (YEAR) documented that the resident was evaluated for wheelchair positioning. The evaluation included that the resident was utilizing a high-back wheelchair. A nurses note dated (MONTH) 11, (YEAR) at 1:45 p.m., revealed a late entry which included that resident #37 fell on (MONTH) 10. The note indicated that the resident was leaning forward at the time of the fall and the resident's high-back wheelchair was reclined for safety. According to an incident and follow-up report dated (MONTH) 11, (YEAR), the resident was found on the floor in the dayroom on (MONTH) 10. The resident was noted with redness on the right side of her head and had a superficial scratch to her right knee. Continued review of the fall care plan revealed that it was not revised to reflect that the resident had multiple falls, nor did it reflect the use of a high-back wheelchair or any additional interventions which were implemented after the falls. On (MONTH) 14, (YEAR) at 10:30 a.m., an interview was conducted with the Director of Nursing (staff #107). She stated that the care plan was not updated after each fall.",2020-09-01
973,LIFESTREAM AT COOK HEALTH CARE,35137,11527 WEST PEORIA AVE,YOUNGTOWN,AZ,85363,2018-03-16,686,D,0,1,XQK011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy and procedures, the facility failed to provide the necessary care and services, by failing to assess the palms of one resident (#77) who was identified to have skin breakdown, due to contractures. Findings include: Resident #77 was admitted on (MONTH) 15, (YEAR), with [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment dated (MONTH) 22, (YEAR) included the resident had severe cognitive impairment. Per the MDS, the resident was totally dependent on staff for personal hygiene and bathing. The MDS also included the resident had functional limitations in range of motion to both upper and lower extremities. A care plan for contractures included the resident had contractures to his arms and legs. A goal included to not have skin breakdown, due to contractions. The care plan further documented that the resident would not allow devices or interventions for his contractures. According to an orthopedic note dated (MONTH) 1, (YEAR), the resident was evaluated for surgical release of his contractures. The consult documented that the resident had contractures of the bilateral upper and lower extremities, with some spastic motion of his left arm and leg. The note included that the resident's ring finger DIP (distal interphalangeal joint) was dislocated and hyperextended on both hands. There are wounds on the resident's palms corresponding to his ring fingers, bilaterally. There is no evidence of infection, but the skin of his palms is macerated. The resident is not a good candidate for surgical release of his contractures, as he is unable to participate in physical therapy. The note included to follow-up with a neurologist or return if resident continues to have skin breakdown or wounds on his hand, due to his finger position. The resident would be a candidate for a partial finger amputation if his wounds progress. A review of health status note dated (MONTH) 1, (YEAR), documented that the resident returned from his appointment at 12:10 p.m., with a physician's note stating that the resident was not a candidate for surgical release of his contractures and may need partial amputation of the ring fingers, if skin is not kept dry. The note was signed by a LPN (licensed practical nurse/staff #104). Despite documentation from the orthopedic physician that the resident had wounds on both palms of his palms due to contractures and that the skin was macerated, there was no clinical record documentation that the resident's palms were assessed for skin breakdown on (MONTH) 1 or 2. There was also no documentation that the resident's physician was notified regarding the wounds on the palms of the resident's hands. Another Health Status dated (MONTH) 3, (YEAR) at 4:35 p.m., included the resident had returned from an appointment the doctors comments were reviewed. The note included that the resident's left hand was checked and there was no redness or excoriation at this time. The note was signed by staff #104. However, there was no documentation that the resident's right hand was assessed for any skin breakdown on (MONTH) 3. In addition, there was no further documentation that the resident's palms were assessed for skin breakdown/wounds from (MONTH) 4 through 15. On (MONTH) 15, (YEAR) at 11:42 a.m., an attempt was made to observe the resident's hands with the DON (staff #107) and a CNA (staff #40). The resident resisted staff attempting to open his fingers and refused to allow the observation. An interview was conducted with staff #107 on (MONTH) 15, (YEAR) at 11:50 a.m. Staff #107 stated that she did not see anything when she observed the resident's left hand (on (MONTH) 3). Staff #107 stated she thought she had observed both of the resident's hands, but only documented about the left hand. Another interview was conducted on (MONTH) 15, (YEAR) at 12:00 p.m. with staff #107, who stated that she would expect nursing staff to observed and document the resident's wounds and to make note if the resident refused. Review of a policy regarding Pressure Ulcer Prevention revealed that the facility should have a system/procedure to assure assessments are timely and appropriate and that changes in condition are recognized, evaluated, and reported to the medical provider, and that changes are addressed. The policy further included that contractures need to be addressed and managed to prevent skin integrity disruption.",2020-09-01
974,LIFESTREAM AT COOK HEALTH CARE,35137,11527 WEST PEORIA AVE,YOUNGTOWN,AZ,85363,2018-03-16,689,E,0,1,XQK011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, facility documentation and review of policies and procedures, the facility failed to ensure that the resident environment remained free of accident hazards, by failing to ensure that fall recommendations were implemented for one resident (#10) with multiple falls, and by failing to ensure one resident's (37) high-back wheelchair was repaired as recommended. Findings include: -Resident #10 was admitted on (MONTH) 13, (YEAR), with [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed a Morse Fall Scale assessment dated (MONTH) 14, (YEAR), which indicated the resident was at high risk for falls. A care plan for falls dated (MONTH) 15, (YEAR) identified that the resident was at risk of falls, due to weakness. Interventions included for a low bed, staff to ensure resident was wearing proper footwear while transferring or ambulating, and for staff to follow the fall protocols. An admission MDS (Minimum Data Set) assessment dated (MONTH) 21, (YEAR), revealed the resident had severe cognitive impairment. The MDS included that the resident required extensive assistance of two or more staff for transfers and extensive assistance of one staff for locomotion on the unit. Per the MDS, the resident was not steady and was only able to stabilize with human assistance, when moving from a seated position to standing. The MDS also included the resident had no history of falls prior to admission and had not had a fall since admission. A health status note dated (MONTH) 22, (YEAR) documented that therapy staff had found the resident on the floor next to her bed. The resident was alert and able to make needs known. The resident denied pain and range of motion was within normal limits. The resident sustained [REDACTED]. According to a fall incident report dated (MONTH) 22, (YEAR), the resident had another fall, which was un-witnessed. The physician was notified. Review of an incident report dated (MONTH) 26, (YEAR) revealed a recommendation for a therapy evaluation and to start therapy on (MONTH) 3, (YEAR). A physical therapy evaluation dated (MONTH) 3, (YEAR), documented there had been an attempt to stand the resident up using a front wheeled walker, but due to pain in the resident's left upper extremity, this could not be done. The recommendation was for occupational therapy to work with the resident, then possibly physical therapy would be appropriate. A therapy screen dated (MONTH) 18, (YEAR) included the resident had a fall on (MONTH) 22, (YEAR) and that the resident had been evaluated by physical and occupational therapy. The evaluation included that occupational therapy has started to address the resident's deficits. The resident has a healing [MEDICAL CONDITION] arm and glenoid that is very painful. A health status note dated (MONTH) 15, (YEAR) revealed the resident had become weak in her right leg and was unable to bear her weight, and a CNA guided the resident to the floor. The resident was assessed with [REDACTED]. Review of an incident report dated (MONTH) 15, (YEAR), revealed the resident had a witnessed fall during a transfer, due to gait imbalance. According to the incident committee notes dated (MONTH) 16, (YEAR), the resident had a fall on (MONTH) 15, with a recommendation for a physical therapy screen. A health status note dated (MONTH) 17, (YEAR), documented that the resident had another fall. The resident was found on the floor in the dayroom. The resident was assessed with [REDACTED]. Review of the fall incident report dated (MONTH) 17, (YEAR) revealed a predisposing factor of the fall as, improper footwear. A Morse Fall Scale assessment dated (MONTH) 16, (YEAR) included that the resident continued to be at high risk for falls. Review of incident committee meeting note dated (MONTH) 19, (YEAR) revealed a recommendation for physical and occupational therapy screens. However, review of the clinical record revealed there was no evidence that the physical or occupational therapy screens had been completed from (MONTH) 15 through (MONTH) 2, (YEAR). A health status note dated (MONTH) 3, (YEAR) included the resident fell out of her wheelchair this morning on her way to the dining room. The resident hit her head and sustained a laceration above her left eye. Resident was alert and oriented and vitals signs were stable. A physician's orders [REDACTED]. A review of the incident report dated (MONTH) 3, (YEAR) revealed the resident was being pushed in her wheelchair to the dining room, and the resident moved her feet from the pedals to the floor, causing her to fall forward onto the floor. The resident hit her head on the floor and sustained a laceration above the left eyebrow. Another health status note dated (MONTH) 3, (YEAR) included the resident returned from the hospital with dermabond over her left eyebrow laceration. According to the incident committee meeting note dated (MONTH) 5, (YEAR), the resident had a fall from her wheelchair when she took her feet off the pedals and fell forward on (MONTH) 3. The resident sustained [REDACTED]. Again, the recommendation was for physical and occupational therapy screens to be done. However, there was no clinical record documentation that the recommended physical and occupational therapy screens were done. An interview was conducted on (MONTH) 16, (YEAR) at 12:07 p.m., with the Therapy Director (staff #175). Staff #175 stated that all resident falls are reviewed during incident committee meetings and at that time therapy would be informed of the need for screens or other recommendations. Staff #175 stated the resident's name would then be placed on the board in the therapy office and the next available therapist would follow-up on the recommendation. Staff #175 stated that she could not find any documentation that the therapy screenings related to the resident's falls on (MONTH) 15 and 17, and (MONTH) 3, had been completed. Per staff #175, resident #10 had been discharged from occupational therapy on (MONTH) 16, (YEAR), and that physical therapy was not implemented. A telephone interview was conducted with a physical therapy assistant (staff #178) on (MONTH) 15, (YEAR) at 12:22 p.m. Staff #178 stated that she had not performed any therapy screens for resident #10. A telephone interview was conducted with a COTA (certified occupational therapy assistant/staff #179) on (MONTH) 16, (YEAR) at 12:24 p.m. Staff #179 stated that she had not performed any therapy screens for resident #10. An interview was conducted with a physical therapist (staff #174) on (MONTH) 16, (YEAR) at 12:30 p.m. Staff #174 stated that he had done the therapy screen on resident #10 regarding a fall in (MONTH) (YEAR), but had not conducted any additional screens regarding resident #10. An interview was conducted with the Director of Nursing (DON/staff #107) on (MONTH) 16, (YEAR) at 2:41 p.m. Staff #107 stated that therapy staff were included in incident committee meetings and given information regarding falls, including recommendations for therapy screens. Staff #107 stated that the therapy screens are an instrumental piece to identify any fall prevention interventions. -Resident #37 was admitted on (MONTH) 25, (YEAR), with [DIAGNOSES REDACTED]. Review of a care plan revealed the resident was at risk for falls related to poor safety awareness. A goal included the resident would not sustain serious injuries. Interventions included anticipating and meeting the resident's needs, low bed, ensure the resident was wearing appropriate footwear when ambulating or mobilizing in wheelchair, and staff were to provide assistance to maintain safety and encourage independence. Review of an activity of daily living (ADLs) care plan revised on (MONTH) 1, (YEAR) revealed the resident had self-care performance deficits, related to Alzheimer disease. A goal included maintaining current levels of function in all ADLs with staff assistance. Approaches included the resident needed assistance of one staff for bed mobility and the assistance of two staff for transfers via Hoyer lift. A quarterly MDS assessment dated (MONTH) 16, (YEAR) included a BIMS (Brief Interview for Mental Status) score of 0, which indicated that the resident had severe cognitive impairment. The MDS included the resident was totally dependent on one staff for bed mobility, locomotion and toilet use, and was totality dependent on two staff for transfers to and from the wheelchair and was non-ambulatory. A nurses note dated (MONTH) 6, (YEAR) included the resident fell and sustained an injury to the middle of her forehead. The physician was notified and ordered to transfer the resident to the hospital for an evaluation. Review of an incident and follow-up report dated (MONTH) 6, (YEAR), revealed the resident was found on the floor with a cut on her forehead. A nurses note dated (MONTH) 7, (YEAR) included the resident had returned from the hospital. The note included that the resident's forehead was swollen and had stitches to her forehead. Per the note, a head/brain scan showed the resident had swelling and a hematoma. Review of a form titled Incident Committee Meeting dated (MONTH) 7, (YEAR), revealed documentation that the resident fell in the dining room on (MONTH) 6, (YEAR) and sustained a cut on her forehead. The resident was sent to the hospital and returned with stitches on her forehead. The report further included a new intervention for Physical/Occupational Therapy (PT/OT) screenings. The note also included that the resident was at high risk for falls. Review of a PTA (physical therapy assistant) note dated (MONTH) 8, (YEAR), revealed the resident was assessed for wheelchair brakes. No other interventions were recommended. A review of the resident's care plans revealed they were not revised to reflect that the resident fell , and there were no new interventions. A nurses note dated (MONTH) 14, (YEAR) at 5:11 p.m. revealed resident #37 was sitting in her wheelchair in front of the nurses station after lunch, when a crash was heard. The resident was found on the floor and no injuries were noted. Review of the Incident Committee Meeting documentation dated (MONTH) 14, (YEAR), revealed that resident #37 was moved from the lunch table to the common area in front of the nurses station. The documentation included that PT was to screen and evaluate the resident for positioning in the wheelchair. A PT evaluation dated (MONTH) 14, (YEAR) included that resident #37 had more than one incident of falling forward out of a standard wheelchair. The PT evaluation recommended for a geri-chair over a high-back reclining chair. The note indicated that the geri-chair would recline for comfort and the resident could sit up more erect for proper posture at meals. A nurses note dated (MONTH) 14, (YEAR) revealed that therapy had screened the resident and recommended a geri-chair. However, there was no further clinical record documentation of any follow up that was done regarding the PT recommendation for a geri-chair from (MONTH) 14 through (MONTH) 8, (YEAR). An Occupational Therapy plan of care evaluation dated (MONTH) 8, (YEAR) documented that the resident was evaluated for wheelchair positioning. The evaluation included that the resident was utilizing a high-back wheelchair. There was no documentation regarding the previous recommendation by PT for a geri-chair, nor was there any documentation as to why the high-back wheelchair was being utilized instead of the recommended geri-chair. The evaluation further included a recommendation to change out or fix the resident's high-back reclining wheelchair, due to right side tilting, as the right side of the backrest did not always lock in place. The OT also recommended a tilt in space wheelchair, if the resident qualified. A nurses note dated (MONTH) 11, (YEAR) at 1:45 p.m., revealed a late entry which included that resident #37 fell on (MONTH) 10, (YEAR). The note indicated that the resident was leaning forward at the time of the fall and the resident's high-back wheelchair was reclined for safety. According to an incident and follow-up report dated (MONTH) 11, (YEAR), the resident was found on the floor in the dayroom on (MONTH) 10. The resident was noted with redness on the right side of her head and had a superficial scratch to her right knee. Review of the Incident Committee Meeting documentation dated (MONTH) 12, (YEAR) revealed that resident #37 was found on the floor in the dayroom. An interviention inlcuded for a PT/OT screen to be done. Further review of the clinical record revealed there was no documentation from (MONTH) 8 through (MONTH) 13, that the resident's high-back wheelchair had been repaired or replaced. According to a PT evaluation dated (MONTH) 14, (YEAR), the resident fell on (MONTH) 10, (YEAR). The documentation included that the elevation mechanism on the wheelchair allows the right side to recline down unintentionally, and that a maintenance work order was completed. The evaluation also included that the wheelchair needed a footboard to span gap between legs rests to hold legs in better alignment/position. On (MONTH) 15, (YEAR) at 11:36 a.m., an interview was conducted with a Licensed Practical Nurse (LPN/staff #1) via telephone. Staff #1 stated that she was assigned to work on the unit when the resident sustained [REDACTED]. She stated that the resident had a tendency to bend forward in the wheelchair and would fall out. On (MONTH) 16, (YEAR) at 8:26 a.m., an interview was conducted with PT (staff #174) and the Rehabilitation and Wellness Manager (staff #175). Staff #174 stated that OT determined on (MONTH) 8, that when the resident's high-back chair was reclined backwards, it gradually tilted over to the right. Staff #174 and #175 stated that OT completed the evaluation on (MONTH) 8, and recommended to fix the resident's high-back wheelchair, but that was not done. Staff #174 and 175 stated OT staff usually share their recommendations with the nurse right away, but they did not know what happened. Staff #175 stated that the resident initially had a standard wheelchair, then nursing placed the resident in a high-back wheelchair for comfort, after she fell on (MONTH) 14. Staff #175 stated that the resident fell out of the high-back wheelchair on the (MONTH) 10, and that it had not been repaired as recommended by OT on (MONTH) 8. Staff #174 and staff #175 stated that on (MONTH) 14, (YEAR), the therapy department was asked to re-evaluate resident #37's high-back wheelchair. Staff #175 stated they found out that when the resident's high-back wheelchair was reclined back, it gradually tilted over to the right. Staff #175 stated that the resident's wheelchair was switched out on (MONTH) 14, with a new high-back tilting wheelchair, which had a cushion with wedges and a foot board. On (MONTH) 15, (YEAR) at 10:20 a.m., an interview was conducted with the Director of Nursing (DON/staff #107). Staff #107 stated the interdisciplinary team discussed the geri-chair and the high-back wheelchair and they thought that the geri-chair would place the resident at a higher risk for pressure ulcers, so they opted to use the high-back tilting wheelchair. Staff #107 stated that there was no safety assessment done for the use of the high-back wheelchair until (MONTH) 14. Staff #107 also stated that the resident was in the high-back wheelchair when she fell on (MONTH) 10, (YEAR). Review of the policy regarding Falls and Fall Management revealed that staff, with the input of the attending physician will identify and implement appropriate interventions to reduce the risk of falls. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. Staff will monitor and document each resident's response to interventions to reduce falling. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions.",2020-09-01
975,LIFESTREAM AT COOK HEALTH CARE,35137,11527 WEST PEORIA AVE,YOUNGTOWN,AZ,85363,2018-03-16,692,G,1,1,XQK011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, hospital and facility documentation and policy and procedures, the facility failed to ensure that one resident (#382) was provided sufficient fluids to prevent dehydration. Findings include: Resident #382 was admitted on (MONTH) 30, (YEAR), with [DIAGNOSES REDACTED]. Review of the hospital documentation dated (MONTH) 25, (YEAR) revealed the resident had a [DIAGNOSES REDACTED]. Review of the nursing admission assessment dated (MONTH) 31, (YEAR) revealed the resident's mouth was moist. Review of a daily skilled nurse's note dated (MONTH) 31, (YEAR) revealed to monitor fluid intake to prevent dehydration. According to the care plan conference notes dated (MONTH) 31, (YEAR), the resident was at high nutritional risk related to poor oral intake and had no signs or symptoms of dehydration. The documentation further included that the resident was resistant to eating. Physician orders [REDACTED]. A physician's progress note dated (MONTH) 3, (YEAR) revealed the resident was in the facility following a transition of care from the hospital for treatment of [REDACTED]. There was no documentation that the resident exhibited any signs or symptoms of dehydration or had a [DIAGNOSES REDACTED]. A daily skilled nurse note dated (MONTH) 3, (YEAR) included to monitor fluid intake to prevent dehydration. Review of an occupational therapy evaluation dated (MONTH) 3, (YEAR) revealed the resident required moderate assistance with self-feeding. Review of a nurse's progress note dated (MONTH) 4, (YEAR) at 6:01 a.m. revealed the resident was straight catheterized for 400 cubic centimeters (cc) of dark yellow urine. Review of the daily skilled nurse's note dated (MONTH) 4, (YEAR) included to monitor fluid intake to prevent dehydration. A nurse's progress note dated (MONTH) 5, (YEAR) included the resident was straight catheterized for 700 cc of dark urine, which was communicated to the physician. Review of the CNA documentation dated (MONTH) 5, (YEAR) at 1:59 p.m., revealed the resident did not void during that CNA's shift. Review of the daily skilled nurse's note dated (MONTH) 6, (YEAR) revealed the resident had poor/restricted intake of fluids and to monitor fluid intake to prevent dehydration. An admission Minimum Data Set (MDS) assessment dated (MONTH) 6, (YEAR), revealed a Brief Interview of Mental Status (BIMS) score of 99, which meant the resident was unable to complete the interview. The staff interview was completed and indicated that the resident had memory problems and was severely impaired with decision making. The MDS included that the resident had rejected care 1-3 days during the assessment period. Per the MDS, the resident required extensive assist with bed mobility, transfers, locomotion on the unit and eating. Under Section [NAME] Health Conditions, the documentation included that the resident did not have a chronic condition that may result in a life expectancy of less than 6 months, and the resident did not have dehydration as a problem condition. Review of the nutrition progress note dated (MONTH) 7, (YEAR) revealed the resident would be placed on the nutrition alert list for the interdisciplinary team to follow and that the diet technician was to continue to work with the resident to see if there was anything that could be done to improve the resident's oral intakes. Review of a daily skilled nurse's note dated (MONTH) 7, (YEAR) included to monitor fluid intake to prevent dehydration. A daily skilled nurse's note dated (MONTH) 9, (YEAR) documented that the resident had poor/restricted intake of fluids. A physician's orders [REDACTED]. Occupational therapy documentation dated (MONTH) 9, (YEAR) revealed the resident required supervision set-up with self-feeding to locate items on the tray and plate, which included to open containers and bring food and fluid to his mouth. Review of a nutrition risk assessment dated (MONTH) 9, (YEAR) revealed the resident required 3,120 (ml) milliliters of fluid daily and needed 2-3 cups of fluid offered with meals. The assessment identified that the resident was at risk for dehydration, as he was not meeting his estimated needs and that a care plan would be developed. Review of the daily skilled nurse's note dated (MONTH) 10, (YEAR) revealed the resident had poor/restricted intake of fluids, difficulty swallowing and included to monitor fluid intake to prevent dehydration. A progress note dated (MONTH) 13, (YEAR) included the resident was not eating well and was drinking better than eating. A progress note dated (MONTH) 14, (YEAR) revealed the resident continued to feed himself, with poor intake and that dietary had been notified. A physician's note dated (MONTH) 15, (YEAR) included documentation that the resident had no new issues or complaints. The physical exam indicated that the resident was well nourished and appeared ill. There was no documentation that the resident had any signs or symptoms of dehydration or had a [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of the care plan initiated on (MONTH) 16, (YEAR) revealed the resident had a potential for weight loss, due to variable intakes. A goal included that the resident would show no signs or symptoms of dehydration. The approaches included that the resident was moved to an assisted table so nursing could help him eat and drink, for nursing staff to continue to encourage him to eat and drink, and that nursing staff would monitor his oral intake and weekly weight. Review of the CMP lab results (which were done on (MONTH) 16) revealed the resident had an elevated BUN (blood urea nitrogen/test to see how well the kidneys are functioning) of 30 (normal range is 7-25). Physician orders [REDACTED]. Review of a nutrition note dated (MONTH) 17, (YEAR) revealed the resident's oral intakes remained poor. The note included that they spoke to a family member about the resident's preferences. The note reflected that dietary would continue supplements, encourage intakes, and to monitor the resident's weights. Per the note, dietary would send fortified ice cream and fortified pudding with lunch and dinner. However, there was no order for the fortified ice cream at this time. A review of a nutrition progress note (MONTH) 19, (YEAR) revealed the resident remains on the nutrition at risk (NAR) list. A physician's orders [REDACTED]. The orders also included for the resident to be placed on contact isolation and intravenous antibiotic therapy for [MEDICAL CONDITION]-Resistant Staphylococcus Aureus (MRSA) Urinary Tract Infection [MEDICAL CONDITION]. Review of the CMP lab results revealed that the resident's BUN level had increased to 40. A nurse's progress note dated (MONTH) 20, (YEAR) included that fluids were being encouraged. A physician's orders [REDACTED]. Review of a nurse's progress note dated (MONTH) 23, (YEAR) revealed the resident would not feed himself and needed a lot of encouragement to drink. A nurse's progress note dated (MONTH) 24, (YEAR) included that the resident did not eat much for breakfast and lunch, but ate 100% of dinner and had 240 milliliter (ml) of water. Review of a progress note dated (MONTH) 26, (YEAR) revealed the resident did not eat or drink well. Review of the visual/bedside individual care service plan that communicated to the certified nursing assistants (CNA) how to care for the resident, revealed there was no direction to encourage fluids. Review of the documented fluid intake on the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The daily fluid amounts listed below include the fluids from the IV antibiotic, med pass, ice cream, cups at meals, pro stat and milk shakes. The total daily fluid amounts are as follows: January 9 = 1125 ml January 10 = 1860 ml January 11 = 1756 ml January 12 = ml January 13 = 1245 ml January 14 = 1840.5 ml January 15 = 1680 ml January 16 = 1950 ml January 17 = 1863 ml January 18 = 2061 ml January 19 = 2661 ml January 20 = 2326 ml January 21 = 2326 ml January 22 = 1438 ml January 23 = 2323 ml January 24 = 1960 ml January 25 = 970 ml January 26 = 1360 ml January 27 = 250 ml and resident discharged to the hospital. For 19 days, the resident did not receive the required fluid amount of 3,120 ml per day, as determined by dietary on (MONTH) 9. A nurse's progress note dated (MONTH) 27, (YEAR) revealed that staff had reviewed the resident's current medical status including meal and supplement intakes. The note indicated that the physician directed that the resident could go to the emergency room (ER) for an evaluation, if the family wished. Another nurse's progress note dated (MONTH) 27, (YEAR) revealed the resident was not eating or drinking and was being sent to the ER for an evaluation. Review of the hospital records revealed that the resident was admitted on (MONTH) 27, (YEAR) at 1:35 p.m. The hospital records revealed that the resident had a temperature of 101.4 degrees Fahrenheit, a sodium level of 168 (normal 136-144), potassium level of 3.5 (normal 3.7 to 5.2), chloride level of 132 (normal 101-111), glucose level of 271 (normal of 64-100), BUN of 113 (normal 7-20) and a creatinine level of 3.10 (normal 0.8 to 1.2). It was further noted that the resident was immediately evaluated and fluid resuscitation was initiated. The documentation included that the resident had acute [MEDICAL CONDITION], severe [MEDICAL CONDITION], was very dehydrated and was admitted to the intensive care unit in critical condition. Review of the renal consult dated (MONTH) 28, (YEAR) revealed the resident had [DIAGNOSES REDACTED]. An interview was conducted with the diet technician (staff #173) and with the registered dietician (staff #172) on (MONTH) 15, (YEAR) at 10:34 a.m. Staff #173 stated that when a resident is identified as at risk for dehydration or has laboratory values that are changing, then the resident is placed on the nutrition alert plan and staff push fluids at meals. She stated that staff in the dining room watch what percentage of the meal is eaten and document it, but if a resident was on isolation they would receive a room tray and nursing staff on the hall would monitor the percentages. She stated that to monitor the resident's status she would ask the CNAs and the nurses how well the resident was eating and drinking. Staff #173 stated that she is not always given the information on fluid intake in cubic centimeters (cc's). She stated that a cup as documented by the CNA would represent 180 cc's if the resident was served in the dining room as the cups are smaller, and 240 cc's if the resident was receiving a room tray. Staff #173 was unable to state if the fluid status for this resident was communicated to the physician, as that is done by nursing staff. An interview was conducted with the Director of Nursing (DON/staff #107) on (MONTH) 15, (YEAR) at 10:42 a.m. She stated that staff document how many glasses of fluid a resident consumes per meal and in between meals. She stated that they do not do strict intake and outputs, unless it is ordered by the physician. She stated that staff do not do any additional assessment or documentation on fluid status including physician notification, unless the physician ordered strict intake and output. Another interview was conducted with the DON on (MONTH) 15, (YEAR) at 11:26 a.m. She stated that she was unable to locate any other documentation regarding the resident's hydration status or that the physician was notified. She stated that all residents are provided with water pitchers and that supplement intakes are noted on the MAR. She stated that the CNAs report changes in fluid intakes to the nurse and the nurse should follow up from there. An interview was conducted with a CNA (staff #40) on (MONTH) 15, (YEAR) at 11:50 a.m. She stated that the resident was a very poor eater and did not want to eat or drink. She stated that she would encourage him to take fluids but that he would say that he didn't want it. She stated that she would document in the computer if the resident refused food or drink and would let the nurse know. An interview was conducted with a Licensed Practical Nurse (LPN/staff #104) on (MONTH) 15, (YEAR) at 11:58 a.m. She stated that the resident was receiving med pass and health shakes. She stated that he was not on intake and output monitoring and that he was total care and on isolation, so he did not leave his room. She stated that he had no limitations which would keep him from taking fluids and would initiate drinking fluids. An interview was conducted with a CNA (staff #153) on (MONTH) 15, (YEAR) at 12:12 p.m. She stated that this resident was a room tray, so staff would bring him drinks and they had to bring the cup to his mouth. She stated that he was not drinking enough fluids and was not urinating as much. She stated that she would let the nurse know if a resident did not eat or drink well. An interview was conducted with an LPN (staff #85) with the DON (staff #107) in attendance, on (MONTH) 15, (YEAR) at 1:04 p.m. Staff #85 stated that the process for a resident with altered hydration would be to call the physician to communicate the resident's vital signs and report their assessment. She stated that most of the time the physician would give the order to encourage fluids. She stated that staff should continue to monitor the resident's vital signs and make sure the resident was not exhibiting a change in condition. Staff #85 stated that staff should document how many fluids the resident is taking in and measure intake and output. She stated that if she felt that the resident was not eating or drinking enough, then she would notify the physician. She stated that staff documented in the nurse's notes if the resident was taking in very little food/fluids and would report the information to the physician. An interview was conducted with a Registered Nurse (RN/staff #117) on (MONTH) 15, (YEAR) at 1:13 p.m. She stated that if a resident is identified as at risk for dehydration, the team would encourage fluids. Staff #117 stated that if the resident had abnormal laboratory results, staff should call the physician and possibly start intravenous hydration. She stated the resident may be placed on the nutrition at risk list, where staff discuss the resident's needs and potentially start supplements. Staff #117 stated that if the interventions were not working, staff should communicate the information to the physician. Staff #117 stated that the need and desire for a feeding tube would also be discussed and speech therapy may become involved to rule out an issue with the swallowing. An interview was conducted with the Administrator (staff #171) on (MONTH) 16, (YEAR) at 11:49 a.m. Staff #171 stated that there are no facility policies on resident assessment or physician notification. She stated that they use CMS guidelines for those areas. A follow up interview was conducted with the Administrator (staff #171) on (MONTH) 16, (YEAR). She stated that the resident was admitted with dehydration (although there was no clinical documentation of this). She stated that the resident was in a decline and was receiving maximum assistance with activities of daily living. She stated that when his labs came back on (MONTH) 15 and (MONTH) 19, (YEAR), and the resident was noted to be declining, the facility had conversations with the family. During those conversations she stated that the family was given a choice of sending the resident to the hospital or keeping him in the facility. She stated that the family chose to send the resident to the hospital, so the conversation of what to do next for the resident (i.e. hospice) did not occur. However, review of the clinical record revealed there was no documentation from (MONTH) 15 to (MONTH) 25, (YEAR) that the family was contacted regarding the resident's declining condition, until a nursing progress note on (MONTH) 26, (YEAR), when the resident's family member requested a meeting or a call from the physician for an update on the resident. A nursing progress note dated (MONTH) 27, (YEAR) included that the DON spoke with the resident's family to review current medical status, at which point the family chose for the resident to go to the emergency room for an evaluation. An interview was conducted with a registered dietician (staff #176) on (MONTH) 16, (YEAR) at 8:40 a.m. She stated that the resident was offered 2,820 cc's a day and fluids were being offered at least 13 times a day, but the resident was taking them poorly. Staff #176 stated that she was unable to determine how many cc's the resident was actually taking in. She stated that he lost 14 pounds in 2 weeks and that dehydration was a part of his overall decline. She stated that it would not have mattered how many fluids the resident was being offered, if the resident would not take the fluids. She stated that all interventions were put in place the evening of (MONTH) 16, and labs were drawn on (MONTH) 19, but that would not have given time to reflect whether the interventions were effective. She stated that communication with the physician would be important, but that each resident situation would be subjective in how soon the communication would occur. During the survey, the DON (staff #107) stated that the facility did not have a policy on resident change of condition. Review of a facility policy on hydration revealed that staff with the physician's input, will identify individuals with signs and symptoms or lab test results that might reflect existing fluid and electrolyte imbalance and will report this information promptly to the attending physician. The policy further revealed that the physician will help identify the cause of existing fluid and electrolyte imbalance or document why the resident should not be tested or evaluated. In addition, the policy noted that the physician will manage significant fluid and electrolyte imbalance and associated risks appropriately and in a timely manner. The policy also included the physician will help to monitor for the development, progression, or resolution of fluid and electrolyte imbalance in at-risk individuals and that the physician will adjust the treatments based on specific information relevant to the resident. Review of a policy regarding the Nutrition Alert Committee revealed the facility will have a systematic interdisciplinary approach to identify, track, intervene, and monitor residents that are at high risk for weight loss, dehydration and pressure ulcers. The policy also noted that all residents identified by nutrition alert criteria will be monitored to prevent weight loss and dehydration",2020-09-01
976,LIFESTREAM AT COOK HEALTH CARE,35137,11527 WEST PEORIA AVE,YOUNGTOWN,AZ,85363,2018-03-16,758,E,0,1,XQK011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, facility documentation and policy review, the facility failed to ensure that a GDR (gradual dose reduction) was attempted or that there was documentation that it was contraindicated for one resident (#81), and failed to ensure an as needed [MEDICAL CONDITION] medication which was ordered for longer than 14 days for one resident (#52) had documentation from the physician/practitioner for the rationale for its continued use. Findings include: -Resident #81 was admitted on (MONTH) 30, (YEAR), with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The [MEDICAL CONDITION] medication care plan dated (MONTH) 5, (YEAR) included the resident's use of [MEDICATION NAME] for dementia with behaviors. Interventions included administering the [MEDICAL CONDITION] medication as ordered by the physician, monitoring for side effects and effectiveness every shift and monitoring/documenting/reporting as needed any adverse reactions of [MEDICAL CONDITION] medication. Review of the clinical record revealed that [MEDICATION NAME] 200 mg one tablet by mouth two times a day continued to be ordered and administered from (MONTH) (YEAR) through (MONTH) (YEAR). According to a pharmacy review for (MONTH) 1, through (MONTH) 30, (YEAR), the resident was on [MEDICATION NAME] 200 mg every day (the order was for 200 mg twice a day) for dementia with behaviors. Per the documentation, the last GDR was done on (MONTH) 30, (YEAR). However, further review of the clinical record revealed there was no documentation that a GDR was attempted or any documentation by the physician/practitioner that it was contraindicated. Review of the behavior monitoring for (MONTH) (YEAR) revealed the resident was being monitored every shift for hoarding and taking off clothes in inappropriate places. The documentation included a check mark to indicate the behavior was being monitored, however, the documentation did not indicate whether or not the resident manifested any behaviors during the shift. Review of the progress notes for (MONTH) (YEAR) revealed no evidence that the resident's behavior had increased or escalated during this period. The physician's orders [REDACTED]. The MAR for (MONTH) (YEAR) showed that [MEDICATION NAME] 200 mg continued to be administered twice daily as ordered. According to a pharmacy review for (MONTH) 1, through (MONTH) 31, (YEAR), the resident was on [MEDICATION NAME] 200 mg by mouth twice a day for dementia. The pharmacy review further documented that the last GDR was on (MONTH) 30, (YEAR), but also documented that the GDR was contraindicated. Review of the behavior monitoring for (MONTH) (YEAR) revealed the resident was being monitored every shift for hoarding and taking off clothes in inappropriate places. The documentation included a check mark to indicate the behavior was being monitored, however, the documentation did not indicate whether or not the resident manifested any behaviors during the shift. Review of the progress notes for (MONTH) (YEAR) revealed no evidence that the resident's behavior had increased or escalated during this period. A health status note dated (MONTH) 18, (YEAR) included that the physician saw the resident and there were no new orders at this time. A physician's note dated (MONTH) 18, (YEAR) included the resident had Alzheimer's dementia and to continue medications. Current medications included [MEDICATION NAME] 200 mg 1 tablet by mouth twice a day. The documentation did not include for any dose reduction for the [MEDICATION NAME] or any indication that dose reduction was contraindicated. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Further review of the clinical record revealed there was no evidence that a GDR was attempted from (MONTH) (YEAR) through (MONTH) 24, (YEAR), or that a GDR was contraindicated. A health status note dated (MONTH) 25, (YEAR) revealed that the psychiatric nurse practitioner (NP) ordered a very slow tapering of [MEDICATION NAME]. Review of an order dated (MONTH) 25, (YEAR) revealed for [MEDICATION NAME] 150 mg by mouth every morning and [MEDICATION NAME] 200 mg at bedtime for one month until (MONTH) 24, (YEAR). The order further included that on (MONTH) 25, (YEAR), start [MEDICATION NAME] 100 mg by mouth every morning and 200 mg by mouth at bedtime. An interview with the Director of Nursing (DON/staff #107) was conducted on (MONTH) 16, (YEAR) at 1:02 p.m. She stated the pharmacist reviews medications every month and if there are recommendations, the physician will review the recommendation, agrees or disagrees and signs the form. She said that once the form is signed by the physician, it becomes an order. She stated that pharmacy recommendations will then be scanned in the electronic record. After reviewing the clinical record with staff #107, she stated that the GDR noted in the pharmacy review on (MONTH) 30, (YEAR) must have been a typographical error, because there was no order for a GDR prior to or on (MONTH) 30, found in the clinical record. Staff #107 stated that the only GDR that was done was on (MONTH) 25, (YEAR). An interview with a registered nurse (RN/staff #117) was conducted on (MONTH) 16, (YEAR) at 1:30 p.m. She stated that the pharmacist's reviews all medications every 30 days. She said if a resident is on a [MEDICAL CONDITION] medication, the pharmacist and the IDT (interdisciplinary team) determine who needs a GDR. She said that the pharmacist will then make a recommendation for a GDR to the physician, who either accepts or denies the recommendation. During an interview with the administrator (staff #171) conducted on (MONTH) 16, (YEAR) at 3:40 p.m., she stated that the facility does not have a policy regarding GDR and uses the CMS (Centers for Medicare/Medicaid Services) standards for GDRs. -Resident #52 was admitted to the facility on (MONTH) 5, (YEAR), with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set assessment dated (MONTH) 12, (YEAR) revealed the resident had a brief interview of mental status (BIMS) score of 15, which indicated that the resident was cognitively intact. The MDS did not reflect any moods or behaviors that the resident exhibited, but did include the resident was receiving anti-anxiety medication and had a [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The order did not include a stop date. Review of the (MONTH) and (MONTH) (YEAR) Medication Administration Records (MAR) revealed the above order. There was no documentation of a stop date on the MARs. Further review of the MARs showed that in (MONTH) the resident received [MEDICATION NAME] 4 times and in (MONTH) received the medication 2 times. Review of a Pharmacy report for the month of (MONTH) (YEAR) revealed the resident's medications were reviewed and there were no recommendations. Review of the clinical record revealed there was no documentation by the physician of a rationale to extend the [MEDICATION NAME] for over the 14 days. An interview was conducted with a Licensed Practical Nurse (LPN/staff #112) on (MONTH) 16, (YEAR) at 1:03 p.m. He stated there should always be a stop date for the use of a PRN psychoactive medication. Staff #112 was unable to locate a stop date for the [MEDICATION NAME]. An interview was conducted with the DON (staff #107) on (MONTH) 16, (YEAR) at 1:32 p.m. She stated that a PRN psychoactive medication can be used for 14 days and then needs to be re-evaluated for use or discontinued. She reviewed the [MEDICATION NAME] order in the electronic record and stated that the PRN [MEDICATION NAME] had been ordered on (MONTH) 21, (YEAR), and that she was unable to locate any documentation that the physician had reviewed the medication and gave a rationale to continue the medication beyond 14 days. An interview was conducted with the Administrator (staff #171) on (MONTH) 16, (YEAR) at 1:42 p.m. She stated that if the medication was being used they would look at the risks and benefits of the medication and speak with the provider. A policy regarding [MEDICAL CONDITION] medication use included if there is a need to continue PRN orders for [MEDICAL CONDITION] medications beyond 14 days, it requires that the practitioner document the rationale for the extended order and that the duration of the PRN order will be indicated in the order.",2020-09-01
977,LIFESTREAM AT COOK HEALTH CARE,35137,11527 WEST PEORIA AVE,YOUNGTOWN,AZ,85363,2019-06-06,684,E,0,1,SL3C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, and policies and procedures, the facility failed to ensure that one of two sampled residents (#7) received treatment and care to maintain positioning in the wheelchair. The deficient practice could result in residents not receiving proper positioning devices to maintain comfort and safety. Findings include: Resident #7 was admitted to the facility on (MONTH) 15, (YEAR), with [DIAGNOSES REDACTED]. A physician's progress note dated (MONTH) 1, (YEAR) documented the resident requires elevating leg rests as his current leg rests are damaged beyond repair and they are medically necessary to support patient's legs due to [MEDICAL CONDITION]. He also requires a footbox as his legs are spastic and frequently fall off the leg rests. Therefore, he requires this to contain his legs within the confines of chair due to [MEDICAL CONDITION]. A physician's orders [REDACTED]. Footbox due to legs are spastic and frequently fall off leg rests. Therefore he requires this to contain his legs within the confines of chair due to [MEDICAL CONDITION]. A care plan dated (MONTH) 5, (YEAR) included I have contractures to my arms and legs with my arms being more pronounced. My contractures in my legs and spasms leave me to dangle my legs while in the the wheelchair. When wheelchair legs are in place, I do not use them. Further review of the care plan revealed there were no approaches addressing how to maintain the resident's positioning and comfort, due to dangling his legs while in the wheelchair. A NP (nurse practitioner) note dated (MONTH) 13, (YEAR) documented .Patient is wheelchair bound and requires leg rests-patient requires elevating leg rests. Current leg rests are damaged beyond repair and they are medically necessary to support patient's legs due to [MEDICAL CONDITION] . Another NP note dated (MONTH) 12, (YEAR) documented .Patient is wheelchair bound and requires leg rests-patient requires elevating leg rests. Current leg rests are damaged beyond repair and they are medically necessary to support patient's legs due to [MEDICAL CONDITION] . Review of the clinical record revealed no documentation that the resident received the new leg rests or why the leg rests were not obtained. There was also no documentation of other interventions which were implemented to provide support to the resident's legs. A Health Status Note dated (MONTH) 1, 2019 revealed Resident evaluated by therapy and appears appropriate for a high-back wheelchair at this time. High-back wheelchair does not restrict mobility, unable to rise or transfer on own. The note did not include any reference regarding the foot rests. A quarterly MDS (Minimum Data Set) assessment dated (MONTH) 17, 2019 included the resident was rarely or never understood and had impairment on both sides to the upper and lower extremities. A podiatry note dated (MONTH) 26, 2019 included .Patient is in elevated, tilted wheelchair without foot and leg rests--legs swing freely. Difficult to work on . Review of a Rehabilitation Screening Form dated (MONTH) 22, 2019 completed by a physical therapy assistant (PTA/staff #92) revealed the following: Wheelchair screen at nursing request .Patient is appropriate for his wheelchair. The screening also included that the resident does not have footrests at the request of a family member, due to movements of his legs. However, this statement was not added to the screening until (MONTH) 6, 2019, per an interview with staff #92. An interview was conducted with a family member of the resident on (MONTH) 3, 2019 at 9:50 a.m. The resident's family member stated that when the resident was at a previous facility, he had specialized footrests on his wheelchair which his legs could be secured to so they weren't dangling. The resident's family member further stated that this facility would not allow this, as they stated it would be a restraint. Multiple observations were conducted of the resident during the morning and afternoon on (MONTH) 5, 2019. The resident was observed seated in his wheelchair in the central activity area of the facility. His legs and feet were not supported by any type of leg or foot rest. His toes on both feet were pointed toward the floor and were approximately eight inches from the floor. An observation of the resident was conducted on (MONTH) 6, 2019 at 8:52 a.m. The resident was being transported in his wheelchair from the dining room to the central activity area. There were no leg or foot rests or other supports devices in place. Both legs were observed in a flexed position with the left leg close to his chest. An observation was conducted of the resident on (MONTH) 6, 2019 at 9:31 a.m., in the central activity area. The resident was seated in his wheelchair during an exercise class. Again, his legs and feet were not supported. His right leg was flexed with his toes approximately eight inches from the floor and the left leg was flexed with his toes approximately twelve to sixteen inches from the floor. An interview was conducted with a certified nursing assistant (CNA/staff #144) on (MONTH) 6, 2019 at 9:26 a.m. Staff #144 stated that the resident has leg rests for his wheelchair, but he won't keep them on. Staff #144 stated the leg rests were in the resident's closet. Staff #144 retrieved two elevating leg rests from the back of the resident's closet in his room. The calf rest for the left leg rest was not on the leg rest. Staff #144 stated that he did not know the leg rest was broken. An interview was conducted with a licensed practical nurse (LPN/staff #78) on (MONTH) 6, 2019 at 9:36 a.m. Staff #78 stated the leg rests were not on the resident's wheelchair, because he would swing his legs out, which caused injuries. Staff #78 stated the resident did not like the leg rests. She also stated that she was not aware of the left leg rest being in disrepair. Staff #78 said the resident's care plan should reflect when a resident refused a necessary treatment or service. Staff #78 further stated that she was not aware of the (MONTH) 13 and (MONTH) 12, (YEAR) NP notes regarding the resident requiring elevating leg rests to support his legs, due to [MEDICAL CONDITION]. An interview was conducted with the Administrator (staff #27) on (MONTH) 6, 2019 at 9:50 a.m. Staff #27 stated that the resident had been screened by therapy and that the resident's family member did not want leg rests on the resident's wheelchair. An interview was conducted with a physical therapy assistant (PTA/staff #92) on (MONTH) 6, 2019 at 10:29 a.m. Staff #92 stated that she conducted the physical therapy screen on (MONTH) 22, 2019 but was not supposed to assess the resident, as she is not a physical therapist. Staff #92 stated that it was up to the physical therapist whether or not an assessment is done, after she conducts the physical therapy screen. Staff #92 stated the physical therapist was unavailable as she was on vacation. Staff #92 further stated that she spoke with the resident's family member before she did the screen on (MONTH) 22, 2019, and the resident's family member did not want the leg rests and thought this had been documented in the resident's care plan. However, she also stated that she talked to the resident's family member on (MONTH) 22, 2019, but did not document that until today (June 6, 2019). When informed that the resident's family member stated in an interview on (MONTH) 3, 2019 with a surveyor that they wanted the leg rests on the wheelchair, staff #92 said she needed a minute to think about the conversation which she had with the resident's family member. Review of the facility's policy regarding Turning and Repositioning revealed .Repositioning techniques in chair: Ensure the feet are properly supported on footrests . A facility policy titled Therapy Screen included Therapy Services will perform a screen for needed services. The IDT (interdisciplinary team) will identify services .",2020-09-01
978,HAVEN OF SHOW LOW,35139,2401 EAST HUNT STREET,SHOW LOW,AZ,85901,2017-06-29,241,D,0,1,ZQLK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, resident and staff interviews, and policy and procedures, the facility failed to promote care in a manner that enhanced two residents (#35 and #60) quality of life. Findings include: -Resident #60 was admitted on (MONTH) 17, (YEAR), with [DIAGNOSES REDACTED]. A care plan dated (MONTH) 17, (YEAR) included the resident had a self-care deficit with completing ADL's (activities of daily living), due to a stroke. An intervention included for staff to encourage the resident to participate to the fullest extent possible, with each interaction. An admission MDS (Minimum Data Set) assessment dated (MONTH) 24, (YEAR) included the resident had severe cognitive impairment. A meal observation in the main dining room was conducted on (MONTH) 26, (YEAR) at 12:51 p.m. Resident #60 was observed wearing a hospital type gown. The gown was tied in the back, however, part of the resident's upper back was exposed. On (MONTH) 28, (YEAR) at 10:00 a.m., an interview was conducted with a CNA (certified nursing assistant/staff #45), who stated he was currently providing cares to resident #60. Staff #45 stated a resident should not go to the dining room in a hospital gown. He stated that he did not know if the resident had adequate clothing. He said that staff can go to the laundry room and obtain clothing for residents, who do not have enough clothing. An interview was conducted on (MONTH) 28, (YEAR) at 10:05 a.m. with another CNA (staff #43), who stated that she had provided cares to resident #60. Staff #43 stated the resident did not have adequate clothing and that she had gone to the laundry room and got a shirt and pair of pants for the resident. An interview was conducted at 10:10 a.m. on (MONTH) 28, (YEAR), with a RN (registered nurse/staff #67), who was the resident's nurse. Staff #67 stated she was not sure if the resident had adequate clothing, but there was clothing available. She said that the resident should not be going to the dining room in a hospital gown. Staff #67 stated that if she saw a resident in the dining room in a hospital gown, she would direct a CNA to take the resident back to their room and obtain appropriate clothing. A telephone interview was conducted on (MONTH) 28, (YEAR) at 10:20 a.m., with the CNA (staff #70) who had provided cares to the resident on (MONTH) 26. Staff #70 stated she had taken resident #60 to the dining room wearing a hospital gown. Staff #70 stated she could not find a pair of pants for the resident, so she left the resident in the gown and wheeled him to the dining room. Staff #70 stated she didn't tell the nurse on the floor or the social worker that the resident needed clothing. An interview was conducted on (MONTH) 28, (YEAR) at 10:35 a.m., with the social services director (staff #54). Staff #54 stated she had not been made aware that resident #60 needed clothing. She said there were clothing items in the laundry room, which could be used for residents who need clothing. She stated that no resident should be going to the dining room in a hospital gown and that staff should let her know, so she can obtain clothing for a resident. A review of the facility policy regarding resident quality of life and dignity revealed that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. The policy further included that residents shall be encouraged and assisted to dress in their own clothes, rather than a hospital gown. -Resident #35 was admitted from the hospital to the facility on (MONTH) 22, (YEAR), with [DIAGNOSES REDACTED]. A skin care plan dated (MONTH) 23, (YEAR) included the resident had a stage III pressure injury to the coccyx area, a stage III to the right buttock, and an unstageable pressure injury to the right/left ischium. The goal was for the resident to have no complications related to skin injury through the next review date. An ADL care plan included the resident had self-care deficits, due to fatigue and shortness of breath. The goal was for the resident to maintain the current level of functioning with ADLs. An intervention included to encourage the resident with using the call light for staff assistance. A review of the admission MDS assessment dated (MONTH) 29, (YEAR) revealed a Brief Interview for Mental Status score of 12, which indicated the resident had moderate cognitive impairment. The MDS also assessed the resident to require extensive assistance of two staff members for bed mobility, transfer, dressing and personal hygiene. During a resident interview conducted on (MONTH) 26, (YEAR) at 2:08 p.m., the resident stated that at times it took staff a long time to respond when she put on her call light for assistance. The resident stated that she was waiting for the nurse to come and do her wound treatment/dressing change, as she had just gotten out of the shower and there was no dressing on her buttocks wounds. The resident stated that about five minutes ago, she asked a CNA (staff #13) to tell the nurse that the treatments to her buttock wounds needed to be done. Additional interviews were conducted on (MONTH) 26, (YEAR), between 2:09 p.m. and 3:09 p.m., with resident #35. The resident stated that staff had not attended to her request for wound treatments to be done. An interview was conducted on (MONTH) 26, (YEAR) at 3:10 p.m., with staff #13. Staff #13 stated that she gave the resident a shower and the wound dressings were removed during the shower. Staff #13 stated that she put the resident in bed around 2:03 p.m., and then told the Licensed Practical Nurse (staff #3) that the resident needed her wound treatments done. Staff #13 confirmed that the resident was still waiting on staff #3 to provide the wound treatments and that staff #3 was very busy attending to other residents. An interview was conducted with staff #3 on (MONTH) 26, (YEAR) at 3:15 p.m. Staff #3 confirmed that she was aware of resident #35's request for wound treatment, but had been busy caring for other residents. Following the interview, staff #3 provided the wound treatments to the resident, which was approximately one hour after the resident requested to have the care provided. An interview was conducted on (MONTH) 29, (YEAR) at 8:40 a.m., with the Assistant Director of Nursing (ADON/staff #52). The ADON stated that she expected nursing staff would request help from the ADON or Unit Manager if they did not have time to attend to residents' needs in a timely manner. The ADON stated resident #35 should not have waited more than five minutes, after she requested nursing care.",2020-09-01
979,HAVEN OF SHOW LOW,35139,2401 EAST HUNT STREET,SHOW LOW,AZ,85901,2017-06-29,278,D,0,1,ZQLK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure MDS (Minimum Data Set) assessments for one resident (#32) were accurately coded to reflect that hospice services were being provided. Findings include: Resident #32 was admitted on (MONTH) 20, 2014, with [DIAGNOSES REDACTED]. A review of the clinical record revealed a physician's orders [REDACTED]. Further review of the clinical record revealed the resident was continuing to utilize hospice services through (MONTH) (YEAR). However, review of a quarterly MDS assessment dated (MONTH) 31, (YEAR) and a quarterly MDS assessment dated (MONTH) 2, (YEAR), revealed that in Section O. (Special Treatments and Programs) the resident was not coded as receiving hospice services. An interview was conducted with the MDS coordinator (staff #55) on (MONTH) 28, (YEAR) at 12:05 p.m. Staff #55 stated that resident #32 had been on continuous hospice services since (MONTH) (YEAR). Upon review of the resident's MDS history, staff #55 stated that the MDS assessments dated (MONTH) 31, (YEAR) and (MONTH) 2, (YEAR) were coded inaccurately and should have documented that the resident was receiving hospice services. Staff #55 further stated that their policy was the RAI manual for the MDS coding. A review of the RAI manual 3.0 revealed that the MDS should be coded for hospice services for residents identified as being in a hospice program for terminally ill persons, where an array of services are provided for the palliation and management of terminal illness and related conditions.",2020-09-01
980,HAVEN OF SHOW LOW,35139,2401 EAST HUNT STREET,SHOW LOW,AZ,85901,2017-06-29,281,B,0,1,ZQLK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and policy review, the facility failed to develop an interim care plan for one resident (#191) who was receiving psychoactive medications. Findings include: Resident #191 was admitted on (MONTH) 20, (YEAR), with [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed physician's orders [REDACTED]. -June 20, (YEAR): [MEDICATION NAME] (an anti-anxiety medication) 2 mg (milligrams) every 8 hours for anxiety -June 21, (YEAR): Duloxetine (an anti-depressant) 60 mg at bedtime for depression -June 21, (YEAR): Trazadone (an anti-depressant) 50 mg every 24 hours at bedtime, as needed for [MEDICAL CONDITION] -June 21, (YEAR): Buproprion (an anti-depressant) 100 mg twice a day for depression However, review of the resident's initial care plans dated (MONTH) 20, (YEAR), revealed there was no interim care plan which had been developed to address the resident's needs related to depression and anxiety, and the use of psychoactive medications. An interview was conducted on (MONTH) 27, (YEAR) at 3:15 p.m., with the DON (Director of Nursing/staff #5). Staff #5 stated that interim/initial care plans should be developed at the time of admission for the use and monitoring of psychoactive medications. Staff #5 reviewed the resident's clinical record and stated that the interim/initial care plans did not reflect the administration and monitoring for psychoactive medications. Staff #5 stated that the nurse completing the admission or the nurse taking the physician's orders [REDACTED]. Staff #5 stated that the interim/initial care plans were to be in place until the resident's comprehensive assessment was completed. A policy regarding preliminary/interim care plans included documentation that a preliminary plan of care shall be developed for each resident within 24 hours of admission to meet the resident's immediate care needs.",2020-09-01
981,HAVEN OF SHOW LOW,35139,2401 EAST HUNT STREET,SHOW LOW,AZ,85901,2017-06-29,312,D,0,1,ZQLK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review and staff interviews, the facility failed to ensure one resident (#70) received appropriate assistance with eating. Findings include: Resident #70 was admitted to the facility on (MONTH) 8, (YEAR), with [DIAGNOSES REDACTED]. A review of the MDS (Minimum Data Set) assessment dated (MONTH) 24, (YEAR) revealed the resident had severe cognitive impairment. The MDS also included the resident required extensive assistance of one staff member for eating. An ADL (activities of daily living) care plan identified that the resident was at risk for nutritional problems, due to a variation with meal intake. The care plan also included that the resident had experienced significant weight loss. An intervention included to encourage the resident with oral food intake. Although, the MDS identified extensive assistance with eating, it was not reflected in the care plan. An observation was conducted on (MONTH) 27, (YEAR) at 1:05 p.m., in the main dining room. Resident #70 was seated at the assisted dining table. At this time, three bowels containing pureed food were placed on the table in front of resident #70. A CNA (staff #3) sat between resident #70 and another resident at the assisted dining table. Staff #3 briefly assisted the resident with eating, and then placed a spoon in the resident's right hand. Staff #3 was sitting on a stool with wheels and then wheeled herself to another assisted dining table. Between 1:06 p.m. and 1:10 p.m., resident #70 was observed to make multiple attempts to scoop food out of the bowels, however, she was unable to scoop up the food and the spoon kept landing on the table. The resident also placed the spoon without food into her mouth, multiple times. Staff #3 continued to assist other residents at another table. At 1:11 p.m., resident #70 tried four times to scoop up food onto the spoon, but was unsuccessful. The resident also placed the spoon without any food into her mouth multiple times. At 1:13 p.m., the resident closed her eyes and appeared to be asleep. At 1:14 p.m., staff #3 returned to the table and sat by resident #70. Staff #3 picked up resident #70's spoon, filled it with food, then woke up the resident. With staff #3's encouragement and assistance, the resident opened her mouth and ate spoonfuls of the food. At 1:19 p.m., staff #3 placed the spoon in resident #70's right hand and encouraged the resident to feed herself. Staff #3 then left the table and the resident attempted to scoop of food onto the spoon multiple times, but was unsuccessful. The resident also placed a spoon without food into her mouth. The resident made no further attempts to feed herself, nor did any other staff attempt to assist the resident. An interview was conducted on (MONTH) 27, (YEAR) at 2:57 p.m., with staff #3. Staff #3 stated there were only two CNAs helping nine residents who were at three different assisted dining tables. CNA #3 stated that resident #70 needed to be fed. Staff #3 stated that she periodically gave resident #70 a spoonful of food, but then had to assist other residents with eating. She stated there was not sufficient staff to appropriately assist residents with eating and acknowledged that sometimes residents got tired of waiting to be fed. On (MONTH) 28, (YEAR) at 8:19 a.m., the Dietary Manager (staff #66) was interviewed. She stated the CNA was supposed to stay with resident #70 consistently through the meal to make sure she ate her food. She stated there should have been three staff assisting residents with eating, during meal time. On (MONTH) 28, (YEAR), the Registered Dietitian (RD) was interviewed who stated that resident #70 was not getting the appropriate assistance, as she was unable to scoop up her food, without assistance from staff. The RD stated maybe the resident would eat more food with the appropriate assistance in place. She stated resident #70's care plan was updated and now reflected that she required 1:1 assistance with eating.",2020-09-01
982,HAVEN OF SHOW LOW,35139,2401 EAST HUNT STREET,SHOW LOW,AZ,85901,2017-06-29,323,G,1,1,ZQLK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, resident and staff interviews, facility documentation and policies and procedures, the facility failed to ensure the environment remained as free from accident hazards as is possible, by failing to ensure that one resident (#35) was transferred safely, resulting in a fall with injury. Findings include: Resident #35 was admitted to the facility on (MONTH) 22, (YEAR), with [DIAGNOSES REDACTED]. Review of a nurse report sheet dated (MONTH) 22, (YEAR) revealed the resident had bilateral lower extremity weakness and was a two person assist with transfers. The admission nursing assessment dated (MONTH) 23, (YEAR) indicated the resident required extensive assistance of two staff members with transfers. An interim care plan dated (MONTH) 23, (YEAR) indicated that the resident was at risk for falls. The goal was to have no falls through the next review. One of the interventions included for staff to assist with transfers. The care plan did not indicate how many staff were required to assist with transfers, nor the resident's weight bearing status. Review of the physical therapy plan of care dated (MONTH) 24, (YEAR) revealed the resident required total assistance (100% assistance) with sit to stand transfers and maximum assistance (76-99% assistance) with transfers from bed to chair. A fall risk evaluation dated (MONTH) 25, (YEAR) identified that the resident was at moderate risk for falls. The assessment noted the resident required hands-on assistance to move from place to place. Review of the occupational therapy plan of care dated (MONTH) 25, (YEAR) revealed the resident was dependent on staff for transfers and that the helper does all of the effort. The documentation further included that the resident does none of the effort to complete an activity and that two or more helpers are required to complete an activity. Review of a nursing note written at 12:40 p.m. on (MONTH) 26, (YEAR), revealed the resident fell during a Certified Nursing Assistant (CNA) transfer. The resident denied pain or discomfort. A nursing note dated (MONTH) 26, (YEAR) at 12:40 p.m., revealed the resident was complaining of pain in her upper arms and chest. The physician was notified and a chest X-ray was ordered. Review of the X-ray report revealed the resident had an acute (new) fracture of the anterlolateral segment of the left fourth rib. A late entry Inter-Disciplinary Team (IDT) fall review dated (MONTH) 27, (YEAR) revealed the resident had an assisted fall, with a fracture of the left rib. The note indicated that the resident was now to be transferred by mechanical lift. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 29, (YEAR) revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The resident was also assessed to require extensive assistance of two persons with transfers. A history and physical completed by the resident's physician dated (MONTH) 29, (YEAR), indicated the resident had a history of [REDACTED]. The note included that the resident was informed by her neurosurgeon that she would likely not walk again. Review of the facility's investigation regarding the fall revealed the resident had been lowered to the floor by two CNA's (staff #25 and staff #31), who were attempting to transfer her from the wheelchair to the bed. The incident occurred around 12:40 p.m. on (MONTH) 26, (YEAR). Around 4:30 p.m., the resident complained of bilateral arm and chest pain. An X-ray showed that the resident had sustained a single rib fracture. The investigation further included that staff #25 was approached by staff #31 to help transfer the resident from her wheelchair to the bed. The two CNAs positioned the resident's wheelchair beside the bed and then hooked their arms under the resident's armpits, grabbed her pants and lifted her up. The two CNAs attempted to transfer the resident to the bed, but her weight became unbearable. They attempted to put her back into her wheelchair, but were unsuccessful, and had to lower the resident to her knees. The CNAs then placed their arms under the resident's armpits, grabbed her pants and were able to get her into bed. According to the investigation, neither CNA had used a gait belt during the transfer. The report included that the resident was appropriate for a two person lift per therapy, however, the CNA's should have used a gait belt. An interview was conducted with resident #35 at 11:30 a.m. on (MONTH) 27, (YEAR). She said that prior to coming to the facility, she had surgery and is now paralyzed from her chest area down. She stated that she was dropped by two CNAs, as they were in a hurry. She said that it was the first time she had received care from them. She stated that they did not use gait belts and that prior to this event, all of the staff have used gait belts. She said that the fall caused a rib fracture and that it caused a good amount of pain. She stated that she was trying to help them get her up, by using her arms. She said that one of the CNAs was very tiny and she did not think she was strong enough to lift a person. During an interview with a Certified Occupational Therapist Assistant (staff #96) at 11:55 a.m. on (MONTH) 27, (YEAR), she stated that when a resident is admitted , the CNA's know how to transfer the resident based on what the nurses tell them and the nurses know based on their assessment. She said that the CNAs are educated on how to safely perform transfers. She said that therapy evaluations are done either on the same day of admission or within 24 hours. Staff #96 stated that as part of therapy's evaluation, there might be a recommendation for a Hoyer lift. She reviewed the therapy notes and indicated that while most of the notes indicated that the resident required total assistance, one of them indicated that the resident needed extensive assist. She said based off of this, an extensive two person assist without a Hoyer would have been appropriate. She said however, that gait belts should be used with all transfers. She said the CNAs should have them on at all times. She said that this resident is paralyzed and cannot provide much assistance, when being transferred. She stated that the CNA's should have used one hand on the gait belt and one under the shoulder to properly lift the resident. Staff #96 stated that the way that they moved the resident, could have contributed to her rib fracture in that the emphasis would have been more on her shoulders, which could cause extra movement and injury. An interview was conducted with a Licensed Practical Nurse (LPN/staff #3) at 12:55 p.m. on (MONTH) 27, (YEAR). She said the standard practice for CNAs to have a gait belt on them and that they use them with all transfers. An interview was conducted with a CNA (staff #71) at 1:00 p.m. on (MONTH) 27, (YEAR). She stated that she always uses a gait belt when transferring or ambulating a resident. She said that she does a lot of the training in the facility regarding gait belts and she always educates the CNAs to use gait belts with all transfers. She said that regarding this incident, the CNAs should have used a gait belt during the transfer. During an interview with a CNA (staff #43) at 1:30 p.m. on (MONTH) 27, (YEAR), she stated that she uses a gait belt every time she performs a transfer with a resident. She said that the gait belt is part of her uniform and should be in her possession at all times. In an interview with a nurse consultant (staff #113) at 2:24 p.m. on (MONTH) 27, (YEAR), she stated that the facility has a policy that mentions gait belts, but there is no specific policy regarding gait belt use. An interview was conducted on (MONTH) 28, (YEAR) at at 8 a.m., with one of the CNAs (staff #25) involved in this incident. Staff #25 stated that it was the first time working with this resident. She said they put their arms underneath her armpits and while they were trying to get her to bed, her knees buckled and they realized that they were bearing all of her weight, so they assisted the resident to her knees. She stated that they were able to get the resident back up off of the ground and into the bed. Several attempts were made via telephone to interview CNA (staff #31), however, no returned call was received. In an interview with the Director of Nursing (DON/staff #5) at 8:30 a.m. on (MONTH) 28, (YEAR), she stated the issue with this incident was that the two CNAs did not use gait belts when they should have. She said the resident was not a Hoyer lift at the time of the incident and so the CNAs were appropriate with the amount of assistance provided, however, they should have used gait belts for the safety of the resident and themselves. She said that the expectation is that staff have gait belts on their person at all times. She said that when a CNA is hired, they are given a gait belt and are taught to use gait belts with all transfers. The DON further stated that one of the CNAs (staff #31) was a small individual and likely was not strong enough to lift the resident, and this may have contributed to the issue. Another interview was conducted with staff #25 at 12:30 p.m. on (MONTH) 28, (YEAR). She stated that during the incident, they did not use a gait belt and that neither of them had gait belts on them at the time of the incident. She said that she had not been given one and did not know how to obtain one. She stated that she was taught to always use gait belts during transfers. During an interview with the ADON (staff #52) at 12:35 p.m. on (MONTH) 28, (YEAR), she stated that all CNAs receive training on gait belts and that part of the training also includes telling the staff that they need to use gait belts for all transfers. Review of the facility's policy regarding safe lifting and movement of residents revealed that in order to protect the safety and well-being of staff and residents and to promote quality care, the facility uses appropriate techniques and devices to lift and move residents. The policy included that resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and movement of residents. The policy noted that manual lifting of residents shall be eliminated when feasible. Also, nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' need for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan, which will include the resident's preferences for assistance, resident's mobility, and weight bearing ability. The policy further included that staff responsible for direct resident care will be trained in the use of manual lifting devices such as gait/transfer belts and mechanical lifting devices. A policy regarding safety and supervision of residents included that the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The policy included that employees shall be trained and in-serviced on potential accident hazards and try to prevent avoidable accidents. Also noted was that the facility will implement interventions to reduce accident risks and hazards, provide training, as necessary, and ensure that interventions are implemented.",2020-09-01
983,HAVEN OF SHOW LOW,35139,2401 EAST HUNT STREET,SHOW LOW,AZ,85901,2018-09-19,607,D,0,1,4BUB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, staff interviews, and policy, the facility failed to implement its policy regarding reporting an allegation of misappropriation of resident property for one resident (#46). Findings include: Resident #46 was admitted on (MONTH) 22, (YEAR) with [DIAGNOSES REDACTED]. Review of the closed record revealed a hospital physician's clinical report dated (MONTH) 21, (YEAR) (prior to admission) that had been uploaded to the resident's clinical record on (MONTH) 22, (YEAR). The report included that a hospital case manager had referred resident #46 to APS (Adult Protective Services) because the hospital had recommended long term care for the resident, and the resident's responsible family member had insisted that the resident be released to her home. An admission MDS (Minimum Data Set) assessment dated (MONTH) 29, (YEAR) included that the resident had a BIMS (Brief Interview for Mental Status) score of 3, which indicated that the resident had severely impaired cognition. A health status note dated (MONTH) 22, (YEAR) at 10:05 a.m. included that the resident had been discharged home with the resident's responsible family member. A social services progress note dated (MONTH) 22, (YEAR) at 7:24 p.m. revealed that on (MONTH) 22, (YEAR) at 9:45 a.m., the social worker had been notified by an outside agency that the resident had a trust, and an undisclosed amount of money, and that it was possible that the responsible family member is abusing funds. The note included the statement: APS may or may not be called. Review of the record did not reveal the allegation was reported to the administrator or to APS. An interview was conducted on (MONTH) 18, (YEAR) at 12:13 p.m. with a resident relations manager (staff #35) and a corporate staff (staff #69). Staff #35 stated that if she had a suspicion of abuse, including a suspicion that a family member was misappropriating a resident's money, she would report her suspicion to the administrator right away, and then notify the Director of Nursing, APS, and the police. Staff #35 stated that she was suspicious that the responsible family member of resident #46 was taking her money because she had been informed by an outside source on the day that the resident was discharged that the family member may be stealing her money. Staff #35 stated that she did not remember who the outside source was. Staff #35 stated that she did notify APS and the administrator of her suspicion on the day that the resident was discharged . Staff #35 also stated that although I didn't know if the (family member) was stealing or not she felt it was safe to discharge the resident home with that family member. An interview was conducted on (MONTH) 18 at 12:26 p.m. with the Administrator (staff #42). The Administrator stated that staff are to report allegations of financial misappropriation immediately to him, and that he would report the allegation to APS and the police within 2 hours. The Administrator stated that no allegation regarding misappropriation of funds by a family member for this resident had been reported to him. During an interview conducted on (MONTH) 18, (YEAR) at 1:15 p.m. with staff #35, the staff referred to the hospital physician's clinical report dated (MONTH) 21, (YEAR) and stated that because the hospital case manager had notified APS that the resident's family member had refused to place her in a long term care facility, she believed that the family member may be taking her money. Staff #35 stated that when she notified APS on (MONTH) 22, (YEAR) she was informed that there was an open case regarding this resident and that nothing more had to be done. On (MONTH) 18, (YEAR) at 1:35 p.m. an e-mail record from APS was provided that was dated (MONTH) 18, (YEAR). The e-mail from APS confirmed that staff #35 had contacted APS on (MONTH) 22, (YEAR) regarding resident #46 and that at the time there was an ongoing APS investigation. The e-mail did not include any details regarding the investigation, or any additional information that the investigation included an allegation of misappropriation of resident funds. The facility's policy titled Abuse Prohibition Program included a policy statement that the facility prohibits any abuse of residents and that potential abusers can be residents, employees or family members. The policy included that if abuse is suspected, the Executive Director will be notified, and the Executive Director will notify the State Survey Agency, APS and Law enforcement (where applicable). Suspected abuse will be reported in accordance with timeframes and standards required by the Department of Health Services.",2020-09-01
984,HAVEN OF SHOW LOW,35139,2401 EAST HUNT STREET,SHOW LOW,AZ,85901,2018-09-19,609,D,0,1,4BUB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record review, staff interviews, and policy, the facility failed to ensure that an allegation of misappropriation of one resident's (#46) property was reported the administrator, the State agency, and to Adult Protective Services (APS). Findings include: Resident #46 was admitted on (MONTH) 22, (YEAR) with [DIAGNOSES REDACTED]. Review of the clinical record revealed a hospital physician's clinical report dated (MONTH) 21, (YEAR) (prior to admission) that had been uploaded to the resident's clinical record on (MONTH) 22, (YEAR). The report included that a hospital case manager had referred resident #46 to APS because the hospital had recommended long term care for the resident, and the resident's responsible family member had insisted that the resident be released to her home. An admission MDS (Minimum Data Set) assessment dated (MONTH) 29, (YEAR) revealed a BIMS (Brief Interview for Mental Status) score of 3, which indicated the resident had severely impaired cognition. A health status note dated (MONTH) 22, (YEAR) at 10:05 a.m. revealed the resident had been discharged home with the resident's responsible family member. A social services progress note dated (MONTH) 22, (YEAR) at 7:24 p.m. included that on (MONTH) 22, (YEAR) at 9:45 a.m. that the social worker had been notified by an outside agency that the resident had a trust, and an undisclosed amount of money, and that it was possible that the responsible family member is abusing funds. The note included the statement: APS may or may not be called. Review of the clinical record did not reveal any documented evidence that an allegation regarding the resident's family member may have been abusing her funds was reported to the administrator or to APS. An interview was conducted on (MONTH) 18, (YEAR) at 12:13 p.m. with a resident relations manager (staff #35) and a corporate staff (staff #69). Staff #35 stated that if she had a suspicion of abuse, including a suspicion that a family member was misappropriating money from a resident, she would report her suspicion to the administrator right away, then notify the Director of Nursing, APS, and the police. Staff #35 stated that she was suspicious that the responsible family member of resident #46 was taking her money because she had been informed by an outside source on the day that the resident was discharged that the family member may be stealing her money. Staff #35 stated that she did not remember who the outside source was. Staff #35 stated that she did notify APS and the administrator of her suspicion on the day that the resident was discharged . Staff #35 also stated that although I didn't know if the (family member) was stealing or not she felt it was safe to discharge the resident home with that family member. An interview was conducted on (MONTH) 18 at 12:26 p.m. with the Administrator (staff #42). The Administrator stated that staff are to report allegations of financial misappropriation immediately to him, and that he would report the allegation to APS and the police within 2 hours. The Administrator stated that no allegation regarding misappropriation of funds by a family member for this resident had been reported to him. During an interview conducted on (MONTH) 18, (YEAR) at 1:15 p.m. with staff #35, the staff referred to the hospital physician's clinical report dated (MONTH) 21, (YEAR) and stated that because the hospital case manager had notified APS that the resident's family member had refused to place her in a long term care facility, she believed that the family member may be taking her money. Staff #35 stated that when she notified APS on (MONTH) 22, (YEAR) she was informed that there was an open case regarding this resident and that nothing more had to be done. On (MONTH) 18, (YEAR) at 1:35 p.m. an e-mail record from APS was provided that was dated (MONTH) 18, (YEAR). The e-mail from APS confirmed that staff #35 had contacted APS on (MONTH) 22, (YEAR) regarding resident #46 and that at the time there was an ongoing APS investigation. The e-mail did not include any details regarding the investigation, or any additional information that the investigation included an allegation of misappropriation of resident funds. The facility's policy titled Abuse Prohibition Program included a policy statement that the facility prohibits any abuse of residents and that potential abusers can be residents, employees or family members. The policy included that if abuse is suspected, the Executive Director will be notified, and the Executive Director will notify the State Survey Agency, APS and Law enforcement (where applicable). Suspected abuse will be reported in accordance with timeframes and standards required by the Department of Health Services.",2020-09-01
985,HAVEN OF SHOW LOW,35139,2401 EAST HUNT STREET,SHOW LOW,AZ,85901,2018-09-19,640,E,0,1,4BUB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that one resident's (#2) discharge MDS (Minimum Data Set) assessment was transmitted to the CMS (Centers for Medicare and Medicaid Services) system. Findings include: Resident #2 was admitted to the facility on (MONTH) 19, (YEAR) with [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed the resident was discharged from the facility on (MONTH) 17, (YEAR). Further review of the resident's clinical record revealed that the discharge MDS assessment was completed but not submitted to CMS. An interview was conducted with the MDS coordinator (staff #46) on (MONTH) 19, (YEAR) at 1:27 p.m. The MDS coordinator stated that the staff person who completed the discharge MDS assessment never submitted the assessment and that it should have been submitted by (MONTH) 4, (YEAR). The MDS coordinator stated that she would submit the discharge MDS assessment today. The MDS coordinator further stated that the facility did not have a specific policy as to when the assessment should have been submitted as the facility follows the RAI manual. Review of the RAI manual revealed the discharge MDS completion date which is the date the Registered Nurse certifies the assessment is complete with her signature (Z0500B) must be no later than 14 days after the ARD (Assessment Reference Date). The manual also included the discharge assessment must be transmitted within 14 days of the MDS assessment completion date (Z0500B + 14 days) to the CMS (Centers for Medicare & Medicaid Services) system.",2020-09-01
986,HAVEN OF SHOW LOW,35139,2401 EAST HUNT STREET,SHOW LOW,AZ,85901,2018-09-19,641,E,0,1,4BUB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, policy, and the RAI (Resident Assessment Instrument) manual, the facility failed to ensure two residents' (#26 and #46) MDS (Minimum Data Set) assessments were accurate. Findings include: -Resident #46 was admitted on (MONTH) 22, (YEAR) with [DIAGNOSES REDACTED]. An admission MDS assessment dated (MONTH) 29, (YEAR) revealed a BIMS (Brief Interview for Mental Status) score of 3, which indicated the resident had severely impaired cognition. A social services discharge summary dated (MONTH) 19, (YEAR) revealed the social worker had discussed the resident's discharge with her responsible family member and that the resident was going to be discharged to her home on (MONTH) 22, (YEAR). Review of a health status note dated (MONTH) 22, (YEAR) revealed the resident was discharged home with family. However, review of the Discharge MDS assessment dated (MONTH) 22, (YEAR), revealed the resident was discharged to an acute hospital. An interview was conducted on (MONTH) 18, (YEAR) at 2:40 p.m. with the MDS Nurse/Care Coordinator (staff #46). Staff #46 stated that she utilizes the RAI manual and reviews the clinical record, reviews facility documentation, and conducts observations to obtain information for the MDS assessments. The MDS Coordinator stated that she obtains discharge information from social services and the discharge meetings. The MDS Coordinator stated that the discharge MDS assessment for this resident was an error. She stated the resident was discharged to her home. -Resident #26 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the care plan dated 2/14/18 revealed the resident had a communication problem related to her dominant language. The goal was to restore communication losses by communicating with others, understanding others, and being involved in every day decision making. The interventions were for the staff to anticipate the resident's needs, provide a safe environment, and to use a translator for communication. Review of the admission MDS assessment dated [DATE] revealed the resident needed or wanted an interpreter. The MDS assessment included the resident was able to clearly understand others and was able to make self understood. However, the section regarding cognitive patterns was coded the resident was rarely or never understood by others. A review of the quarterly MDS assessment dated [DATE] revealed the resident did not need an interpreter. The assessment included the resident was able to clearly understand others and was able to make self understood. However, the section of the assessment regarding cognitive patterns was blank. The quarterly MDS assessment dated [DATE] revealed the resident did not need an interpreter and was able to clearly understand others and able to make self understood. However, the assessment also included the resident was rarely or never understood by others for cognitive patterns. A psychiatric evaluation dated 8/29/2018 revealed the resident speaks a different language and required a staff member to be present to assist with interpretation throughout the entire appointment. Review of a physician's progress notes dated 9/18/2018 revealed the resident was not having difficulty with her speech or displaying discomfort. It also revealed that she was alert and oriented x 3 and appeared to be in a calm mood. An interview was conducted on 09/18/18 at 02:45 PM with a Licensed Practical Nurse (LPN/staff #55). The nurse stated that the resident understands and speaks very little English. The LPN also stated that in order to do a thorough assessment, she utilizes an interpreter for translation. During an interview conducted on 09/19/18 at 08:50 AM with an Occupational Therapist (staff #69), the therapist stated that when he is working with the resident and the resident is unable to be understood, he asks for an interpreter to clarify the resident's needs. An interview was conducted on 09/19/18 at 11:05 AM with the MDS coordinator (staff #46). The MDS coordinator stated that she does not speak or understand the resident's dominant language. She also stated that the resident answers questions exclusively in her dominant language. The coordinator stated that an interpreter should be used when interviewing this resident. Staff #46 acknowledged that the assessment coded that the resident is rarely or is never understood by others is a contradiction. During an interview conducted with the Director of Nursing (DON/staff #9) on 09/19/18 at 01:20 PM, the DON stated that the expectation is that the MDS assessments are accurate and that a very high priority is given to the MDS assessments. The RAI manual instructs to review the medical record including the discharge plan and discharge orders for documentation of the discharge location. The RAI manual also instructs to ask the resident if he or she needs or wants an interpreter to communicate with a doctor or health care staff. If the resident is unable to respond, a family member or significant other should be asked. If neither source is available, review the record for evidence of a need for an interpreter. If an interpreter is wanted or needed, ask for the preferred language. The RAI manual instructs to assess how the resident makes self understood and the resident's ability to understand others using the resident's preferred language. Consult with direct care staff over all shifts and observe the resident's interactions with others. The RAI manual further instructs to refer to the Language section to determine if the resident needs or wants an interpreter. If the resident needs or wants an interpreter, complete the interview for cognitive patterns with an interpreter. The RAI manual also included that the importance of accurately completing and submitting the MDS assessment cannot be over emphasized. The facility's policy and procedure titled Resident Assessment revealed It is the policy of this facility to ensure that the resident assessment accurately reflect the resident's status.",2020-09-01
987,HAVEN OF SHOW LOW,35139,2401 EAST HUNT STREET,SHOW LOW,AZ,85901,2018-09-19,684,D,1,1,4BUB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, and policy, the facility failed to ensure two residents (#47 and #48) received treatment and care in accordance with professional standards of practice. Findings include: Resident #47 was admitted to the facility on (MONTH) 17, (YEAR) from the hospital with [DIAGNOSES REDACTED]. Review of the clinical record revealed hospital orders for admission to the facility dated (MONTH) 17, (YEAR), for [MEDICATION NAME] (antibiotic) 600 mg by mouth twice a day. However, review of the physician's orders did not reveal an order for [REDACTED]. A care plan initiated on (MONTH) 20, (YEAR), included the resident was on Antibiotic Therapy ([MEDICATION NAME]) related to osteo[DIAGNOSES REDACTED] of the right foot with an open area. Review of the Medication Administration Record for (MONTH) (YEAR), revealed the resident was not administered [MEDICATION NAME] until (MONTH) 21, (YEAR). During an interview conducted on (MONTH) 18, (YEAR) at 10:37 a.m., with the Assistant Director of Nursing (staff #41), she stated that when a resident is admitted to the facility, the medical records staff transcribes the orders received from the hospital into the electronic medical record. She also stated once entered into the electronic record, the nurses are to verify the orders for accuracy. She stated that this resident was admitted with two sets of orders from the hospital, one set printed and one set hand written. Staff #41 stated that except for the [MEDICATION NAME] order, the two sets of orders were identical. Staff #41 further stated that the medical records staff transcribed the printed orders which did not include the [MEDICATION NAME]. She stated the discrepancy was not discovered until the following Monday morning when an audit was conducted of the orders. She also stated that as soon as the problem was identified, the physician was notified and an order was obtained. During an interview conducted on (MONTH) 18, (YEAR) at 10:51 a.m. with the medical records (staff #19), she stated that when the resident was admitted , she received paperwork with two sets of orders, one printed and one written. She stated that she had used the printed orders to transcribe the orders into the computer system as she thought the orders were identical. She further stated that the resident was admitted Friday evening and that the discrepancy was not discovered until Monday when the Assistant Director of Nursing reviewed the records. The facility's policy on Medication Orders revealed that a current list of orders must be maintained in the clinical record of each resident and that the orders must be written and maintained in chronological order. Additionally the Medication Administration Policy requires that medications are administered in accordance with written orders. -Resident #48 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident resided on the skilled nursing unit. A physician's order dated 5/19/18 revealed an order for [REDACTED]. Review of a care plan dated 5/19/18 revealed the resident had altered cardiovascular status related to hypertension. The goal was for the resident to be free from signs/symptoms of complications of cardiac problems. Interventions included for Vital Signs as ordered and to notify the physician of any abnormal readings. The admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. A physician's order dated 6/4/18, revealed an order for [REDACTED]. Review of the Weights and Vitals Summary dated 6/1/18 to 6/18/18 included the following: 1) 6/1/18 revealed the resident's blood pressure (B/P) was 174/95 2) 6/3/18 revealed the resident's blood pressure (B/P) was 144/68 3) 6/4/18 revealed the resident's blood pressure (B/P) was 160/100 4) 6/7/18 revealed the resident's blood pressure was 156/81 5) 6/9/18 revealed the resident's blood pressure was 166/92 6) 6/10/18 revealed the resident's blood pressure was 147/89 7) 6/16/18 revealed the resident's blood pressure was 162/112 8) 6/18/18 revealed the resident's blood pressure was 144/79 The daily skilled nursing notes dated 6/19/18 and 6/21/18 revealed the Blood pressure from 6/18/18 (B/P 144/79). Review of the clinical record did not reveal blood pressures were consistently obtained every shift. A Nurse Practitioner (NP) progress note dated 6/20/18 revealed the NP was asked to see the resident due to abnormal blood pressures. The note included that the resident's blood pressure was 144/79. The note further included the ACE inhibitor was maxed out and that the resident will be started on a low dose calcium channel blocker to try to get better control of his blood pressure. Review of a physician's order dated 6/21/18 revealed an order to increase the [MEDICATION NAME] to 40 mg daily. During an interview conducted with a Registered nurse (RN/staff #6) on 9/19/18 at 11:58 AM, the RN stated that vital signs are obtained on every shift for residents residing on the skilled unit. An interview was conducted with a Certified Nursing Assistant (staff #54) on 09/19/18 at 12:10 PM. She stated that vital signs are obtained every shift. Staff #54 also stated that a nurse may request additional vital signs for a resident that has a change in condition. During an interview conducted with a RN (staff #55) on 09/19/18 at 12:20 PM, she stated that vital signs are obtained on every shift for all residents. An interview was conducted with the Director of Nursing (DON/staff #9) and the Clinical Compliance Director (staff #171) on 09/19/18 at 1:30 PM. Staff #9 stated that the expectation is that vital signs be obtained every shift and that current vital signs are documented in the skilled notes. Staff #9 stated that if there was a resident with an abnormal blood pressure, she would expect staff to do vital signs every shift and chart them. The DON also stated that they do not have a protocol for vital signs. The facility's policy regarding blood pressure revealed hypertension is usually defined as blood pressures over 140/90 and hypertension should be reported to the physician. If a resident has a hypertensive reading, staff should record several readings taken at different times of the day. Staff should note any pertinent medications and/or recent changes of condition when reporting to the physician.",2020-09-01
988,HAVEN OF SHOW LOW,35139,2401 EAST HUNT STREET,SHOW LOW,AZ,85901,2018-09-19,685,E,0,1,4BUB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy, the facility failed to make an audiology appointment ordered by the physician for one resident (#23). Findings include: Resident #23 was readmitted on (MONTH) 14, (YEAR) with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 21, (YEAR), revealed the resident had a Brief Interview of Mental Status (BIMS) score of 14 indicating the resident was cognitively intact. The assessment also included the resident had some difficulty hearing and does not use hearing aids. Review of a physician's progress note dated (MONTH) 5, (YEAR) revealed the resident has difficulty hearing in the left ear. Review of a physician's orders [REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 21, (YEAR) revealed the resident had a Brief Interview of Mental Status (BIMS) score of 14 indicating the resident was cognitively intact and that the resident had some difficulty hearing and does not use hearing aids. The current care plan revealed the resident had a communication problem related to a hearing deficit. One of the interventions included referring to Audiology for a hearing consult as ordered. A review of the clinical record did not reveal the resident had an audiologist consult as ordered on (MONTH) 21, (YEAR). An interview was conducted on (MONTH) 18, (YEAR) at 1:07 p.m. with the unit secretary (staff #43). Staff #43 stated that when a physician orders [REDACTED]. Staff #43 stated that this electronic communication is available to all staff who use electronic documentation which includes the physician staff. After reviewing her appointment book, staff #43 stated that resident #23 had not been out to an audiologist appointment. An interview was conducted on (MONTH) 18, (YEAR) at 1:16 p.m. with a Family Nurse Practitioner (FNP/staff #70) who stated that after entering a consultation order, the order is sent to the unit secretary to make the appointment via the electronic dashboard system. During an interview conducted on (MONTH) 19, (YEAR) at 12:16 p.m. with the Director of Nursing (DON/staff #9), the DON stated that the unit secretary schedules appointments for residents. Staff #9 stated that when a physician enters a new order into the electronic chart, a message will automatically be sent to the nursing staff dashboard, informing them of a new order. The DON stated that all new orders are placed in a que for the nurses to acknowledge. The DON stated that the nurse will send the appointment orders to the unit secretary for scheduling and transportation. Staff #9 stated that the unit secretary will schedule the appointment, set up transportation, and inform the resident of the appointment. The DON also stated that a report is ran every morning to inform the DON or assistant DON of all new orders so that the management team is aware of any changes that may need to be addressed. The facility's policy regarding appointment setting guidelines included to call to schedule an appointment and to note it on the calendar.",2020-09-01
989,HAVEN OF SHOW LOW,35139,2401 EAST HUNT STREET,SHOW LOW,AZ,85901,2018-09-19,757,E,0,1,4BUB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy and procedures, the facility failed to ensure one resident's (#20) drug regimen was free of unnecessary drugs, by failing to ensure that a pain medication was administered per the physician orders. Findings include: Resident #20 was admitted to the facility on (MONTH) 17, (YEAR), with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. Additional review of the physician's orders [REDACTED]. The admission Minimum Data assessment dated (MONTH) 24, (YEAR) revealed the resident had a Brief Interview of Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. A review of the Medication Administration Record [REDACTED] -July 18: [MEDICATION NAME] 10 mg tablet administered for a pain level of 5. -July 21: [MEDICATION NAME] 10 mg tablet administered for a pain level of 4. -July 22: [MEDICATION NAME] 10 mg tablet administered for a pain level of 3. -July 26: [MEDICATION NAME] 10 mg tablet administered for a pain level of 5. -July 27: [MEDICATION NAME] 10 mg tablet administered for a pain level of 3. -July 28: [MEDICATION NAME] 10 mg tablet administered twice for pain levels of 4. -July 29: [MEDICATION NAME] 10 mg tablet administered for a pain level of 4. -July 30: [MEDICATION NAME] 10 mg tablet administered for a pain level of 5. -July 31: [MEDICATION NAME] 10 mg tablet administered twice for pain levels of 5. A review of the Medication Administration Record [REDACTED] -August 2: [MEDICATION NAME] 10 mg tablet administered twice for pain levels of 5 and once for a pain level of 4. -August 3: [MEDICATION NAME] 10 mg tablet administered for a pain level of 5. -August 4: [MEDICATION NAME] 10 mg tablet administered for a pain level of 5. -August 7: [MEDICATION NAME] 10 mg tablet administered for a pain level of 5. -August 8: [MEDICATION NAME] 10 mg tablet administered twice for pain levels of 5. -August 9: [MEDICATION NAME] 10 mg tablet administered twice for pain levels of 5. -August 10: [MEDICATION NAME] 10 mg tablet administered twice for pain levels of 5. -August 24: [MEDICATION NAME] 10 mg tablet administered for a pain level of 5. -August 25: [MEDICATION NAME] 10 mg tablet administered for a pain level of 5. -August 26: [MEDICATION NAME] 10 mg tablet administered for a pain level of 5. A review of the Medication Administration Record [REDACTED] -September 7: [MEDICATION NAME] 10 mg tablet administered for a pain level of 0. -September 10: [MEDICATION NAME] 10 mg tablet administered for a pain level of 5. An interview was conducted on (MONTH) 19, (YEAR) at 11:21 a.m. with a Registered Nurse (RN/staff #6). The RN stated that a resident's pain is assessed prior to administering the resident a prn pain medication. Staff #6 stated that the nurses are supposed to administer prn pain medications according to the ordered pain scale. The RN stated that if a resident requested a prn pain medication outside of the ordered pain levels, this nurse would call the physician and obtain a revised order prior to administering the medication. During an interview conducted with the Director of Nursing (DON/staff #9) on (MONTH) 19, (YEAR) at 11:56 a.m., the DON stated that most residents have two prn pain medications: [REDACTED]. Staff #9 stated that if a prn pain medication was administered outside of the ordered pain scale, it would be unacceptable because the expectation and policy is to administer medications per the physician's orders [REDACTED]. Review of the facility's policy titled 'Medication Administration General Guidelines' revealed that medications should be administered in accordance with written orders of the prescriber.",2020-09-01
990,HAVEN OF SHOW LOW,35139,2401 EAST HUNT STREET,SHOW LOW,AZ,85901,2018-09-19,880,D,0,1,4BUB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of personnel records, staff interviews, and policies, the facility failed to ensure two staff members (#67 and #68) had evidence of freedom from [MEDICAL CONDITION]. Findings include: Review of facility personnel records revealed the following: -A contracted physical therapy assistant (staff #67) was hired on (MONTH) 17, (YEAR) and provided physical therapy services to residents part time. Review of the personnel record for staff #67 revealed a chest x-ray report dated (MONTH) 10, 2014. The chest x-ray report included that staff #67 had a previous positive PPD (Purified Protein Derivative) skin test result, and that there was no evidence that staff #67 had TB ([MEDICAL CONDITION]). Continued review of the personnel record for staff #67 did not reveal any additional documented evidence of freedom from TB after (MONTH) 10, 2014. -A contracted occupational therapy assistant (staff #68) was hired on (MONTH) 20, (YEAR) and provided occupational therapy services to residents full time. Review of the personnel record for staff #68 revealed a chest x-ray report dated (MONTH) 21, (YEAR). The chest x-ray report included that staff #68 had a previous positive PPD skin test result and a cough. The chest x-ray also included that there was no evidence that staff #68 had TB. Continued review of the personnel record for staff #68 did not reveal any additional documented evidence of freedom from TB after (MONTH) 21, (YEAR). Interviews were conducted on (MONTH) 19, (YEAR) at 2:00 p.m. and 2:30 p.m. with a Business Office Manager (staff #52). Staff #52 stated that documented evidence of freedom from TB is obtained on or before the employee's first day of orientation and then annually. Staff #52 stated that the contracted service provider provides the records for the contracted staff. Staff #52 stated that the facility's policy is to follow the policy of the contracted service provider. She also stated that she had requested additional documentation from the service provider regarding freedom from TB for the two contracted employees. Staff #52 was unable to provide up to date documented evidence of freedom from TB for staff #67 and staff #68. She stated that's all we have. The facility's policy titled [MEDICAL CONDITION] Testing and Chest X-Ray Requirements-Contracted Employees included the statement that contracted employees are required to remain free of [MEDICAL CONDITION] (TB). The policy revealed to verify this status according to their respective company policies, in as much as such policies are in accordance with regulations. A policy provided by the facility for the contracted therapy services provider titled TB Test Requirements included that when a chest x-ray is necessary; it is valid for 5 years. The policy also included that if the physician will not continually perform an x-ray every 5 years, then the original chest x-ray is required along with an annual check from the physician stating that TB is not present.",2020-09-01
991,HAVEN OF SHOW LOW,35139,2401 EAST HUNT STREET,SHOW LOW,AZ,85901,2019-11-07,550,D,0,1,COXI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure one resident (#8) was treated with dignity by failing to respond timely to the resident's requests for toileting assistance. The deficient practice could result in residents not being treated with dignity. Findings include: Resident #8 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the care plan initiated (MONTH) 29, 2019 revealed the resident had an ADL (activities of daily living) self-care performance deficit related to activity intolerance. The goal was that the resident would maintain the current level of function in transfers and toilet use. Interventions included the resident required 2 staff participation with transfers and 1-2 staff participation to use the toilet. The admission Minimum Data Set assessment dated [DATE] revealed a score of 15 on the Brief Interview for Mental Status which indicated the resident had no cognitive impairment. The assessment included the resident required extensive assistance of two+ staff for transfer and toilet use. The assessment also included the resident was frequently incontinent of urine and occasionally incontinent of bowel. An interview was conducted with the resident on 11/4/2019 at 12:19 PM. The resident stated that she feels the staff have purposely ignored her when she needs help to go to the toilet. She stated that on at least two separate occasions she has urinated and soiled herself waiting for assistance. She stated that she has notified the nursing staff and social services of the issue. During an observation conducted on 11/05/19 at 11:19 AM, the resident was placed at the nursing station to wait to use the bathroom. The nurse informed the resident that she would take the resident to the bathroom after she finished her charting. The resident was observed to wait 7 minutes before being assisted to the bathroom. An interview was conducted on 11/05/19 at 1:02 p.m. with a Certified Nursing Assistant (CNA/staff #43), who stated that there has been times that she has been the only CNA working providing care for approximately 35 residents. She said the residents have complained to her about the time it takes for her to respond to their requests and that the residents have had to wait up to 30 minutes because she is helping other residents. Another interview was conducted with the resident on 11/05/19 at 1:23 PM. She stated she notified the nurse that the staff did not want to help her. She stated that she has been at the nurses' station asking for help. She stated that she urinates in her brief because of the wait time and has to wait 30 minutes to two hours to be changed. The resident stated that one night she called her family and asked them to call the facility to have someone help her. An interview was conducted with a CNA/Restorative Nursing Assistant (RNA/staff #35) on 11/05/19 at 2:05 PM. She stated that it normally takes about 5 minutes to answer a call light. She stated that there are times when there is only one CNA in the building for at least 32 residents. An interview was conducted with the social worker (staff #14) on 11/6/2019 at 10:50 AM. She stated the resident has discussed with her the issues with staff not helping her to the bathroom. She stated that she knows that there are times there is only one CNA on the floor which makes it difficult to get the residents up. An interview was conducted on 11/07/19 at 8:26 a.m. with the Director of Nursing (DON/staff #12), who stated that she is aware that there are times when there is only one CNA providing care during a shift. Review of the facility's policy Quality of Life - Dignity revealed demeaning practices and standards of care that compromise dignity are prohibited. The policy included staff shall promote dignity and assist residents as needed by promptly responding to the resident's request for toileting assistance.",2020-09-01
992,HAVEN OF SHOW LOW,35139,2401 EAST HUNT STREET,SHOW LOW,AZ,85901,2019-11-07,561,D,0,1,COXI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, clinical record review, and policies, the facility failed to ensure one sampled resident's (#8) choice regarding meals was supported and accommodated. The deficient practice could result in residents not having the choice about aspects of their life that are significant to them. Findings include: Resident #8 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the care plan initiated (MONTH) 30, 2019 revealed the resident was at risk for nutritional problems related to variable oral intake. The goal was to for the resident to remain hydrated and not experience a significant weight change. Interventions included assisting the resident with meals as needed and encouraging fluid and by mouth intake. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed a score of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident had no cognitive impairment. The assessment included the resident required setup help with meals and supervision with eating. An interview was conducted with the resident on 11/4/2019 at 12:19 PM. She stated that she is at the mercy of the staff because she needs help with setting up her meals. She stated she used to go to the dining room for meals but that now she wants to eat in her room. The resident stated the problem with eating in her room is that she needs someone to set up her tray and help prepare food items (like cutting her meat) so she can eat. The resident stated staff have told her that they are too busy to help her. The resident further stated she has reported it to the social worker and to the nursing staff but nothing has changed. A review of the clinical record revealed no documentation related to concerns with assisting the resident with meals. During a lunch observation conducted on 11/4/2019 at 12:39 PM, the resident's lunch tray was delivered to her room and placed on the bedside table approximately 6 feet away from resident. Seven minutes later, a staff member entered the room, moved the bedside table over to the resident, set up the tray and left without asking the resident if she needed assistance with her meal. An interview was conducted with a Certified Nursing Assistant/Restorative Nurse Assistant (CNA/RNA/staff #35) on 11/5/2019 at 1:20 PM. She stated her goal for every resident is for the residents to do for themselves as long as they can. The CNA stated that resident #8 cannot lift her arms at times to feed herself because of the pain. The CNA also stated she told resident #8 that there is not enough staff to assist her when she eats in her room so she needs to eat in the dining room if she needs assistance. An interview was conducted with a Registered Nurse (RN/staff #15) on 11/5/2019 at 2:01 PM. She stated resident #8 has the right to eat wherever she wants. The RN stated that if the resident wants to eat in her room, staff should assist her with meals as needed in her room. She stated the resident does have difficulty raising her arms to eat but that she is not aware the resident needs any special help with her meals. An interview was conducted with the social worker (staff #14) on 11/6/2019 at 10:50 AM. She stated the resident did discuss with her the concerns she has regarding eating in her room. She stated that the resident, to her knowledge, does not need help with eating. The social worker also stated that she told the administrator and the Director of Nursing (DON) about the resident's concerns. During an interview conducted with the DON (staff #12) on 11/6/2019 at 11:28 AM, she stated that she was not aware of any issues regarding resident #8's choice to eat in her room. The DON stated the resident has the right to eat in the dining or in her room and that the staff would support her choice. A facility's policy titled Quality of Life - Self Determination and Participation revealed the facility respects and promotes the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life. Each resident shall be allowed to choose activities including eating that are consistent with his or her interest. The policy included residents shall be provided assistance as needed to engage in their preferred activities on a routine basis. Review of the facility's policy Resident Rights revealed the facility promotes and protects the rights of residents regarding the right to self-determination which included choice of activities.",2020-09-01
993,HAVEN OF SHOW LOW,35139,2401 EAST HUNT STREET,SHOW LOW,AZ,85901,2019-11-07,623,D,0,1,COXI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to notify two residents (#4 and #180) and/or the resident's representative in writing of the transfers/discharges and failed to send a copy of the notice to the Ombudsman. The deficient practice could result in residents not being provided a written notice of transfer and the Ombudsman not receiving a copy of the notice. Findings include: -Resident #180 was admitted to the facility on (MONTH) 27, 2019, with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 3, 2019, revealed a Brief Interview Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. The face sheet revealed the resident was her own responsible party and included a family member was the Power of Attorney (POA) for care. Review of a progress note dated (MONTH) 3, 2019, revealed that the resident was transferred to the hospital for a change in condition. However, further review of the clinical record revealed no evidence the resident and/or the resident's representative was notified in writing of the transfer or that the Ombudsman was sent a copy of the notice of transfer to the hospital. An interview was conducted with the Resident Relations Manager (staff #14) on (MONTH) 7, 2019 at 1:48 p.m. Staff #14 stated that she does not notify the resident and/or the resident's representative in writing of the transfer to the hospital. She also stated that she does not send a copy of the notice of the transfer to the hospital to the Ombudsman. She said that she and her supervisor are currently working on a process to ensure all residents are notified in writing about their transfers. She said that once a process is developed, she will be the person responsible for providing the written transfer notice and maintaining documentation. -Resident #4 was admitted on (MONTH) 26, 2019 with [DIAGNOSES REDACTED]. The admission MDS assessment dated (MONTH) 2, 2019 revealed a score of 8 on the BIMS which indicated the resident had moderate cognitive impairment. Review of the face sheet revealed the resident was her own responsible party and that a family member was the responsible party. A nursing progress note dated (MONTH) 10, 2019, revealed the resident was sent to the hospital for a change in condition. However, further review of the clinical record did not reveal evidence the resident and/or the resident's representative were notified in writing of the transfer or that the ombudsman was sent a copy of the transfer to the hospital. On (MONTH) 6, 2019 at 9:12 a.m., an interview was conducted with the Resident Relations Manager (staff #14). She stated she had no knowledge regarding notifying the resident and/or their representative in writing of the transfer/discharge to the hospital. She stated that she does not send a notice of the transfer to the ombudsman. An interview was conducted with the Director of Nursing (DON/staff #12) on (MONTH) 6, 2019 at 9:55 a.m. The DON stated that she does not notify the resident or the resident's representative in writing of the transfer. The DON further stated that she only notifies the ombudsman if a resident has been in an accident and/or has an injury. The facility's policy titled Transfer or Discharge Notice revised (MONTH) 2012, revealed a resident and/or the resident's representative will be provided with a thirty (30) day written notice of an impending transfer or discharge except if an immediate transfer or discharge was required by the resident's urgent medical needs. The policy did not include notifying the resident and/or the resident's representative in writing of the immediate transfer or discharge required for the resident's urgent medical needs or sending a copy of the notice to the ombudsman.",2020-09-01
994,HAVEN OF SHOW LOW,35139,2401 EAST HUNT STREET,SHOW LOW,AZ,85901,2019-11-07,625,D,0,1,COXI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure two residents (#4 and #180) and/or the resident's representative were notified in writing of the facility's bed-hold policy upon transfer to the hospital. The deficient practice could result in residents not being informed of the facility's bed-hold policy in writing. Findings include: Resident #180 was admitted to the facility on (MONTH) 27, 2019, with [DIAGNOSES REDACTED]. Review of a nursing progress note dated (MONTH) 3, 2019, revealed the resident was transferred to the hospital for a change in condition. Review of the discharge assessment dated (MONTH) 3, 2019 revealed the facility bed-hold policy had been explained but did not include the resident and/or the resident's representative was notified in writing of the facility's bed-hold policy. Additional review of the clinical record revealed no evidence the resident and/or the resident's representative were notified in writing of the facility's bed-hold policy. An interview was conducted on (MONTH) 7, 2019 at 1:48 p.m. with the Resident Relations Manager (staff #14), who stated that she does not notify a resident or the resident's representative in writing of the facility's bed-hold policy upon transfer to the hospital. She stated that she gives a copy of the bed-hold policy to the insurance case manager when a resident is transferred to the hospital. Staff #14 stated that she thinks residents are given a bed-hold policy when they are admitted to the facility. -Resident #4 was admitted on (MONTH) 26, 2019, with [DIAGNOSES REDACTED]. A nursing progress note dated (MONTH) 10, 2019 revealed the resident was sent to the hospital for a change in condition. However, further review of the clinical record did not reveal evidence the resident and/or the resident's representative were notified in writing of the facility's bed-hold policy. On (MONTH) 6, 2019 at 9:12 a.m., an interview was conducted with the Resident Relations Manager (staff #14). She stated that when a resident is transferred to the hospital, either she or the Business Office Manager (staff #8) will complete a Notice of Bed Hold Request and fax it to the resident's case manager. She stated that she did not know anything about notifying the resident and/or the resident's representative in writing of the facility's bed-hold policy. During an interview conducted on (MONTH) 6, 2019 at 9:48 a.m. with the Business Office Manager (staff #8), staff #8 stated that it has not been part of her process to notify the resident and/or the resident's representative about the facility's bed-hold policy in writing. On (MONTH) 6, 2019 at 9:55 a.m., an interview was conducted with the Director of Nursing (DON/staff #12). She stated her expectation is that in emergent situations, the nurse will educate the resident and/or the resident's family about the bed-hold policy verbally. The DON stated they did not have a bed-hold policy that addressed notifying the resident and/or the resident's representative in writing about the facility's bed-hold policy upon transfer to hospital. Review of the facility's policy regarding bed holds dated (YEAR), did not include a resident and/or the resident's representative will be provided written information about the facility's bed hold policy upon transfer to a hospital.",2020-09-01
995,HAVEN OF SHOW LOW,35139,2401 EAST HUNT STREET,SHOW LOW,AZ,85901,2019-11-07,658,E,1,1,COXI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure services provided or arranged by the facility met professional standards of quality for three residents (#181, #331, and #8). The deficient practice could result in residents having missed appointments and medication errors. Findings include: -Resident #181 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged to the hospital on (MONTH) 31, 2019. Review of the hospital discharge orders dated 5/22/19 revealed orders for [MEDICATION NAME] (antibiotic) 2 grams IV (intravenously) every 12 hours through 7/12/19, a follow up appointment with ID (Infectious Disease) prior to discontinuing the antibiotic treatment, and an EGD (esophagogastroduodenoscopy) and colonoscopy in 4 to 5 weeks. Review of the Medication Administration Records revealed [MEDICATION NAME] was administered every 12 hours from 5/23/19 through 7/12/19. However, review of the clinical record revealed no evidence the resident had a follow up appointment with ID prior to discontinuing the antibiotic treatment or that the resident had an EGD and colonoscopy. Further review of the clinical record, revealed the order was transcribed for a follow up appointment with ID (Infectious Disease) but did not include prior to discontinuing the antibiotic treatment. An interview was conducted with the medical records clerk (staff #4) on 11/07/19 at 09:08 AM. Staff #4 stated that she verifies admission orders [REDACTED]. She stated that after the review, she transcribes the orders as directed onto the MAR and sends the appointment orders to the scheduler to schedule the appointments. Staff #4 also stated that she did not understand the part of the ID appointment order that the appointment was to be scheduled before discontinuing the antibiotic, because discontinuing was scribbled d/c. The clerk stated that she contacted the Director of Nursing for clarification but was not given clarification, so she did not transcribe the part of the order regarding prior to discontinuing the antibiotic treatment. Staff #4 stated that she did send the order to the scheduler to schedule the ID and EGD/colonoscopy appointments. An interview was conducted with the Director of Nursing (DON/staff #12) on 11/07/19 at 11:56 AM. The DON stated that she was not the DON at the time the resident was admitted . She stated the proper procedure should have been to call the hospital physician for clarification of the order regarding the ID appointment. An interview was conducted with the scheduler (staff #51) on 11/07/19 on 12:22 PM. Staff #51 stated that even though she has no documentation of it, she does remember scheduling the resident for an ID appointment. She stated there was no time frame on the order and that the resident was discharged before the appointment date. Staff #51 also stated that she did receive the order to schedule the EGD/colonoscopy appointment, but that she forgot to schedule it. During an interview conducted with the administrator (staff #40) on 11/07/19 at 01:32 PM, the administrator stated transcribing order and scheduling appointments should be should be done correctly for every resident. -Resident #331 was admitted to the facility on (MONTH) 22, 2019, with [DIAGNOSES REDACTED]. Review of the care plan initiated (MONTH) 25, 2019 revealed the resident was receiving antidepressant medications. The goal was that the resident would be free from adverse reactions related to antidepressant therapy. Interventions included monitoring for antidepressant side effects which included constipation. A physician's orders [REDACTED]. During a medication pass observation conducted with a Registered Nurse (RN/staff #15) on (MONTH) 6, 2019 at 08:41 a.m., the nurse was observed to put three spoonful of [MEDICATION NAME] husk (bulk-forming laxative) into a cup of water and mix it. She then administered this mixture to the resident. Immediately following this observation an interview was conducted with the RN. The RN stated the facility was out of [MEDICATION NAME] powder so she gave the [MEDICATION NAME] husk. Staff #15 said that she had spoken with the Nurse Practitioner (NP) about being out of [MEDICATION NAME] and that the NP stated she could substitute [MEDICATION NAME] husk for [MEDICATION NAME]. The RN stated that she had administered [MEDICATION NAME] husk to the resident last night and today. She also stated that she had not written the order to substitute [MEDICATION NAME] husk for [MEDICATION NAME]. In an interview conducted on (MONTH) 7, 2019 at 10:10 a.m. with a Licensed Practical Nurse (LPN/staff #25), the LPN said it is definitely not ok to substitute a medication with another medication without a physician order. In an interview conducted with the NP on (MONTH) 7, 2019 at 10:11 a.m., the NP stated he was not aware that [MEDICATION NAME] husk was being substituted for [MEDICATION NAME] powder. The NP stated that he had not received any messages that he was aware of about medication substitutions for resident #331. He said the nurses should obtain an order for [REDACTED]. An interview was conducted with the Director of Nursing (DON/staff #12) on (MONTH) 7, 2019 at 10:43 a.m. The DON stated that if an over the counter medication is not available, they can purchase the medication from a store. She stated the pharmacy should be contacted to expedite sending the medication. The DON stated her expectation is that the nurse would contact the physician that a medication is not available and let the physician decide what to do. The DON also stated that the nurse should not have administered [MEDICATION NAME] husk to resident #331. -Resident #8 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the care plan initiated 8/30/2019 revealed the resident was on diuretic therapy related to [MEDICAL CONDITION] and [MEDICAL CONDITION]. Interventions included administering medication as ordered. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed a score of 15 on the Brief Interview for Mental Status (BIMS), indicating the resident had no cognitive impairment. Review of the clinical record revealed a physician order [REDACTED]. Review of the Medication Administration Record for (MONTH) revealed the resident was administered the renal multivitamin from 11/2/2019 through 11/5/2019. An interview was conducted with the resident on 11/4/2019 at 12:19 PM. She stated she was started on new medications that she was not made aware of. She stated all medication changes needed to go through her kidney physician. The resident stated a staff member told her the renal multivitamin was ordered by someone in-house. She also stated that she felt she was made to take the medications. In an interview conducted with a Registered Nurse (RN/staff #15) on 11/5/2019 at 2:01 PM, the RN stated a renal multivitamin was ordered for the resident but that the facility did not have the renal multivitamin. Staff #15 stated the facility could not afford the ordered medication so she had to create a substitute. The RN stated she administered a total of 4 medications in place of the renal multivitamin: a regular multivitamin, zinc, folic acid and vitamin C. She stated she did not notify anyone of the substitution because it was handled. She stated that when the resident saw 4 new pills in her medicine cup, the resident became very upset. The RN stated that she was able to educate the resident about the change in medications. She stated she was able to convince the resident to take the medications and that the resident took the 4 medications. An interview was conducted with the Director of Nursing (DON/staff #12) on 11/06/19 at 02:19 PM. She stated if a physician orders [REDACTED]. The DON stated that she was not aware of any staff members substituting medications. The DON stated that the resident should have been administered the medication as prescribed by the physician. The facility's policy titled Medication and Treatment Orders revealed medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications.",2020-09-01
996,HAVEN OF SHOW LOW,35139,2401 EAST HUNT STREET,SHOW LOW,AZ,85901,2019-11-07,684,E,1,1,COXI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, and policy review, the facility failed to ensure two residents (#12 and #26) received treatment and care in accordance with professional standards of practice. The deficient practice could result in residents' changes in condition not being addressed timely. Findings include: -Resident #12 was admitted on (MONTH) 12, 2019, with [DIAGNOSES REDACTED]. Review of the clinical record revealed a physician's orders [REDACTED]. Review of the care plan revealed the resident had liver disease related to alcohol [MEDICAL CONDITION] and was prescribed [MEDICATION NAME] for treatment. The goal was the resident would be free from signs and symptoms of liver complications including cognitive decline or mental status changes. Interventions included administering the medication as ordered. The Nurse Practitioner Note (NP) note dated (MONTH) 14, 2019 revealed no reports of any abusive patterns and staff did not report any incidents or events. The note included the NP had ordered labs which included checking the resident's ammonia level. A physician's orders [REDACTED]. Review of the admission MDS assessment dated (MONTH) 19, 2019, did not reveal the Brief Interview for Mental Status (BIMS) or the Staff Assessment for Mental Status was conducted. The assessment included - for the behavioral symptoms and no documentation for wandering. An admission Social Service assessment dated (MONTH) 19, 2019 revealed the resident had no behavioral concerns, no history of psychiatric treatment, and that no referrals were needed. Review of the Medication Administration Record [REDACTED]. Review of the MAR for (MONTH) 2019 revealed the resident refused [MEDICATION NAME] twice on (MONTH) 1, 2, 9, 15, 16, 19, and 30, and once on (MONTH) 3, 4, 5, 7, 8, 10, 17, 28, 29, and 31. Review of a nursing alert charting note dated (MONTH) 25, 2019 revealed a change of condition summary. The resident was found outside the building for a second time that day, was out at the far driveway, and was very combative towards the Certified Nursing Assistant (CNA). The note included the resident was brought back into the building and a wander guard was applied to the resident's right ankle. A nursing alert charting note dated (MONTH) 30, 2019 revealed another change of condition summary that the resident was upset because the roommate was yelling at her and being mean. The note included the resident was so upset she pulled the fire alarm in the hallway near the dining room. The note also included the resident calmed down when she was moved to another room and that she was adjusting well to the room and the new roommate. However, review of the clinical record revealed no evidence the practitioner was notified the resident was refusing the [MEDICATION NAME] and that the resident had a change in behavior. A NP note dated (MONTH) 1, 2019 revealed the staff had not reported any incidents or events. Review of the MAR for (MONTH) 2019 revealed the resident refused [MEDICATION NAME] twice on (MONTH) 4 and 7, and once on (MONTH) 1, 2, 6, 8, 12, 13, 15, 20, and 30. A nursing alert charting note dated (MONTH) 30, 2019 revealed the resident was adjusting well to the room change, was still angry and refusing medications, and was making angry remarks to the staff. A nursing medication administration note dated (MONTH) 30, 2019 revealed the resident was ignoring staff and that the NP was aware of the behavioral issues. However, the NP note dated (MONTH) 3, 2019 revealed the resident slept well over the weekend without difficulties or problems per staff and that staff did not report any incidents or events. The note included the resident continues to do well in the facility and appears happy. Review of the MAR for (MONTH) 2019 revealed the resident refused [MEDICATION NAME] once on (MONTH) 3, 4, 27, and 30. Review of the care plan dated (MONTH) 10, 2019 revealed the resident exhibited exit-seeking behavior as evidence by trying to exit secure facility exits and wandering. The goal was the exit-seeking behaviors will be reduced to less than daily. Interventions included monitoring the resident for tailgating when staff or visitors come and go from the facility and referring to Social Services as needed. A quarterly Social Service Review dated (MONTH) 12, 2019 revealed the resident's cognitive status, behavioral symptoms, and mental health was the same as the prior assessment on (MONTH) 16, 2019. Review of the laboratory report dated (MONTH) 17, 2019 revealed the resident's ammonia level was 255 ug/dL (micrograms/deciliter). Normal reference interval is 19 - 87 ug/dL. The report also included a handwritten note that the NP was notified on (MONTH) 20, 2019 at 8:35 a.m. Review of a nursing alert charting note dated (MONTH) 18, 2019 revealed a change of condition summary. The resident started cussing at a CNA and kicked the CNA in the jaw while the CNA was trying to provide incontinent care to the resident. The note included the CNA left the room so that the resident could calm down. The quarterly MDS assessment dated (MONTH) 19, 2019 revealed a score of 6 on the BIMS which indicated the resident had severely impaired cognition. The assessment include the resident exhibited wandering behavior 1 to 3 days out of the 7 day look-back period but did not exhibit any physical or verbal behaviors. A nursing alert charting note dated (MONTH) 20, 2019 revealed nursing sent a message to the NP regarding the elevated ammonia level of 255. The NP progress note dated (MONTH) 20, 2019 revealed the resident was not overly lethargic, no reports of fever/chills/nausea/vomiting/diarrhea, and that staff had not reported any incidents or events. The note included the ammonia level is elevated, the resident is asymptomatic and will be watched for now. The note also included the labs would be rechecked next week to ensure this was normal for the resident. However, further review of the clinical record did not reveal follow up labs were ordered or that the resident's behaviors had been reported to the practitioner. Review of a NP progress note dated (MONTH) 1, 2019 revealed the resident frequently refused [MEDICATION NAME] and complained of diarrhea. The note included the [MEDICATION NAME] is needed to keep the ammonia level as low as it is which is high compared to the normal population. The note also included the staff did not report any incidents or events. An alert nursing note dated (MONTH) 10, 2019 revealed resident #12 went into another resident's room and was messing with the bed controls. The note included resident #12 had also thrown all of her bedding (which was not wet) into the hall and purposely run over a CNA's leg with her wheelchair. An alert nursing note dated (MONTH) 23, 2019 revealed the resident had hit and cussed at a CN[NAME] The note included the resident had been violent and verbally abusive with this CNA on one other occasion. Review of the MAR for (MONTH) 2019 revealed the resident refused [MEDICATION NAME] once on (MONTH) 4, 6, 7, 8, 9, 11, 12, 26, 28, and 30 and twice on (MONTH) 10, 13, 14, 15, 16, 17, 18, 21, 22, 23, 24, 27, 29, and 31. A NP progress note dated (MONTH) 1, 2019 revealed the resident has a little bit of an attitude about her medications and refuses to take them but that she does fairly well. The note included staff does not report any significant incidents or events. The note also included no recommendation to change the medications. Review of an Incident Note dated (MONTH) 6, 2019 revealed the resident was in her room with her back to the door sitting in her wheelchair talking to another woman. The resident was visibly upset. The resident was observed holding a butter knife and motioning to cut her wrist. Staff approached the resident cautiously and gently took her hand. The resident then stuck the butter knife under her leg. After 10 minutes of calming the resident and getting the resident to say what was upsetting her, staff were able to take the butter knife from the resident. Review of an alert nursing note dated (MONTH) 6, 2019 revealed the resident had been found with a butter knife and was threatening to cut her wrists. The note included the resident was distraught over family issues and was being sent to the hospital for evaluation of suicidal ideation. Review of the hospital lab report dated (MONTH) 6, 2019 revealed the ammonia level was 36. The normal reference interval is 9 - 30 umol/L (micromole/liter). During an interview conducted with the Medical Records Manager (staff #4) on (MONTH) 7, 2019 at 8:40 a.m., staff #4 stated that other than the laboratory report dated (MONTH) 20, 2019; there were no other laboratory reports for resident #12. An interview was conducted with a Registered Nurse (RN/staff #5) on (MONTH) 7, 2019 at 8:46 a.m. The RN stated that when a resident refuses a medication frequently, the process would be to document an alert progress note and contact the practitioner. The RN also stated that he had not reported resident #12 refusing [MEDICATION NAME] to the practitioner. He said the resident is usually in good spirits, but when she's not feeling well you can tell by her behavior. On (MONTH) 7, 2019 at 9:24 a.m., an interview was conducted with the Nurse Practitioner (NP/staff #49). The NP stated that it was not reported to him that the resident refused [MEDICATION NAME] on a regular basis. He stated it was reported the resident refuses [MEDICATION NAME] sometimes. The NP also stated that he was not aware the resident had assaulted staff. He stated that he would expect staff to notify him of a change in condition and if a resident was frequently refusing medications. He said symptoms of high ammonia levels would include lethargy and increased confusion. The NP stated he ordered the laboratory test to recheck the ammonia level but that he does not remember seeing the laboratory report. On (MONTH) 7, 2019 at 11:00 a.m., an interview was conducted with the DON (staff #12). She stated her expectation is for nursing to notify the practitioner if a resident is refusing medications and if a resident has a change of condition related to behaviors. The DON stated a practitioner writing about an order in the progress note is not the same as writing the order. The DON also stated that the practitioner can write the order or alert staff to write the order. The facility's policy titled Change in a Resident's Condition or Status revised (MONTH) (YEAR), revealed staff shall promptly notify the resident's attending physician of changes in the resident's medical/mental status. The nurse will notify the resident's attending physician when there has been a significant change in the resident's physical/emotional/mental condition and refusal of medications two (2) or more consecutive times. The policy stated that a significant change of condition is a major decline in the resident's status that requires interdisciplinary review and/or revision of the care plan and will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. The policy also revealed that except in medical emergencies, notifications will be made within 24 hours of a change occurring in the resident's medical mental condition or status. The facility's policy regarding Lab and Diagnostic Test Results - Clinical Protocol revised (MONTH) 2012, revealed the physician will identify and order lab testing based on diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests. Nursing staff shall promptly notify the physician if the result is something that should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic regardless of any other factors). -Resident #26 was admitted to the facility on (MONTH) 13, 2019, with [DIAGNOSES REDACTED]. Review of the weights summary report for 2019 revealed weights were obtained monthly from (MONTH) to August. Review of a physician progress notes [REDACTED]. The note included they will continue to monitor the resident's weight loss. However, further review of the weights summary for 2019 revealed no weight was obtained for (MONTH) and October. Review of the clinical record revealed no documentation that the resident had refused to be weighed in (MONTH) or October. A monthly Nursing Summary dated (MONTH) 22, 2019 revealed the resident's most recent weight was on (MONTH) 22, 2019. Review of the dietary WINS (weight intervention nutrition skin) list dated (MONTH) 6, 2019 revealed no weight since (MONTH) and that a new weight was needed. Further review of the clinical record revealed a weight was obtained on (MONTH) 6, 2019. An interview was conducted on (MONTH) 6, 2019 at 1:01 p.m. with the Dietary Manager (staff #32), who stated that the only reason a resident would not be on monthly weights is if the resident was on hospice or was too fragile to move. The dietary manager stated that they have been requesting weights for this resident from nursing. During an interview conducted with the Registered Dietician on (MONTH) 6, 2019 at 1:06 p.m., she stated that at the WINS meeting she makes a list of all the residents who have nutritional concerns. She stated resident #26 is on this list and that they requested a weight be obtained for this resident on September18 and (MONTH) 8, 2019. In an interview conducted with a Restorative Nursing Aide (RNA/staff #35) on (MONTH) 6, 2019 at 1:57 p.m., staff #35 stated that the RNAs and the CNAs are the ones that weigh residents. Staff #35 also stated that she did not know why resident 26 was not weighed monthly. An interview was conducted with the Director of Nursing (DON/Staff #12) on (MONTH) 7, 2019 at 10:43 a.m. The DON stated that her expectations for weights are a resident is weighed when admitted , once for 4 weeks following admission, and then weighed monthly. She stated that this resident refuses care and that if the resident had refused to be weighed, it would be documented. A review of the facility's policy for Nutrition Management Program dated (YEAR), revealed all residents are weighed within 24 hours of admission and for the following four weeks or until stable. Residents that demonstrate a significant weight loss will be placed on weekly weights until weight is stabilized. The policy also revealed all other residents will be weighed monthly.",2020-09-01
997,HAVEN OF SHOW LOW,35139,2401 EAST HUNT STREET,SHOW LOW,AZ,85901,2019-11-07,686,G,1,1,COXI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on closed clinical record review, staff interviews, and policy review, the facility failed to ensure one (#180) of four sampled residents was provided care and services to prevent the development of pressure sores. The deficient practice could result in residents developing pressure sores. Findings include: Resident #180 was admitted to the facility on (MONTH) 27, 2019, with [DIAGNOSES REDACTED]. Review of the care plan initiated (MONTH) 27, 2019 revealed the resident had impairment to skin integrity related to the right hip surgical incision. The goal was that the resident would have no complications related to skin injury. Interventions included pressure relieving/reducing mattress, pillows, sheepskin padding etc. to protect the skin while in bed. The care plan did not include skin concerns to the heels. Review of the clinical record revealed a physician order [REDACTED]. A care plan initiated on (MONTH) 27, 2019 revealed the resident had activities of daily living self-care performance deficit related to activity intolerance. Interventions included the resident required the assistance of one staff for repositioning and turning in bed, and transfers. Review of the Braden Scale for Predicting Pressure Sore Risk dated (MONTH) 27, 2019, revealed a score of 16, indicating the resident was at low risk for developing pressure sores. Review of a nursing wound progress note dated (MONTH) 28, 2019 revealed the resident's heels were blanching with bogginess. The note included the resident was encouraged and educated about frequent activity/repositioning while in bed and in the wheelchair. The note also included the resident was repositioned using a pillow and that heel boots were placed on the resident's feet. The note did not include any description or other assessment of the heels. Additional review of the care plan revealed the care plan was not revised to reflect the heels with bogginess nor was there an intervention for heel boots on the care plan. The Certified Nursing Assistant (CNA) documentation for turning, repositioning, floating the heels when in bed, and wearing heel protective boots consisted of a Yes to indicate it was completed but did not include if some or all of the interventions were completed and how often. Per the documentation on the form from (MONTH) 28 through (MONTH) 2, 2019, Yes was documented three times on (MONTH) 28 and (MONTH) 2, two times on (MONTH) 29 through 31, and one time on (MONTH) 1. Further review of the clinical record revealed no additional documentation to indicate preventative measures were consistently implemented from (MONTH) 28 through (MONTH) 2, 2019. Review of the Braden Scale for Predicting Pressure Sore Risk dated (MONTH) 3, 2019, revealed a score of 18, indicating the resident was at low risk for developing pressure sores despite skin issues being identified to the resident's heels on (MONTH) 27, 2019. Review of the weekly skin check dated (MONTH) 3, 2019, now revealed the resident had pressure sores to the right and left heel and included a recommendation for foam booties to prevent further breakdown. The admission Minimum Data Set (MDS) assessment dated (MONTH) 3, 2019 revealed a score of 15 on the Brief Interview Mental Status which indicated the resident had intact cognition. The assessment included the resident had two unstageable pressure sores with suspected deep tissue injury (DTI) in evolution that were not present at the time of admission. The assessment also included a pressure reducing device was in place for the chair and bed but did not include a turning/repositioning program had been implemented. The assessment also revealed the resident required extensive assistance of two+ staff for bed mobility and transfers, and did not use a wheelchair as a mobility device. Review of the wound physician's note dated (MONTH) 3, 2019, revealed the resident had DTI to the mid-lateral right heel and to the medial left heel. The right heel measured 3.5 centimeters (cm) x 4.5 cm with an area of 12.37 square cm. The left heel measured 2 cm x 3 cm with an area of 4.712 square cm. The right and left heel wound bed had 76-100% [MEDICATION NAME] and the peri-wound skin did not exhibit signs or symptoms of infection. Apply skin prep to the right and left heel and cover with a dry protective dressing daily. Recommendations included floating the heels when in bed, offloading the wound, offloading mattress, and repositioning per facility protocol. Physician orders [REDACTED]. Review of the Pressure Ulcer Documentation and Assessment form dated (MONTH) 3, 2019, revealed the onset of the DTI to the mid-lateral right heel and to the medial left heel was on (MONTH) 3, 2019. The right DTI measured 3.5 cm x 4.5 cm. x 0 and the left DTI measured 3.2 cm x 3.3 cm x 0. Both heels were non-blanchable, deep red and purple in discoloration with epithelization with no drainage or induration noted. Skin prep was applied to the heels and the heels were covered with a dry protective dressing. Interventions included floating the heels while in bed and offloading the wound. The documentation also included the resident was encouraged and educated about frequent activity/repositioning while in the bed and wheelchair and that the resident was repositioned and heel boots were placed on the resident's feet. The care plan regarding skin integrity was revised on (MONTH) 4, 2019, to include the deep tissue injuries to the right and left heel. Further review of the clinical record revealed skin and wound assessments, and pressure sore treatments were provided. The discharge MDS assessment dated (MONTH) 3, 2019, revealed the resident was discharged to the hospital on (MONTH) 3, 2019 with two unstageable DTI sores. An interview was conducted on (MONTH) 6, 2019 at 12:23 p.m. with the wound nurse (staff #17), who said their policy states that residents are to be repositioned every two hours or more. Staff #17 stated that the CNAs are responsible for repositioning residents. She stated the CNAs document the repositioning in the data system every shift and that there is no place for the CNAs to document how often a resident was repositioned each shift. She said there have been times when there was only one CNA on the day shift and that the CNAs have told her that they did not have time to reposition residents every two hours. She also stated that the size and shape of the pressure sores on the resident's heels, is the type of pressure sores a resident gets when the resident uses a wheelchair. Review of the facility's wound management policy dated 2013, revealed the goal of their comprehensive wound management program is to promote the highest level of functioning and well-being of their residents and to minimize the number of residents that develop in-house acquired pressure sores. A thorough head to toe assessment of each resident's skin will be completed on admission and at least weekly thereafter. The skin check will be completed by the wound care team which consists of the wound care nurse and the wound care assistant. A pressure ulcer risk assessment (Braden) will be completed upon admission, the following 4 weeks and quarterly thereafter. Residents with a Braden score less than 12 will have interventions placed to prevent pressure sore development. Skin impairment care plan and goals will be initiated, updated, and reviewed as applicable by the Interdisciplinary team. This is to include all residents at risk as well as those with actual skin impairments.",2020-09-01
998,HAVEN OF SHOW LOW,35139,2401 EAST HUNT STREET,SHOW LOW,AZ,85901,2019-11-07,725,E,0,1,COXI11,"Based on resident and staff interviews, facility assessment, and policy review, the facility failed to ensure there was sufficient nursing staff to meet the needs of residents. The deficient practice resulted in residents' needs not being met. The census was 37. Findings include: During the initial phase of the survey, 5 out of 15 residents reported concerns of not having enough staff. Residents reported that they have waited up to 3 hours for staff to answer their call light. They stated staff have turned off the call light, said they would be back and not come back for a long time. They stated they have had incontinent episodes due to the wait time and have not received showers due to the lack of staffing. They also stated residents have helped other residents who needed help because staff did not help the residents. Review of the facility assessment revealed the purpose is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Ensure each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being. The assessment included a ratio of 1:12-17( residents) or less on the day shift and a ratio of 1:1-15 or less on the night shift for Certified Nursing Assistants (CNAs). The assessment also included the average census range is 34 - 48 residents. An interview was conducted on (MONTH) 5, 2019 at 1:02 p.m. with a CNA (staff #43), who stated that there has been times that she has been the only CNA working providing care for approximately 35 residents. She said the residents have complained to her about the time it takes for her to respond to their requests and that the residents have had to wait up to 30 minutes because she is helping other residents. She said she feels like they are very short staffed. She stated that there is no CNA available to help the residents during mealtimes because she is serving meal trays to the residents' rooms and the other CNA is in the dining room. The CNA also stated that the second CNA takes some of the residents for a smoke break, several times day, and it is difficult for her to answer all the call lights during these breaks. During an observation conducted on 11/05/19 at 01:16 PM, one CNA was observed out with residents that were on a smoke break. The other CNA assigned to the floor was in a meeting. The social worker (staff #14) stated she was a CNA, and that she was the CNA for the residents in the facility. An interview was conducted on (MONTH) 5, 2019 at 2:05 p.m. with another CNA (staff #35), who said that she is in the dining room during mealtimes because she is the Restorative Nursing Assistant (RNA). She stated that she is responsible for assisting residents with eating. She also said she supervises the residents that smoke and that there is only one CNA in the building to help the other residents when smoking breaks occur. She said there have been times when she was the only CNA working a shift and that it was very difficult to help 35 residents. An interview was conducted on (MONTH) 7, 2019 at 8:26 a.m. with the Director of Nursing (DON/staff #12), who stated that she determines the number of staff required to provide care to the residents. The DON stated that she is aware that there are times when there is only one CNA providing care during a shift and agreed that they are short staffed. She said that she would like to have three CNAs for each shift. Review of the facility's policy regarding staffing revised (MONTH) 2007, revealed adequate staffing is provided to meet needed care and services for the resident population. Adequate staffing on each shift is maintained to ensure residents' needs and services are met. The policy included Certified Nursing Assistants/Nursing Assistants are available on each shift to provide the needed care and services of each resident as outlined on the resident's comprehensive care plan.",2020-09-01
999,HAVEN OF SHOW LOW,35139,2401 EAST HUNT STREET,SHOW LOW,AZ,85901,2019-11-07,732,E,0,1,COXI11,"Based on staff interviews, facility documentation, and policy and procedure, the facility failed to ensure nurse staffing data information was posted and maintained for a minimum of 18 months. Findings include: Review of the facility's Daily Staff Posting from (MONTH) 4, 2019 through (MONTH) 4, 2019, revealed no nurse staffing data for (MONTH) 5, 6, 12, 13, 19, 20, 26, 27, and (MONTH) 2 and 3, 2019, which are Saturday and Sunday dates. An interview was conducted on (MONTH) 7, 2019 at 8:26 a.m. with the Director of Nursing (DON/staff #12), who stated that the Central Supply Manager (staff #37) was responsible for posting the Daily Staff Posting. She stated staff #37 works during the week and that she did not know who was posting the staffing schedule on the weekends. Staff #37 joined the interview and said that there is no one posting the staffing schedule on the weekend. Review of the facility's Posting Direct Care Daily Staffing Numbers policy revised (MONTH) 2006, revealed the facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. The policy included records of staffing information for each shift will be kept for a minimum of 18 months or as required by state law (whichever is greater).",2020-09-01
1000,HAVEN OF SHOW LOW,35139,2401 EAST HUNT STREET,SHOW LOW,AZ,85901,2019-11-07,775,D,0,1,COXI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure a laboratory report was filed in one resident's (#2) clinical record. The deficient practice could result in laboratory reports not being filed in residents' clinical records. Findings include: Resident #2 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the clinical record revealed a physician order [REDACTED]. Further review of the clinical record revealed no laboratory report for the urinalysis but revealed the order was pending. During an interview conducted with the Director of Nursing (staff #12) on 11/7/2019 at 11:30 AM, she stated that she would have to go to the nursing station to locate the urinalysis result because the laboratory reports are not scanned into the electronic clinical record. An interview was conducted with the Regional Educator (staff #46) on 11/7/2019 at 12:20 PM. She stated that she had the laboratory fax over the results. She stated that she did not know why there was a delay in receiving the laboratory report. Staff #46 stated that there was a culture indicated on the urinalysis and that the culture came back negative for any growth. The facility policy titled Lab and Diagnostic Test Results - Clinical Protocol revealed the laboratory will report test results to the facility and a nurse will review all results for reporting and documenting the results and their implications. The policy did not include filing laboratory reports.",2020-09-01