cms_DC
Data source: Big Local News · About: big-local-datasette
2,583 rows sorted by complaint
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| Link | rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint ▼ | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2497 | 2497 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2010-12-10 | 323 | D | C9B111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews and record review for one (1) resident, it was determined that facility staff failed to adequate supervise Resident #1, who subsequently eloped from the facility and was missing for approximately five (5) hours and failed to follow the facility ' s " Missing Person " policy and notify the police department and the family of the resident ' s elopement. The findings include: 1. Facility staff failed to adequately supervise Resident #1 who subsequently eloped from the facility. A telephone interview was conducted with Employee #1 on December 2, 2010 at 10:15 AM. Employee #1 was asked about Resident #1's elopement. Employee #1 stated, " We reviewed the camera tapes and we know pretty much how Resident #1 got out of the unit. A new security guard was making rounds at one o ' clock in the morning. We found out later that he/she was never oriented to the home or to the Dementia Unit. The camera shows him/her holding the door open for Resident #1. Resident #1 is dressed in street clothes, wearing a sweat shirt, pants, and sneakers and carrying a bag. We do not have any limitations on our visiting hours, so the guard thought she was a visitor. The camera shows them waiting at the elevator and that the security guard held the door open for him/her to get on. They both got off on the first floor and the guard went one way and Resident #1 went the other. About two minutes later the front door camera picked up Resident #1. He/she was wearing a wander guard bracelet. There appears to be some conversation with the front desk receptionist and then Resident #1 walked out the front door at 1:14 AM. There is a wander guard panel that should have alarmed when Resident #1 left through the front door. We don ' t know why that didn ' t happen. The wander guard people will be here to check the panel. When Resident #1 returned to the facility, the panel alarmed. " A telephone interview was conducted with Employee #… | 2014-04-01 | ||
| 2498 | 2498 | CAROLYN BOONE LEWIS HEALTH CARE CENTER | 95015 | 1380 SOUTHERN AVE SE | WASHINGTON | DC | 20032 | 2010-12-14 | 279 | D | VNKB11 | Based on observation, staff interview and record review for one (1) resident, it was determined that facility staff failed to initiate specific interventions to prevent the development of pressure sores after Resident #1 was identified as being at high risk for pressure sore development. The findings include: The resident was observed on December 13, 2010 at 8:45 AM in the presence of Employee #1. Resident #1 was in bed, turned to his/her right side. There was an air mattress on the bed. His/her buttock was observed with five (5) areas of pink, granulated tissue from healed pressure sores. A pressure sore appeared on the left buttock near the gluteal cleft and appeared to be quarter size, with depth of approximately one inch (1 " ). The depth was cone shaped and the center of the cone at the greatest depth appeared black and was small in size. The surrounding walls of the cone shape were yellow slough. According to the " Nursing Admission Assessment Form " completed on October 26, 2010, under " Skin Assessment, " was written " No pressure ulcer noted. " Additionally, the " Braden Pressure Ulcer Risk Assessment " completed at the same time, totaled 11. According to the directions on the form, a " Total of 12 or less represents HIGH RISK " for developing a pressure sore. Under " Problems Identified: Left side weakness. Resident states she is unable to move. Needs assistance with moving. " A care plan problem, " Potential for Skin breakdown related to immobility and incontinence " was initiated October 26, 2010. Approaches included: " Nurses ---Assess skin condition daily and note any changes. Keep clean and dry. Nurse Aide --- Reposition every two hours. Minimize pressure on bony prominences. Use lift sheet when moving resident in bed. Barrier cream to peri-area as needed. " A face-to-face interview was conducted with Employee #2 on December 13, 2010 at 12:00 PM. He/she acknowledged that there were no interventions initiated when the resident was admitted to prevent pressure sores. The record was reviewed December … | 2014-04-01 | ||
| 2499 | 2499 | CAROLYN BOONE LEWIS HEALTH CARE CENTER | 95015 | 1380 SOUTHERN AVE SE | WASHINGTON | DC | 20032 | 2010-12-14 | 514 | D | VNKB11 | Based on observation, staff interview and record review, for one (1) resident, it was determined that facility staff failed to accurately document the condition of Resident #1 ' s skin in the gluteal area which subsequently was noted with a Stage III pressure sore. The findings include: The resident was observed on December 13, 2010 at 8:45 AM in the presence of Employee #1. Resident #1 was in bed, turned to his/her right side. There was an air mattress on the bed. His/her buttock was observed with five (5) areas of pink, granulated tissue from healed pressure sores. A pressure sore appeared on the left buttock near the gluteal cleft and appeared to be quarter size, with depth of approximately one inch (1 " ). The depth was cone shaped and the center of the cone at the greatest depth appeared black and was small in size. The surrounding walls of the cone shape were yellow slough. According to the " Nursing Admission Assessment Form " completed on October 26, 2010, under " Skin Assessment, " was written " No pressure ulcer noted. " There was no evidence that the nurse assessor documented the five (5) areas of pink, granulated tissue from healed pressure sores. There was no documentation in the record from the date of admission until December 8, 2010 that described an assessment of the resident ' s buttocks prior to the development of the Stage III pressure sore. A face-to-face interview with Employee #2 was conducted on December 13, 2010 at 12:00 PM. He/she acknowledged that there was no description of the resident ' s skin prior to the development of the Stage III pressure sore. The record was reviewed December 13, 2010. | 2014-04-01 | ||
| 2500 | 2500 | CAROLYN BOONE LEWIS HEALTH CARE CENTER | 95015 | 1380 SOUTHERN AVE SE | WASHINGTON | DC | 20032 | 2010-12-14 | 314 | G | VNKB11 | Based on observation, staff interview and record review for one (1) resident, it was determined that facility staff failed to assess the condition of the left gluteal area prior to the development of a Stage III ulcer for Resident #1. The findings include: The resident was observed on December 13, 2010 at 8:45 AM in the presence of Employee #2. Resident #1was in bed turned to his/her right side. There was an air mattress on the bed. His/her buttock was observed with five (5) areas of pink, granulated tissue from healed pressure sores. The pressure sore appeared on the left buttock near the gluteal cleft and appeared to be quarter size, with depth of approximately one inch (1 " ). The depth was cone shaped and the center of the cone at the greatest depth appeared black and was small in size. The surrounding walls of the cone shape were yellow slough. According to the " Nursing Admission Assessment Form " completed on October 26, 2010, under " Skin Assessment, " was written " No pressure ulcer noted. " Additionally, the " Braden Pressure Ulcer Risk Assessment " totaled 11. According to the directions on the form, a " Total of 12 or less represents HIGH RISK " for developing a pressure sore. Under " Problems Identified: Left side weakness. Resident states he/she is unable to move. Needs assistance with moving. " There was no evidence that the admission assessment accurately documented the five (5) areas of previously healed pressure sores on Resident #1 ' s gluteal area. A care plan problem, " Potential for Skin breakdown related to immobility and incontinence " was initiated October 26, 2010. Approaches included: " Nurses ---Assess skin condition daily and note any changes. Keep clean and dry. Nurse Aide --- Reposition every two hours. Minimize pressure on bony prominences. Use lift sheet when moving resident in bed. Barrier cream to peri-area as needed. " There was no evidence that specific interventions were initiated after the resident was assessed as being at high risk for pressure sore development upon admissi… | 2014-04-01 | ||
| 2501 | 2501 | CAROLYN BOONE LEWIS HEALTH CARE CENTER | 95015 | 1380 SOUTHERN AVE SE | WASHINGTON | DC | 20032 | 2010-12-14 | 157 | D | VNKB11 | Based on record review and staff interview for Resident #1, it was determined that facility staff failed to notify the physician of the resident ' s agitated behaviors. The findings include: A review of the nurses ' notes revealed the following: October 23, 2010 at 6:00 AM: " Resident alert and verbally responsive with confusion. Keeps saying she has to go upstairs and asking about her son ... " October 28, 2010 at 7:00 AM: " ...Periods of confusion stated ' my nephew stole my things. Call the police. Take me upstairs. I don ' t live here ' . Calmed down after a while and slept for about 4-5 hours. No respiratory distress. " November 10, 2010 at 5:00 AM: " Resident calling out at times very confused. Tylenol tabs (2) 325 mg po at 1:30 PM for Left shoulder pain with good results. Up in gerichair and seen in Physical Therapy. " December 3, 2010 at 9:00 AM -late entry for November 11, 2010: " Resident was agitated x 3. Constantly calling about being here. The writer in to see client about meds and gave meds. Resident confused, and constantly kept calling ' Isaiah and Jeremiah " come get me out of here ... " December 8, 2010 11:10 PM: " Resident constantly calling " Isaiah and Jeremiah " to please come and get her ... " There was no evidence in the record that facility staff notified the physician of the resident ' s behaviors or request a consult to the psychiatrist until December 11, 2010. A face-to-face interview with Employee #2 was conducted on December 13, 2010 at 12:00 PM. He/she stated, " Resident #1 had behavior issues from the time of his/her admission. I don ' t know why a psychiatric consult was not ordered until December 11, 2010. That should not have happened. " The record was reviewed December 13, 2010. | 2014-04-01 | ||
| 2502 | 2502 | SPECIALTY HOSPITAL OF WASHINGTON - HADLEY SNF | 95024 | 4601 MARTIN LUTHER KING JR AVENUE SW | WASHINGTON | DC | 20032 | 2010-12-02 | 241 | D | GC5D11 | Based on observation and staff interview for two (2) of 15 sampled residents, it was determined that facility staff failed to maintain Residents' dignity when facility staff wrote on residents' dressings after they were placed on the residents' bodies. Residents #1 and 2. The findings include: 1. Employee #11 failed to enhance and respect Resident #1's dignity by signing his/her name and writing the date and time of the dressing on the tape after it was placed over the dressing on the resident ' s buttock. A dressing change was observed at approximately 11:35 AM on November 30, 2010. After applying the dressing to Resident #1 ' s buttock Employee #10 removed a pen from his/her pocket and used the pen to sign his/her name and write the date and time (of the dressing change) on the tape which covered the dressing on the resident ' s buttock. A face-to-face interview was conducted with Employees #11 at approximately 11:35 AM on December 1, 2010. He/she acknowledged the finding. Facility staff failed to enhance and respect Resident #1's dignity. 2. Facility staff failed to maintain Resident #2's dignity as evidenced by writing the date, time and his/her initials on the dressing after it was placed on the resident's sacrum. During wound care observation on December 1, 2010 at 12:15 PM, the surveyor observed employee #13 cleansed the wound and placed new Exuoderm dressing on Resident #2's wound. After placing the dressing on the wound the employee removed a pen from his/her pocket and used the pen to write the date, time and his/her initials on the dressing that was covering the resident's sacral wound. A face-to-face interview was conducted on December 1, 2010 at 12:30 PM with Employee #13 immediately after the wound care. He/she stated " I did not know I could not do that(write on Exuoderm dressing after it was placed on resident sacrum.) | 2014-04-01 | ||
| 2503 | 2503 | SPECIALTY HOSPITAL OF WASHINGTON - HADLEY SNF | 95024 | 4601 MARTIN LUTHER KING JR AVENUE SW | WASHINGTON | DC | 20032 | 2010-12-02 | 278 | D | GC5D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 15 sampled residents, it was determined that facility staff failed to accurately code the Minimum Data Set (MDS) assessment 3.0 for influenza and pneumococcal for Resident #2. The findings include: Facility staff failed to accurately code Resident #2 's readmit MDS 3.0 for influenza and pneumococcal immunization. According to the readmit Minimum Data Set (MDS) 3.0 assessment completed November 8, 2010, the resident was coded in Section O0250(C) -- (Influenza Vaccine) as "5" indicating the resident was not offered Influenza Vaccine and Section O0300 (B) -- (Pneumococcal Vaccine) as "3" indicating the resident was not offered Pneumococcal Vaccine. A review of the " Consent for treatment for [REDACTED]." No I do not wish to receive the Pneumococcal vaccine this year " . A face-to-face interview was conducted with Employees #8 and 9 on November 30, 2010 at approximately 11:15 AM. They acknowledged to the findings on " Consent for treatment for [REDACTED]. The record was reviewed November 30, 2010. | 2014-04-01 | ||
| 2504 | 2504 | SPECIALTY HOSPITAL OF WASHINGTON - HADLEY SNF | 95024 | 4601 MARTIN LUTHER KING JR AVENUE SW | WASHINGTON | DC | 20032 | 2010-12-02 | 279 | D | GC5D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for three (3) of 15 sampled residents, it was determined that facility staff failed to initiate care plans for allergy for two (2) residents and a care plan for use of pain medications for one (1) resident. Residents #3, 5, and 6. The findings include: 1. Facility staff failed to develop a care plan with goals and approaches to address Resident #3's allergies [REDACTED]. A review of November 2010 physician's orders [REDACTED]. " According to the resident ' s Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]" allergies [REDACTED]. The resident's care plan initiated November 3, 2010, lacked evidence that a care plan with goals and approaches was developed to address the resident's allergies [REDACTED]. A face-to-face interview was conducted on December 1, 2010 at approximately 2:00 PM with Employee #12. He/she acknowledged that there was no care plan for allergies [REDACTED]. The record was reviewed on December 1, 2010. 2. Facility staff failed to initiate a care for the use of pain medications for Resident #5. The quarterly review assessment Minimum Data Set (MDS) 3.0 completed " November 20, 2010 revealed that the resident was coded " 1 " in Section J0100(A) Pain Management" indicating resident been on a pain medication regimen in the last 5 (five) days. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]" A review of the care plans that were last updated on November 18, 2010, revealed that there was no problem identified and no care plan developed with appropriate goals and approaches for the use of pain medications. A face-to-face interview was conducted with Employee #11on December 1, 2010 at approximately 10:00 AM. After review of the care plans he/she acknowledged that the record lacked a care plan for the use of pain medications. The record was reviewed on December 1, 2010. 3. Facility staff failed to develop a care plan wi… | 2014-04-01 | ||
| 2505 | 2505 | SPECIALTY HOSPITAL OF WASHINGTON - HADLEY SNF | 95024 | 4601 MARTIN LUTHER KING JR AVENUE SW | WASHINGTON | DC | 20032 | 2010-12-02 | 286 | D | GC5D11 | Based on record review and staff interview for two (2) of 15 sampled residents, it was determined that facility staff failed to maintain 15 months of completed Minimum Data Set (MDS) assessments in the active records two (2) residents. Residents #2, and #7. The findings include: 1. A review of the clinical record for Resident #2 revealed that he/she admitted to the facility was October 16, 2006 and no MDS was found on the resident active clinical record. A review of the MDS binders located on the unit failed to reveal any MDS assessments for the resident. A face-to-face interview was conducted with Employee #8 at 8:50 AM on November 30, 2010. He/she acknowledged that there was no MDS " I will call MDS coordinator now for you " Another face-to-face interview was conducted with Employees #8 and #9 on November 30, 2010 at 9:00 AM. During the interview, employee #9 stated that he/she has copies of the completed MDS and a copy of the completed MDS was requested. Employee #9 presented a copy of the five (5) day PPS/MDS 3.0 with a completion date of November 12, 2010 and a readmission/return assessment MDS 3.0 with a completion date of November 24, 2010. Employee #9 explained why the completed MDS was not in the resident's record. He/she stated, "The MDS was completed and because the MDS are 30 pages long they were being transitioned to another binder to be stored on the unit." The record was reviewed on November 30, 2010. 2. Facility ' s staff failed to maintain 15 months of completed Minimum Data Set (MDS) assessments on Resident #7 ' s active record. A review of the clinical record for the resident revealed MDS assessments dated March 18, 2010, June 18, 2010 and September 3, 2010. A review of the MDS binders on the unit failed to reveal any additional MDS assessments for the resident. A face-to-face interview was conducted with Employee #9. He/she acknowledged that the resident's record did not contain 15 months of MDS assessments. He/she added, " The new MDS has over 30 pages. We keep them in binders on each unit as… | 2014-04-01 | ||
| 2506 | 2506 | SPECIALTY HOSPITAL OF WASHINGTON - HADLEY SNF | 95024 | 4601 MARTIN LUTHER KING JR AVENUE SW | WASHINGTON | DC | 20032 | 2010-12-02 | 309 | E | GC5D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview for two (2) of 15 sampled residents and one (1) supplemental resident, it was determined that facility staff failed to follow physician's orders [REDACTED]. bag with cloudy and sedimented urine on the resident's bed, to decrease [MEDICATION NAME] for cholesterol, and to obtain labs for one (1) resident and to obtain stool cultures in a timely manner for one (1) resident. Residents #1,11, and F2. The findings include: 1a. Facility staff failed to follow the physician's orders [REDACTED]. During a dressing change observation on November 30, 2010 at approximately 11:30AM, Employee #10 cleansed the resident's ulcer with Normal Saline Solution (NSS) and applied Santyl Ointment to the site. No Hydrogel was applied to the ulcer. A review of a physician's orders [REDACTED]. Cover with absorbent pad daily." Facility staff failed to follow the physician's order [REDACTED]. 1b. Facility staff failed to provide quality care to Resident #1 by placing the resident's foley bag with cloudy and sedimented urine flat on the resident's bed. On November 30, 2010 at approximately 11:30AM Employee #10 placed the resident ' s foley bag with cloudy urine on top of the resident ' s mattress while the dressing change procedure was performed. Cloudy and sedimented urine was also noted in the tubing that was connected to the resident's foley catheter. A review of the resident ' s record revealed that the resident was being treated for [REDACTED]. A face-to-face interview was conducted with Employee # 11 at approximately 11:35AM on December 1, 2010 regarding the aforementioned observation. He/she acknowledged the finding. 2. Facility staff failed to follow physician's order [REDACTED].#11. a. A review of the Pharmacy " Consultation Report " signed and dated by the physician on August 3, 2010, (no time indicated) revealed that the physician accepted the following recommendation(s) with the following modifications: (1… | 2014-04-01 | ||
| 2507 | 2507 | SPECIALTY HOSPITAL OF WASHINGTON - HADLEY SNF | 95024 | 4601 MARTIN LUTHER KING JR AVENUE SW | WASHINGTON | DC | 20032 | 2010-12-02 | 322 | D | GC5D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview for one (1) of 15 sampled residents, it was determined that facility staff failed to monitor gastrostomy tube ([DEVICE]) feeding administration for Resident #2. The findings include: An observation of Resident #2 was conducted on [DATE] at approximately 3:15 PM. At this time Employee # 10 was observed holding the feeding tube that was connected to Resident # 2 ' s gastrostomy tube. Employee #10 was milking the tubing into a white Styrofoam cup. He/she then stated, " It is clumped up in the tubing and sometimes it gets like that. " The employee was asked to view the tube feeding product bottle. There was no comment from the employee regarding the solidified bottle of enteral feeding product. A review of the bottle of Glucerna 1.5 (1000 mls)indicated that the feeding was being delivered at 55ml/hr. The bottle was hung on [DATE] at 8:30 PM. The expiration date printed on the top of the bottle was [DATE]. A review of the Medication Administration Records for [DATE], revealed that Resident #2 received Glucerna 1.5 at 55 ml times 18 hours. The start time 6:00 AM and Completion time 12:00 Midnight. The feeding was initialed as being administered on [DATE] and 30, 2011. The facility staff signed each shift the Glucerna 1.5 was being administer, there was no documentation in the record as to when the feeding actually started. The spike (the tubing) was initialed as being changed on [DATE] and 30, 2010. There was no explanation given to the State Agency as to why the bottle of Glucerna 1.5 was hung at 8:30 PM on [DATE] instead of 6:00 AM on [DATE]. A review of the facility " Gastrostomy Tube Feeding Policy " revised on [DATE] revealed that there is no recommended time for the tube feeding to be hung. According to the manufactures recommendations for continuous tube feeding hang time: " According to the manufactures description ... " Glucerna? 1.5 Cal is a high calorie/high protein specialized liqu… | 2014-04-01 | ||
| 2508 | 2508 | SPECIALTY HOSPITAL OF WASHINGTON - HADLEY SNF | 95024 | 4601 MARTIN LUTHER KING JR AVENUE SW | WASHINGTON | DC | 20032 | 2010-12-02 | 514 | D | GC5D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 15 sampled residents it was determined that facility staff failed to document wound care for Resident #2. The findings include: Facility staff failed to document resident #2 ' s wound care in the clinical records and on the Treatment Administration Record. (TAR). A review of the " physician's orders [REDACTED]." A review of the TAR revealed the aforementioned physician's orders [REDACTED]. The review of the documentation in the TAR revealed the following: November 7, 2010 - November 22, 2010 wound care done as indicated by nurses' initials in date box. November 23, 2010 -November 24, 2010 wound care not done as indicated by the absence of any nurse's initials in the date boxes. November 25, 2010 wound care done as indicated by nurse's initials in date box. November 26, 2010- November 27, 2010 wound care not done as indicated by the absence of nurse's initials in date box. November 28, 2010 wound care done as indicated by nurse initials in date box. November 29, 2010-November 30, 2010 wound care not done as indicated by absence of nurse's initials in date box. A review of the clinical records between November 7, 2010 and December 2, 2010 revealed the following nurses' notes: On November 25, 2010 2:00PM one nurse's note stated, " Exuoderm applied to sacral area " . On November 30, 2010 3:30PM another nurse's note stated " Exuoderm applied to sacral area "; and on December 2, 2010 1:00PM a nurse's note stated, " Sacral wound dressing performed " . The TAR lacked evidence that facility staff documented the resident's sacral wound care daily. A face-to-face interview was conducted with Employee # 9 on December 2, 2010 at 10:00 AM. The employee acknowledged that the record lacked daily documentation of the resident's wound care. The record was reviewed December 2, 2010. | 2014-04-01 | ||
| 2509 | 2509 | SPECIALTY HOSPITAL OF WASHINGTON - HADLEY SNF | 95024 | 4601 MARTIN LUTHER KING JR AVENUE SW | WASHINGTON | DC | 20032 | 2010-12-02 | 225 | D | GC5D11 | Based on record review, resident and staff interview for one (1) of 15 sampled residents, it was determined that facility staff failed to ensure that an alleged incident of staff-to-resident abuse was investigated and reported to the State Agency for Resident #10.. The findings include: A face-to-face interview was conducted with Resident #6 at approximately 1:00 PM on December 2, 2010. (Resident) stated, "While in the wheelchair going down the hallway, a CNA (Certified Nurse Aide) threw a deodorant can and it hit my leg. He/she saw me coming down the hallway. He/She apologized to me and said he/she was sorry. So, I just forgot about it. " A review of the resident's clinical record failed to reveal any documentation of the incident. A face-to-face interview was conducted with Employees #2 and 12 on December 2, 2010 at approximately 12:30 PM. They acknowledged that the incident occurred, and that no investigation of the allegation of abuse was completed and no notification of the incident was sent to the State Agency. The record was reviewed on December 2, 2010. | 2014-04-01 | ||
| 2510 | 2510 | SPECIALTY HOSPITAL OF WASHINGTON - HADLEY SNF | 95024 | 4601 MARTIN LUTHER KING JR AVENUE SW | WASHINGTON | DC | 20032 | 2010-12-02 | 371 | D | GC5D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations made during a tour of the dietary services on November 29, 2010 it was determined that the facility failed to prepare and serve food under sanitary conditions as evidenced by low dishwashing machine rinse temperatures, incomplete and pre-recorded dishwashing machine temperature logs, one (1) of one (1) ice machine, one (1) of one (1) steamer and one (1) of one (1) water softener that were inoperative, three (3) of five (5) half-pans, five (5) of five (5) hotel pans and 10 of 10 sheet pans and the floor of the freezer that were soiled, expired food items such as two (2) of two (2) half-full bags of parmesan cheese, one (1) of one (1) half-full bag of baby carrots, 11 of 17 [MEDICATION NAME] nutritional supplements; nine (9) of twenty-one cucumbers and two (2) of four (4) pineapples that were spoiled. The findings include: 1. Dishwashing machine rinse temperatures were lower (168 degrees) than the required temperature of 180 degrees Fahrenheit (F). 2. Dishwashing machine temperatures were not recorded on the following days and shifts: November 3, and 25, 2010 for the morning and noon shifts; November 13, and 14, 2010 the evening shifts; and November 27, and 28, 2010 for all three shifts. 3. A copy of the dishwashing machine temperature log for the month of November was provided to this surveyor at 10:35 am on November 29, 2010 and the noon temperatures for that day had already been recorded. 4. The ice machine, the steamer and the water softener were out of order and had been down for several months according to staff interviews. 5. Three (3) of five (5) half-pans and five (5) of five (5) hotel pans were soiled. In addition, 10 of 10 sheet pans were greasy and the freezer floor was dirty. 6. The following food items stored in walk-in refrigerator number two were expired or spoiled: Two (2) of two (2) half-full bags of parmesan cheese were expired as of 11-28-2010. One (1) half-full bag of peeled baby carrots were expired a… | 2014-04-01 | ||
| 2511 | 2511 | SPECIALTY HOSPITAL OF WASHINGTON - HADLEY SNF | 95024 | 4601 MARTIN LUTHER KING JR AVENUE SW | WASHINGTON | DC | 20032 | 2010-12-02 | 253 | D | GC5D11 | Based on observations made during an environmental tour of the facility on December 1 and 2, 2010, it was determined that the facility failed to provide effective maintenance services as evidenced by a leaky cold water faucet and a rusty water faucet system in two (2) of fourteen resident's rooms and marred walls in seven (7) of fourteen (14) resident 's rooms. The findings include: 1. The cold water faucet was leaking in room #342 and the water faucet assembly was rusty in room #339. 2. The walls were marred in residents' rooms #301, 318, 330, 334, 337, 339 and 342. These findings were acknowledged by Employee # 5 who was present at the time of observation. | 2014-04-01 | ||
| 2512 | 2512 | SPECIALTY HOSPITAL OF WASHINGTON - HADLEY SNF | 95024 | 4601 MARTIN LUTHER KING JR AVENUE SW | WASHINGTON | DC | 20032 | 2010-12-02 | 456 | D | GC5D11 | Based on observations made during the kitchen and environmental tours of the facility from November 29 - December 2, 2010, it was determined that the facility failed to maintain essential patient care equipment in safe operating condition as evidenced by high hot water temperatures in three (3) of fourteen (14) rooms, non-functioning exhaust vents in two (2) of fourteen (14) resident's rooms, one (1) of one (1) ice machine, one (1) of one (1) steamer and one (1) of one (1) water softener were inoperative, The findings include: 1. Water temperatures were as high as 115 degrees Fahrenheit in resident ' s rooms #330, 339, 342. 2. Exhaust vents were not functioning in resident ' s rooms #330 and 334. 3. The ice machine, the steamer and the water softener were out of order and had been down for several months according to staff interviews. These observations were made in the presence of employee # 5 who acknowledged these findings during the survey. | 2014-04-01 | ||
| 2513 | 2513 | SPECIALTY HOSPITAL OF WASHINGTON - HADLEY SNF | 95024 | 4601 MARTIN LUTHER KING JR AVENUE SW | WASHINGTON | DC | 20032 | 2010-12-02 | 468 | D | GC5D11 | Based on observations made during the environmental tour of the facility on December 1 and 2, 2010, it was determined that the facility failed to ensure that handrails are firmly attached to the wall as evidenced by loose handrails in one (1) of two (2) resident 's wings surveyed. The findings include: 1. Handrails were loose next to rooms #331 and 334. These observations were made in the presence of Employee #5 who acknowledged these findings during the survey. | 2014-04-01 | ||
| 2514 | 2514 | SPECIALTY HOSPITAL OF WASHINGTON - HADLEY SNF | 95024 | 4601 MARTIN LUTHER KING JR AVENUE SW | WASHINGTON | DC | 20032 | 2010-12-02 | 469 | D | GC5D11 | Based on observations made during the environmental tour of the facility on December 1 and 2, 2010, it was determined that the facility failed to maintain an effective pest control program as evidenced by the presence of crawling and flying pests observed in one (1) of two (2) units located on the third floor of the facility. The findings include: 1. Flying insects were observed in the hallway on 3 East and in the recreation room on 3 East. These observations were made in the presence of employee # 5 who acknowledged these findings during the survey. | 2014-04-01 | ||
| 2515 | 2515 | SPECIALTY HOSPITAL OF WASHINGTON - HADLEY SNF | 95024 | 4601 MARTIN LUTHER KING JR AVENUE SW | WASHINGTON | DC | 20032 | 2010-12-02 | 329 | D | GC5D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 15 sampled residents, it was determined that facility staff failed to adequately monitor the use of antipsychotic medications for Resident #6. The findings include: Facility staff failed to adequately monitor the use of [MEDICATION NAME] for mood stabilization and [MEDICATION NAME] for [MEDICAL CONDITION] for Resident #6. A review of Resident #6 ' s interim orders dated October 30, 2010 and signed by the physician on October 31, 2010 directed [MEDICATION NAME] 50mg via GT (gastrostomy tube) BID (twice a day) for [MEDICAL CONDITION] and [MEDICATION NAME] 100 mg via GT (gastrostomy tube) at HS(hour of sleep) for mood stabilization. A review of the resident ' s Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A further review of the resident ' s clinical record revealed no Behavior Monitoring Flow Record for the months of October through November 30, 2010 that consistently monitored for [MEDICAL CONDITION] and mood stabilization.. The resident ' s clinical record including the Behavior Monitoring Flow Record lacked documented evidence that he/she was monitored for mood stabilization and agitation while he/she was receiving [MEDICATION NAME] and Trazadone. A face-to-face interview was conducted with Employee #11 on December 1, 2010 at approximately 12: 20 PM. After a review of the resident's clinical record, he/she acknowledged the aforementioned findings. The record was reviewed December 1, 2010. | 2014-04-01 | ||
| 2516 | 2516 | SPECIALTY HOSPITAL OF WASHINGTON - HADLEY SNF | 95024 | 4601 MARTIN LUTHER KING JR AVENUE SW | WASHINGTON | DC | 20032 | 2010-12-02 | 334 | D | GC5D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for two (2) of 15 sampled residents, it was determined that the facility staff failed to ensure that the residents' medical record included documentation that the residents received the pneumococcal immunization. Residents #3 and #6. The findings include: The facility ' s policy and procedures stipulated; "Social Worker will notify the Responsible Party by letter that the facility is preparing for the flu season by offering our current residents and new admissions the Influenza and Pneumococcal vaccine. Once the resident is identified and we have a signed consent form for the vaccination, the Nursing Home ' s designee nurse will administer the Pneumococcal vaccine. A signed copy of the Pneumococcal vaccine will be placed on the resident ' s medical chart. A log will be kept of the Residents on 3 East and 3 West Authorizations and date administered for pneumococcal vaccines, as well as for those residents who did not receive the vaccines. " The Admission Minimum Data Set (MDS) 3.0 completed November 24, 2010 for Resident #3, revealed under Section O Special Treatments and Procedures( Pneumococcal Vaccine) 3B, If Pneumococcal vaccine not received, state reason: (3) Not offered. The Admission MDS 2.0 completed September 24, 2010 for Resident #6, revealed under Section W(3b) Supplemental MDS Items, Pneumococcal Vaccine: If PPV (Pneumococcal [MEDICATION NAME] Vaccine) not received, state reason: (3) Not offered. " According to the facility ' s " Chart Audit for Code Status and Flu/Pneumonia Vaccine Administration " report revealed no documentation that the residents received the immunization(s) or refused the vaccination(s), or did not receive the vaccines(s). A review of the residents clinical record revealed, no "Immunization Consent and Acknowledgment" form(s) in the clinical record for the pneumococcal vaccine. There was no documented evidence on the clinical record indicating that the resident/respon… | 2014-04-01 | ||
| 2517 | 2517 | SPECIALTY HOSPITAL OF WASHINGTON - HADLEY SNF | 95024 | 4601 MARTIN LUTHER KING JR AVENUE SW | WASHINGTON | DC | 20032 | 2010-12-02 | 281 | D | GC5D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F -281 Based on observation of three (3) sampled residents and one (1) supplemental resident it was determined that facility staff failed to meet professional standards for medication administration and/or failed to obtain a physician's order [REDACTED]. Residents #5, 11, 12 and D1. The Findings include: a. During a medication pass observation conducted with Employee #17 on November 29, at approximately 9:30 AM he/she failed to administer [MEDICATION NAME] 20mg capsules according to manufacturer specifications for Resident #5. According to the " physician's order [REDACTED]. During the above observation Employee #17 opened the capsule of [MEDICATION NAME], mixed the granules with water and proceeded to administer the medication via the [DEVICE]. The granules did not flow freely through the tubing. Review of the pharmacy administration directed on the resident ' s medication box " The capsules should be swallowed whole, and not opened, chewed or crushed... " According to the facility ' s Drug Clinical Reference Guide/Geriatric Drug Therapy Handbook page 806 under " Administration: capsules should be swallowed whole. Do not chew, crush, or open; May be opened and contents added to applesauce. Administration via Nasogastric tube should be in an acidic juice. " Review of the physician's order [REDACTED]. A telephone interview was conducted with Employee#15 on December 1, 2010 at 10:42 AM. He/she acknowledged that the medication can be opened, but that the physician must indicate that it can be done and any other instructions. A face-to-face interview was conducted with Employee #17 on December 2, 2010 at 1:00 PM. After review of the pharmacy recommendations he/she acknowledged that the [MEDICATION NAME] should have been mixed with an acidic based juice prior to gastrostomy tube administration of medications and that the physician's order [REDACTED]. Facility staff failed to administer [MEDICATION NAME] 20mg capsules according to manufacturer ' s … | 2014-04-01 | ||
| 2518 | 2518 | SPECIALTY HOSPITAL OF WASHINGTON - HADLEY SNF | 95024 | 4601 MARTIN LUTHER KING JR AVENUE SW | WASHINGTON | DC | 20032 | 2010-12-02 | 332 | D | GC5D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation of three (3) sampled residents and one (1) supplemental resident it was determined that facility staff failed to maintain a medication error rate of less than five (5) percent by not administering medications according to manufacturer specification for two (2) residents receiving [MEDICATION NAME], one (1) receiving [MEDICATION NAME], one (1) resident receiving a MDI (Metered Dose Inhaler) and one (1) resident receiving zinc sulfate. There were five (5) medication errors in 49 opportunities resulting in a medication error rate of 10.20%. Residents #5, 11, 12 and D1. The Findings include: a. During a medication pass observation conducted with Employee #17 on November 29, at approximately 9:30 AM he/she failed to administer [MEDICATION NAME] 20mg capsules according to manufacturer specifications for Resident #5. According to the " physician's order [REDACTED]. During the above observation Employee #17 opened the capsule of [MEDICATION NAME], mixed the granules with water and proceeded to administer the medication via the [DEVICE]. The granules did not flow freely through the tubing. Review of the pharmacy administration directed on the resident ' s medication box " The capsules should be swallowed whole, and not opened, chewed or crushed... " According to the facility ' s Drug Clinical Reference Guide/Geriatric Drug Therapy Handbook page 806 under " Administration: ...capsules should be swallowed whole. Do not chew, crush, or open; May be opened and contents added to applesauce. Administration via Nasogastric tube should be in an acidic juice. " Review of the physician's order [REDACTED]. A telephone interview was conducted with Employee#15 on December 1, 2010 at 10:42 AM. He/she acknowledged that the medication can be opened, but that the physician must indicate that it can be done and any other instructions. A face-to-face interview was conducted with Employee #17 on December 2, 2010 at 1:00 PM. After review of the pharma… | 2014-04-01 | ||
| 2519 | 2519 | SPECIALTY HOSPITAL OF WASHINGTON - HADLEY SNF | 95024 | 4601 MARTIN LUTHER KING JR AVENUE SW | WASHINGTON | DC | 20032 | 2010-12-02 | 431 | D | GC5D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, of one (1) of two (2) narcotic interim boxes, it was determined that facility staff failed to conduct a medication review to identify expired narcotic medication (Acetaminophen 300mg/30mg with codeine #3) and failed to secure the portable Interim Narcotic box to a permanently affixed compartment. The findings include: 1. A review of the Narcotic Interim Box was conducted with Employee #19 on [DATE] at 3:38 PM. Upon review of the punch card of Acetaminophen 300mg/30 mg quantity remaining nine (9) it revealed that the medication had expired [DATE]. A telephone interview was conducted with Employee #15 on [DATE] at 10:42 AM. He/she indicated that the Narcotic Interim box is exchanged daily during the evening shift Monday through Friday except Saturdays and Sundays. A face-to-face interview was conducted with Employee #11 and #7 on [DATE] at approximately 4:45 PM. After review of the above process the employees acknowledged the findings. Facility staff failed to conduct a medication review to identify expired narcotic medication (Acetaminophen 300mg/30mg with codeine #3). The observation was made on [DATE]. 2. Review of one (1) of two (2) Narcotic Interim Boxes revealed that facility staff failed to secure the portable narcotic box in a locked permanently affixed storage area and limited access to authorized personnel. An observation of the narcotic interim box was made on [DATE] at 9:40 AM with Employee #12 revealed that the box was on the counter in the medication room. Although the box was locked, the box was in area that allowed all personnel to have access to the area. Employee #12 indicated that the cabinet used for the second lock was jammed. After he/she readjusted items in the cabinet the cabinet was able to lock. A face-to-face interview was conducted with Employee #12 at the time of the observation. After review of the above, he/she acknowledged that the Narcotic Interim Box should have been … | 2014-04-01 | ||
| 2520 | 2520 | SPECIALTY HOSPITAL OF WASHINGTON - HADLEY SNF | 95024 | 4601 MARTIN LUTHER KING JR AVENUE SW | WASHINGTON | DC | 20032 | 2010-12-02 | 441 | E | GC5D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews for four (4) of 15 sampled residents, it was determined that facility staff failed to use protective barriers for two(2) of two (2) residents during dressing change, failed to wash hands during dressing change for two (2) of three (3) residents, used a contaminated yanker suction catheter to suction one (one) resident's mouth, stepped on one resident 's fall prevention mat (during a med pass observation), and attempted to use sink in shower room to provide perineal care to one (1) resident. Residents #1, 2, 7, and 11. The findings include: 1a. Facility staff failed to use a protective barrier during a dressing change of Resident #1's wound. During a dressing change observation on November 30, 2010 at approximately 11:30AM all of the dressing change materials (Normal Saline Solution /NSS, gauze, Santyl Ointment and tape) were observed on the resident's bedside table. No barrier was noted under the materials. Employee #10 removed the materials from the table and placed them on a pad (that was between the resident's body and the sheet covering the mattress) on the resident's mattress. The employee poured NSS over gauze and used the saturated gauze to cleanse the pressure ulcer. No barrier was ever used to protect and prevent contamination of the resident's bed. b. Facility staff failed to wash his/her hands after providing dressing change to Resident #1 ' s pressure ulcer and prior to suctioning the resident. Upon completing the dressing change procedure the employee changed his/her gloves, suctioned the resident ' s tracheostomy, then picked up a yanker suction catheter that was lying on top of the ventilator (exposed/no covering), held the yanker under an open faucet for approximately 15 seconds and used it to suction the resident's mouth. Upon completing the procedure the employee placed the yanker into the trash can. The aforementioned incident occurred at approximately 11:30AM on Nov… | 2014-04-01 | ||
| 2521 | 2521 | SPECIALTY HOSPITAL OF WASHINGTON - HADLEY SNF | 95024 | 4601 MARTIN LUTHER KING JR AVENUE SW | WASHINGTON | DC | 20032 | 2010-12-02 | 312 | D | GC5D11 | Based on observation, record review and staff interview for one (1) of 15 sampled residents, it was determined that facility staff failed to provide incontinent care to Resident #7 in a timely manner. The findings include: Facility staff failed to provide incontinent care to Resident #7 who was observed with urine soaked and mal odorous clothing. At approximately 9:30AM on December 1, 2010 Resident #7 was observed seated in a geri chair with a lap tray. The resident was observed between 9:30Am and 12:30PM. No employee assessed the resident between 9:30AM and 12:30PM. At approximately 12:45PM the assigned Certified Nursing Assistant (CNA) was asked to evaluate resident ' s incontinent status. He/she complied and the resident was taken to the Shower Room. Employee #20 (the assigned CNA) removed the resident's slacks and revealed a "soggy" urine soaked and mal-odorous incontinent pad and a pair of slacks with urine soaked crotch. The employee was queried when the resident was last toileted. The employee responded that he/she had left the facility to escort another resident on an appointment and only returned around 12:30PM. The employee added "Usually when we go out another CNA takes care of our residents." A review of the Treatment Administration Record (TAR) for December 1, 2010 revealed the following directive, " Bowel and Bladder Program, Toilet resident every two (2) hours while awake. " A review of the signature boxes for December 1, 2010 revealed a signature in the 8AM block which indicated that the treatment was carried out at that time. The signature boxes for 10:00AM and 12:00PM on December 1, 2010 were blank which indicated that the resident was not toileted at those times. A face-to-face interview was conducted with Employee #11 at approximately 1:30PM on December 1, 2010. Employee #11 stated when a CNA is sent out to transport a resident, that CNA's residents are usually reassigned to the remaining CNAs. Someone should have been assigned to cover but I am not sure if anyone was." Facility staff failed t… | 2014-04-01 | ||
| 2522 | 2522 | SPECIALTY HOSPITAL OF WASHINGTON - HADLEY SNF | 95024 | 4601 MARTIN LUTHER KING JR AVENUE SW | WASHINGTON | DC | 20032 | 2010-12-02 | 157 | D | GC5D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 15 sampled residents, it was determined that facility staff failed to notify the physician of their inability to obtain stool cultures for [MEDICAL CONDITION] (C. diff) for Resident F2 for 13 days. The findings include: A physician's orders [REDACTED]. Give Questran 1 pack 4 x (times) a day PRN for diarrhea. 2. Stool specimen to r/o (rule out) [DIAGNOSES REDACTED] " . The nursing notes revealed the following: "July 11, 2010 at 10:15 PM ...had one large soft brownish BM (bowel movement)..." "July 17, 2010 at 6:30 AM Unable to obtain stool specimen endorsed to next shift." "July 19, 2010 at 3:00 PM ...Unable to obtain specimen (stool) to r/o [DIAGNOSES REDACTED], will continue to monitor and follow up..." "July 24, 2010 at 3:00 PM ...unable to obtain stool specimen..." "July 25, 2010 at 3:05 PM Resident's stool could not be collected at 11 PM-7 AM and 7 AM-3:30 PM. Will continue (to) check. Endorsed to the incoming nurse. " "July 27, 2010 at 3:00 PM ...Unable to collect stool specimen ..." "July 28, 2010 at 4:00 PM ...C/O (complains of) 'I can ' t move my bowels right now.' Unable to obtain stool specimen for [DIAGNOSES REDACTED]. Will cont. (continue) to monitor. " "July 29, 2010 at 4:30 PM...Obtained stool for [DIAGNOSES REDACTED] it was sent." "July 30, 2010 at 4:00 PM Resident had large loose stool this AM. Stated, 'I took that laxative last night.' No further stool noted." "July 30, 2010 at 10:00 (PM) Resident dx with [DIAGNOSES REDACTED]. ABT (antibiotics) orders given, place on contact isolation..." The laboratory report collected July 29, 2010 and verified July 30, 2010 revealed, "Positive for [MEDICAL CONDITION] toxin." A physician's orders [REDACTED]. Put resident on contact isolation. Questran one pack po three times a day for loose stool " . The record lacked evidence that the physician was notified that the facility staff were unable to obtained Resident F2's stool for [DIAG… | 2014-04-01 | ||
| 2523 | 2523 | SPECIALTY HOSPITAL OF WASHINGTON - HADLEY SNF | 95024 | 4601 MARTIN LUTHER KING JR AVENUE SW | WASHINGTON | DC | 20032 | 2010-12-02 | 490 | E | GC5D11 | Based on observation, record review and staff interviews, it was determined that administration failed to implement and/or ensure that a process and/or system to communicate equipment failures from facility staff to administration was in place when essential equipment needs repair. The findings include: Observations made during a tour of the dietary services on November 29, 2010 revealed low dishwashing machine rinse temperatures, incomplete and pre-recorded dishwashing machine temperature logs; one (1) of one (1) ice machine, one (1) of one (1) steamer and one (1) of one (1) water softener that were inoperative. 1. On November 29, 2010 at 10:30 AM the dishwashing machine was observed and the rinse temperature was 168 degrees Fahrenheit (F). The required rinse temperature is 180 degrees F. 2. On November 29, 2010 at 10:35 AM a copy of the dishwashing machine temperature log was reviewed for the month of November 2010. At the time of the review the noon temperatures for November 29, 2010 had already been recorded as 190 degrees F for washing and 191 degrees F for rinse. These observations were made in the presence of Employee # 3 who acknowledged these findings during the survey. A review of the Ecolab invoice dated November 24, 2010 revealed, " Work order ...Equipment Description: Dish machine; Problem Description: Dish machine not filling; Service Performed: I checked the unit out and found the unit filling normally. I turned the unit on and found rinse temp too low, high limit on booster tripped. Rest high limit and tested unit, working the thermostat and high limit need to be replaced. Adjusted the wash tank temp control (higher). There is one missing curtain and the other two are dry rotted and should be replaced. The wash arm orings need to be replaced. Three final rinse nozzles need to be replaced left an estimate for repairs. " A face-to-face interview was conduct with Employee # 20 on December 1, 2010 at 12:15 PM. According to the facility staff member that was present when the Ecolab technician was prese… | 2014-04-01 | ||
| 2524 | 2524 | SPECIALTY HOSPITAL OF WASHINGTON - HADLEY SNF | 95024 | 4601 MARTIN LUTHER KING JR AVENUE SW | WASHINGTON | DC | 20032 | 2010-12-02 | 425 | D | GC5D11 | Based on observation and review of one (1) of one (1) In House Interim medication supply boxes it was determined that facility staff failed to failed to conduct a medication review to replace the in house supply of Zithromax 250 mg quantity ten (10). The findings include: 1. A review of the In House Interim Box was conducted with Employee #19 on November 30, 2010 at 3:38 PM. Upon review of the box it was revealed that the drawer that should have contained a quantity of ten (10) tablets of Zithromax 250mg was empty. A query was made as to where the pharmacy return slip was to replace the medication. Employee #19 was unable to produce that slip. The inventory list on the front of box revealed that the last time that the box was exchanged was signed and dated for November 25, 2010. A telephone interview was conducted with Employee #15 on December 1, 2010 at 10:42 AM. He/she indicated that the In House Interim Box is exchanged at least once a week. A face-to-face interview was conducted with Employee #11 and #7. After review of the above process he/she acknowledged the findings. Facility staff failed to conduct a medication review to replace the in house supply of Zithromax 250 mg quantity ten (10). The observation was made on November 30, 2010. | 2014-04-01 | ||
| 2525 | 2525 | SPECIALTY HOSPITAL OF WASHINGTON - HADLEY SNF | 95024 | 4601 MARTIN LUTHER KING JR AVENUE SW | WASHINGTON | DC | 20032 | 2010-12-02 | 428 | D | GC5D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review of one (1) of 15 sampled residents it was determined that facility staff failed to follow pharmacy recommendations to decrease Simvastatin 80 mg to Simvastatin 60 mg; and obtaining labs for Resident #11. The findings include: 1. A review of the Pharmacy " Consultation Report " signed and dated by the physician on August 3, 2010, (no time indicated revealed) revealed that the physician accepted the following recommendation(s) with the following modifications: (1) decrease Simvastatin 80 mg to 60 mg. Review of the current POS (Physicians' Order Sheet) dated and signed October 29, 2010 and the MAR (Medication Administration Record) signed for October 29, 2010 revealed that the order directed Simvastatin 80 mg give one (1) tablet by mouth/via [DEVICE] every day for Hypercholesterolemia. Further review of the September, October and November 2010 POS and MAR indicated [REDACTED]. Facility staff failed to follow pharmacy recommendations to decrease the Simvastatin from 80mg to 60mg. The record was reviewed on November 27, 2010. 2. Review of the Pharmacy "Consultation Report" signed and dated by the physician on August 3, 2010, (no time indicated revealed) revealed that the physician accepted the following recommendation(s) with the following modifications: obtain a Hgb A1C (hemoglobin A1C) routine, Fasting Lipid Panel, CBC (complete blood count) routine, and AST, ALT, and Alkaline Phosphate routine. Review of the current laboratory data revealed that there were no labs results for the Hgb A1C, Fasting Lipd Panel, CBC routine, AST, ALT or Alkaline Phosphate routine. A face-to-face interview was conducted with Employees #7 and 11 on December 1, 2010 at 10:42 AM. After review of the aforementioned POS, Employee #7 obtained a physician's orders [REDACTED]. Facility staff failed to follow the pharmacy recommendations decreasing the Simvastatin 80 mg to 60 mg and to obtain routine and specific labs for Resident #11. The record was r… | 2014-04-01 | ||
| 2526 | 2526 | SPECIALTY HOSPITAL OF WASHINGTON - HADLEY SNF | 95024 | 4601 MARTIN LUTHER KING JR AVENUE SW | WASHINGTON | DC | 20032 | 2010-12-02 | 502 | D | GC5D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 15 sampled residents it was determined that facility staff failed to follow physician's order [REDACTED]. The findings include: 1. A review of a Pharmacy " Consultation Report " signed and dated by the physician on August 3, 2010, (no time indicated) revealed that the physician accepted the following recommendation(s) with the following modifications: ...obtain a Hgb A1C (hemoglobin A1C) routine, Fasting Lipid Panel, CBC (complete blood count) routine, and AST, ALT, and Alkaline [MEDICATION NAME] routine according to the recommendations. Review of the current laboratory data failed to identify the aforementioned in the medical record. A face-to-face interview was conducted with Employee #7 and 11 after review of the lab recommendations Employee #7 obtained a current physician's orders [REDACTED]. The record was reviewed on November 27, 2010. | 2014-04-01 | ||
| 2527 | 2527 | INGLESIDE AT ROCK CREEK | 95028 | 3050 MILITARY ROAD NW | WASHINGTON | DC | 20015 | 2011-01-26 | 157 | D | OMNS11 | Based on record review and staff interviews for Resident #1, it was determined that facility staff failed to inform the physician of the resident ' s on-going pain and swelling in his/her right leg. The findings include; A review of Resident #1 ' s record revealed the following nurses ' notes: November 24, 2010 at 6:00 AM: " Resident slept well through the night. No acute distress noted, total care provided. Noted with pain 2/10 on pain assessment. Tylenol 325 mg ii tabs administered. Tolerated well with effective results noted. Turn and reposition q 2 hours heels floated for pressure relief. V/S 98.6, 70, 20, 120/68. " November 24, 2010 (no time noted): " Resident alert and verbally responsive. Medicated po as per MD order. PO (oral) fluids encouraged ADL care given. Skin warm and dry to touch. Right leg swelling decreased. Routine pain meds given on pain assessment scale 3/10. Effective no s/s of any distress noted. 98.0, 74, 20, 132/76. " November 24, 2010 at 9:50 PM: " Resident alert and verbally responsive. PM care provided and cooperative. Staff fed the resident in the room and tolerated 100%. Fluids consumed. Right leg swelling slightly reduced. No warmness noted. C/o pain on assessment 2/10 the routine pain medication administered. V/S 97.9, 20, 66, 120/71. " November 26, 2010 at 7:00 PM: " Resident alert and verbally responsive. PM care provided as needed. Resident resting in the bed, maintain position. Staff fed the resident in the bed and tolerated well. Positive attitude. Right leg knee swelling reduced on facial expression noted pain in pain assessment scale 2/10. " November 26, 2010, no time noted: " Noted pain on pain assessment scale 2/10 Routine pain medication administered. " November 28, 2010 at 6:20 AM: " Resident remains alert and verbally responsive. Had a quiet night. Observed with pain when floating heels. 2/10 on pain assessment. Tylenol 325 mg ii tabs given with effective results. " November 28, 2010 at 12:15 PM: " Resident alert and verbally responsive. ADL care given. Skin warm and dry… | 2014-04-01 | ||
| 2528 | 2528 | INGLESIDE AT ROCK CREEK | 95028 | 3050 MILITARY ROAD NW | WASHINGTON | DC | 20015 | 2011-01-26 | 386 | G | OMNS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and physician interview, it was determined for Resident #1 that the physician failed to treat a fracture in a timely manner. The findings include: A review of Resident #1 ' s record revealed a nurse ' s note dated November 23, 2010 at 10:00 PM: " V/S (vital signs) 97.6 (oral temperature in degrees Fahrenheit) 88 (pulse) 18 (Respiratory Rate) 118/74 (blood pressure). Alert and verbally responsive for right swelling, limb, knee 4 views, tibia films received, Physician #1 notified. No new orders given. MD wants results faxed to his office. Results faxed to MD ' s office. Daughter called message left for her to call the facility. Still awaiting R/P ' s (responsible party ' s) call. Pain management in progress. No acute distress or discomfort noted. Ate dinner in bed. Swollen leg elevated on a pillow. Swollen knee intact. No bruises or discoloration noted ... " The physician ordered an x-ray of the right knee and leg, multiple views. The results of the x-rays taken on November 23, 2010 follow: 1. Right Knee: " Results: Views of the right knee show no recent fracture or dislocation. There is evidence of deformity of the distal femur attributed to previous injury. Cyst formation is seen in the proximal tibia. Effusion is noted. Impression: No evidence of recent fracture. Cyst formation of the proximal tibia. 2. Lower Right Leg: Views of the right lower leg show no recent fracture or dislocation. There are cystic changes seen involving the proximal tibia with evidence of an old injury involving the distal femur Effusion is seen. Impression: 1. Benign Cyst formation of the proximal tibia with effusion. 2. Old injury to the distal femur. 3. Right Femur " Results: Views of the right femur show a hip prosthesis in place with the prosthetic head well seated in the acetabulum. The medullary portion of the device is well seated in the proximal femoral shaft. There is a fracture seen involving the proximal third of the femur and there … | 2014-04-01 | ||
| 2529 | 2529 | UNITED MEDICAL NURSING HOME | 95039 | 1310 SOUTHERN AVENUE, SE, SUITE 200 | WASHINGTON | DC | 20032 | 2010-12-09 | 241 | E | 4S0811 | Based on observations and staff interview for seven (7) of eight (8) residents reviewed, it was determined that facility staff failed to promote the residents ' dignity by failing to assist with grooming. The findings include: A complaint from a family member of Resident #1 was received by the state agency on November 29, 2010 that documented, " On November 28, I visited (Resident #1). His/her hygiene was completely neglected (I have photos of his/her fingernails ...). " An observation of the nursing unit where Resident #1 resided was conducted on December 1, 2010 from 2:00 PM through 2:30 PM in the company of Employee #1. The following was observed: Resident #1: fingernails were approximately ? inches long with accumulated debris under the nails. Resident #2: fingernails were observed with accumulated debris under all the nails Resident #3: fingernails were observed long and with accumulated debris under all the nails Resident #4: fingernails were observed approximately ? inches long and with accumulated debris under all the nails Resident #5: fingernails were observed with accumulated debris under all the nails Resident #6: fingernails were observed with accumulated debris under all the nails Resident #7: fingernails were observed long and with accumulated debris under all the nails Concurrently, a recreational aide was conducting the " Nail Salon " activity. This activity was conducted once per week. Six (6) other residents were in the day room waiting for nail care. A face-to-face interview was conducted with Employee #1 at the time of the observation. He/she acknowledged that facility nursing staff had failed to assist residents with appropriate nail care. | 2014-04-01 | ||
| 2530 | 2530 | UNITED MEDICAL NURSING HOME | 95039 | 1310 SOUTHERN AVENUE, SE, SUITE 200 | WASHINGTON | DC | 20032 | 2010-12-09 | 309 | D | 4S0811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review for one (1) of two (2) residents reviewed, it was determined that facility staff failed to follow a physician's order [REDACTED]. The findings include: A review of Resident #1 ' s record revealed the following telephone order dated August 25, 2010 at 3:00 PM and signed by the physician on September 27, 2010, and directed, " Resident is to return back for hearing test and hearing aid assessment after ENT when ears are clear. Please call to schedule appointment at (facility) for hearing evaluation. " Resident #1received ear drops to loosen the ear wax beginning on September 22, 2010. On October 11, 2010, he/she returned to the (facility) and had the wax removed from both ears. However, there was no evidence that an appointment was scheduled for a hearing test and hearing aid assessment post wax removal. A face-to-face interview was conducted with Employee #2 on December 1, 2010 at 3:30 PM. He/she was asked if a follow-up appointment was scheduled. Employee #2 stated, " I looked at the consult sheet when (Resident #1) came back from getting his/her ears clean and it said return PRN (as needed). I didn ' t realize the original consult recommended a follow-up visit after his/her ears were cleaned out. " Employee #2 immediately contacted the (facility) and scheduled a follow-up visit for January 4, 2011. The record was reviewed December 1, 2010. | 2014-04-01 | ||
| 2531 | 2531 | UNITED MEDICAL NURSING HOME | 95039 | 1310 SOUTHERN AVENUE, SE, SUITE 200 | WASHINGTON | DC | 20032 | 2010-12-09 | 386 | D | 4S0811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and pharmacy interviews for two (2) of two (2) residents reviewed, it was determined that the physician failed to review the total plan of care as evidence by signing orders for one (1) resident to receive a medication he/she was allergic to and for one (1) resident to receive a flu shot who was allergic to eggs. Residents #1 and #8. The findings include 1. The physician signed monthly orders for Tylenol #3 for Resident #1, who had an allergy to [MEDICATION NAME]. A review of Resident #1 ' s record revealed a physician ' s orders dated November 30, 2010 that directed: " Tylenol with [MEDICATION NAME] #3. Take 2 tablets (600/60mg) by mouth every 6 hours as needed for pain. " The physician ' s order sheets dated July 29, September 27, and October 30, 2010 were in the resident ' s active record, included the above order for [MEDICATION NAME] and documented that the resident had an allergy to [MEDICATION NAME]. Employee #1 contacted (Pharmacy) and reported that the medication had not been sent from the pharmacy since February 2010. According to the August, September, October and November 2010 Medication Administration Records, the resident did not received the medication. A face-to-face interview was conducted on December 1, 2010 at 3:30 PM with Employee #1. He/she acknowledged that the physician consistently signed orders for Tylenol with [MEDICATION NAME] despite that Resident ' s allergy to [MEDICATION NAME]. The record was reviewed December 1, 2010. 2. The physician signed an order for [REDACTED]. A review of Resident #8 ' s record revealed that he/she was identified as having an allergy to eggs. A telephone order dated September 24, 2010, and signed by the physician on September 29, 2010, directed, " Administer flu vaccine 0.5 ml. I.M. Give Tylenol 325 mg po q 4 hours pro for pain at injection site and for temp > 100 degrees F (Fahrenheit) x 3 days. " Resident #8 received the flu vaccine on September 24, 2010… | 2014-04-01 | ||
| 2532 | 2532 | UNITED MEDICAL NURSING HOME | 95039 | 1310 SOUTHERN AVENUE, SE, SUITE 200 | WASHINGTON | DC | 20032 | 2010-12-09 | 428 | D | 4S0811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for two (2) of two (2) residents reviewed, it was determined that the pharmacist failed to identify that a medication with codeine was ordered for Resident #1 who had an allergy to codeine and that Resident #8, who has an allergy to eggs, received a flu vaccine shot. The findings include: 1. The pharmacist failed to identify that Resident #1, who had an allergy to Codeine, was ordered Tylenol #3. A review of Resident #1 ' s record revealed a physician's order [REDACTED].#3. Take 2 tablets (600/60mg) by mouth every 6 hours as needed for pain. " According to the physician ' s pre-printed orders signed July 29, September 27, and October 30, 2010, the resident was allergic to Codeine. According to the " Medication Regime Review " the pharmacist visited the resident on September 13, October 16, and November 26, 2010. There was no evidence that the pharmacist identified that Resident #1 was allergic to Codeine and had a current order for Tylenol with Codeine #3 2. The pharmacist failed to identify that Resident #8 who received a flu vaccine shot, was allergic to eggs. A review of Resident #8 ' s record revealed that he/she was identified as having an allergy to eggs. A telephone order dated September 24, 2010, and signed by the physician on September 29, 2010, directed, " Administer flu vaccine 0.5 ml. I.M. Give Tylenol 325 mg po q 4 hours pro for pain at injection site and for temp > 100 degrees F (Fahrenheit) x 3 days. " Resident #8 received a flu vaccine on September 24, 2010. There was no evidence in the record that he/she had any untoward reaction to the vaccine. A telephone interview was conducted with a consultant pharmacist with (Pharmacy) on December 3, 2010 at 9:40 AM. The consultant pharmacist was asked if the flu vaccine was grown in an egg base. He/she stated, " Yes, all our flu vaccine was grown in an egg base. It should not have been given to anyone allergic to eggs. " According to the " Res… | 2014-04-01 | ||
| 2533 | 2533 | UNITED MEDICAL NURSING HOME | 95039 | 1310 SOUTHERN AVENUE, SE, SUITE 200 | WASHINGTON | DC | 20032 | 2010-12-09 | 492 | D | 4S0811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for Two (2) of two (2) residents reviewed, it was determined that the charge nurse failed to review the accuracy of medications as directed in 22DCMR 3210.4. Residents #1 and #8. The findings include: According to 22DCMR 3210.4, " The charge nurse shall be responsible for the following: ... (b) Reviewing medication records for completeness, accuracy in the transcription of physician orders [REDACTED]. 1. The charge nurse failed to review the accuracy of Resident #1 ' s medication record. The resident was allergic to [MEDICATION NAME] and an order for [REDACTED]. A review of Resident #1 ' s record revealed a physician's order [REDACTED].#3. Take 2 tablets (600/60mg) by mouth every 6 hours as needed for pain. " The order was printed onto the August, September, October and November 2010 Medication Administration Records. There was no evidence that the charge nurse reviewed the MARs and identified that the resident was allergic to [MEDICATION NAME] and had Tylenol #3 (with [MEDICATION NAME]) ordered. A face-to-face interview was conducted on December 1, 2010 at 3:30 PM with Employee #1. He/she acknowledged that the charge nurse should have identified that the resident had an allergy to [MEDICATION NAME] and called the physician to discontinue the Tylenol #3 order. The record was reviewed December 1, 2010. 2. The charge nurse failed to clarify a physician's order [REDACTED]. A telephone order dated September 24, 2010, and signed by the physician on September 29, 2010, directed, " Administer flu vaccine 0.5 ml. I.M. Give Tylenol 325 mg po q 4 hours pro for pain at injection site and for temp > 100 degrees F (Fahrenheit) x 3 days. " Resident #8 received a flu vaccine on September 24, 2010. There was no evidence in the record that he/she had any untoward reaction to the vaccine. A telephone interview was conducted with a consultant pharmacist with (Pharmacy) on December 3, 2010 at 9:40 AM. The consultant pha… | 2014-04-01 | ||
| 2534 | 2534 | STODDARD BAPTIST NURSING HOME | 95020 | 1818 NEWTON ST. NW | WASHINGTON | DC | 20010 | 2010-11-03 | 253 | D | JV5O11 | Based on observations made during environmental tours of the facility on October 27 and 28, 2010, it was determined that the facility failed to provide effective maintenance services in residents rooms as evidenced by bathroom floors that were torn in three (3) of 14 residents rooms on the first floor, a bathroom floor that was heavily stained in one (1) of 14 residents rooms on the second floor and a urine odor in two (2) of 14 residents rooms on the first floor. The findings include: 1. The bathroom floor in rooms #108, 111 and 115 was torn and needed to be repaired or replaced and the bathroom floor in room #207 was noticeably soiled. 2. A urine odor was evident in rooms #126 and 128. These observations were made in the presence of Employee # 12 who acknowledged these findings during the survey. | 2014-03-01 | ||
| 2535 | 2535 | STODDARD BAPTIST NURSING HOME | 95020 | 1818 NEWTON ST. NW | WASHINGTON | DC | 20010 | 2010-11-03 | 323 | D | JV5O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations made during the environmental tour of the facility on [DATE] and 28, 2010, it was determined that the facility failed to provide an environment that is free from accident hazards as evidenced by three (3) of three (3) expired bottles of eyewash solution and one (1) of three (3) oxygen tank that was stored upright and unsecured on the third floor nursing station and the facility staff failed to consistently monitor and assess Resident #15 after he/she verbalized attempted suicide in one (1) of 24 sampled residents. The findings include: 1A. Three (3) of three (3) bottles of eyewash solution stored in the soiled utility room on the first, second and third floor were expired on the following dates: [DATE], [DATE] and [DATE]. 1B. One (1) of three (3) oxygen tanks located on the third floor next to the IV cart at the nursing station was stored upright and directly on the floor. These findings were acknowledged by Employee # 12 who was present at the time of these observations. 2. Facility staff failed to consistently monitor and assess Resident #15 after he/she verbalized attempted suicide. Resident #15 allegedly took nine (9) of 10 Advil pills. Based on information revealed in the " Facility Occurrence Report " at 5:30 AM on [DATE], Resident #15 informed the facility ' s staff that he/she took 14 Advil pills. The documentation in the report stated, " He/she heard somebody saying that they are going to cut his/her legs off, so he/she took 14 pills of Advil to enable him/her to get to the hospital." A face-to-face interview was conducted with the resident at approximately 12:00PM on [DATE]. He/she acknowledged taking nine (9) Advil pills. He/she stated, " The bottle had 10 pills. I took one (1) (pill) before and I took the other nine (9) that day. You see, something was wrong with my legs. I thought they were going to cut my legs off and I decided I would rather die with my legs. I thought if I took the pills I would die but I… | 2014-03-01 | ||
| 2536 | 2536 | STODDARD BAPTIST NURSING HOME | 95020 | 1818 NEWTON ST. NW | WASHINGTON | DC | 20010 | 2010-11-03 | 371 | D | JV5O11 | Based on observations that were made during a tour of the dietary services on October 27, 2010, it was determined that the facility failed to prepare and serve food under sanitary conditions as evidenced by: 19 of approximately 150 small cartons of milk that were stored beyond their expiration date, insufficient air gap from four (4) of four (4) drain pipes, one (1) of one (1) expired pack of hot dog buns, two (2) of two (2) convection oven that were soiled and a carton of milk on the test tray that exceeded allowable cold food temperature limit. The findings include: 1. A total of 19 half-pint cartons of skim milk located in the walk-in refrigerator and the reach-in cooler were expired as of October 25, 2010. 2. Two (2) drain pipes from the ice machine and two drain pipes from the steamer extended too far into their respective drains and provided no air gap from the drains. 3. One (1) of one (1) pack of hot dog buns was expired as of October 25, 2010. 4. Two (2) of two (2) convection ovens were soiled. 5. A half-pint carton of milk from the test tray was tested at 63 degrees Fahrenheit. These observations were made in the presence of Employee #11 who acknowledged these findings during the survey. | 2014-03-01 | ||
| 2537 | 2537 | STODDARD BAPTIST NURSING HOME | 95020 | 1818 NEWTON ST. NW | WASHINGTON | DC | 20010 | 2010-11-03 | 463 | D | JV5O11 | Based on observations made during the environmental tour of the facility on October 27 and 28, 2010, it was determined that the facility staff failed to maintain resident's call system as evidenced by the failure of the call bell system to operate correctly in two (2) of 23 resident ' s room located on the second and third floors. The findings include: The call bell system in rooms #213 and #319 failed to initiate an alarm when engaged. These findings were acknowledged by Employees # 12 and 13 who were present at the time of these observations. | 2014-03-01 | ||
| 2538 | 2538 | STODDARD BAPTIST NURSING HOME | 95020 | 1818 NEWTON ST. NW | WASHINGTON | DC | 20010 | 2010-11-03 | 492 | E | JV5O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Based on record review and staff interview for one (1) of 24 sampled resident, it was determined that the physician failed to ensure that Resident #18 had a comprehensive assessment every 12 months. The findings include: 22 DCMR 3207.11 stipulates, "Each resident shall have a comprehensive medical examination and evaluation of his or her health status at least every twelve (12) months, and documented in the resident's medical record." During a review of Resident #18 ' s clinical record, it was determined that the physician failed to perform a comprehensive medical examination at least every twelve (12) months, and documented in the resident's medical record.. A review of the physician ' s progress notes revealed that the last documented history and physical was January 21, 2009. Documentation in the physician ' s progress notes revealed that the Nurse Practitioner visited and performed an examination on February 24, 2010. The physician failed to perform a comprehensive medical examination at least evry twelve (12) months, and documented in the resdient's medical record.. A face-to-face interview was conducted with Employee #6 on November 2, 2010 at approximately 1:00 PM. He/she reviewed the physician progress notes [REDACTED]. The clinical record was reviewed on November 2, 2010. B. Based on record review and staff interview for one (1) of 24 sampled residents, it was determined that the Social Worker failed to perform quarterly social assessment and evaluation for Resident #4. The findings include: According to 22 DCMR 3229.5, " The social assessment and evaluation, plan of care and progress notes, including changes in the resident ' s social condition, shall be incorporated in each resident ' s medical record, reviewed quarterly, and revised as necessary. " A review of Resident #4 ' s clinical record revealed that the last social services note was written on February 25, 2010. A face-to-face interview was conducted with Employee# 14 on N… | 2014-03-01 | ||
| 2539 | 2539 | STODDARD BAPTIST NURSING HOME | 95020 | 1818 NEWTON ST. NW | WASHINGTON | DC | 20010 | 2010-11-03 | 497 | E | JV5O11 | Based on employee record review and staff interview for 20 of 100 Certified Nurse Aides, it was determined that facility staff failed to ensure that performance reviews were conducted for CNAs at least once every 12 months. The findings include: A review of the Certified Nurse Aides employee records revealed the following: Employee # 20- Employee Evaluation date January 13, 2009 and signed by the employee on September 7, 2010. Employee # 21- Employee Evaluation date April 5, 2009 and signed by the employee on September 20, 2010. Employee # 22- Employee Evaluation date May 3, 2009 and signed by the employee on September 20, 2010. Employee # 23- Employee Evaluation date May 27, 2009 and signed by the employee on September 20, 2010. Employee # 24- Employee Evaluation date May 30, 2009 and signed by the employee on September 20, 2010. Employee # 25- Employee Evaluation date June 25, 2009 and signed by the employee on September 20, 2010. Employee # 26- Employee Evaluation date July 14, 2009 and signed by the employee on September 20, 2010. Employee # 27- Employee Evaluation date August 6, 2009 and signed by the employee on October 2, 2010. Employee # 28- Employee Evaluation date September 2, 2009 and signed by the employee on September 20, 2010. Employee # 29- Employee Evaluation date September 29, 2009 and signed by the employee on September 20, 2010. Employee # 30- Employee Evaluation date September 29, 2009 and signed by the employee on October 29, 2010. Employee # 31- Employee Evaluation date October 10, 2009 and signed by the employee on September 20, 2010. Employee # 32- Employee Evaluation date October 13, 2009 and signed by the employee on September 20, 2010. Employee # 33- Employee Evaluation date October 22, 2009 and signed by the employee on September 20, 2010. Employee # 34- Employee Evaluation date October 22, 2009 and signed by the employee on October 29, 2010. Employee # 35- Employee Evaluation date October 23, 2009 and signed by the employee on September 10, 2010. Employee # 36- Employee Evaluation dat… | 2014-03-01 | ||
| 2540 | 2540 | STODDARD BAPTIST NURSING HOME | 95020 | 1818 NEWTON ST. NW | WASHINGTON | DC | 20010 | 2010-11-03 | 441 | E | JV5O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Based on a review of the Infection Control Program and staff interviews, it was determined that the facility staff failed to consistently list all residents with infections in the facility on the "Infection Control Surveillance/Investigation" reports for two (2) of 24 sampled residents and two (2) of 14 supplemental residents. Residents #1, 8, F1 and F2. The findings include: A review of the facility's Infection Control Program and review of the "Infection Control Surveillance/investigation" line listing reports for May, June July and August 2010 revealed that all residents in the facility with noted infections were not listed on the report as evidenced by: 1. A review of Resident #1 ' s record revealed the following: A review of the laboratory results reported May 8, 2010 for Resident #1 revealed, " Source of Culture: urine; Organism Isolated: Proteus Mirabilis ... " On May 9, 2010 a physician's order [REDACTED]. " There was no documented evidence on the May 2010 " Infection Control Surveillance/Investigation " that Resident #1 was identified/listed as having a UTI. 2. A review of Resident #8 ' s record revealed the following: A review of the June 11, 2010 laboratory results for Resident #8 revealed, " Source of Culture: urine; Organism Isolated: Proteus Mirabilis ... " On June 11, 2010 a physician's order [REDACTED]. There was no documented evidence on the June 2010 " Infection Control Surveillance/Investigation" line listing that Resident #8 was identified/listed as having a urinary tract infection. 3. A review of Resident F1 ' s record revealed the following: A review of the ophthalmology reported dated July 30, 2010 for Resident #F1 revealed, " Diagnosis/Plan 1. Bacterial Conjunctivitis ...Iritis; New Orders: start [MEDICATION NAME] 1 gtt (drop) QID (four times a day) left eye 4 days, then TID (three times daily) left eye for 3 days. " A review of the physician's order [REDACTED]. " A review of the July and August 2010 MAR (Medication… | 2014-03-01 | ||
| 2541 | 2541 | STODDARD BAPTIST NURSING HOME | 95020 | 1818 NEWTON ST. NW | WASHINGTON | DC | 20010 | 2010-11-03 | 279 | D | JV5O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview for two (2) of 24 sampled residents, it was determined that facility staff failed to develop a care plan with appropriate goals and approaches for one (1) resident for refusing to wear a hearing aid and one (1) resident with an allegation of attempted suicide. Residents #6 and 15. The findings include: 1. Facility staff failed to initiate a care plan for Resident #6's refusal to wear his/her hearing-aid. At approximately 3:30 PM on November 1, 2010 Resident #6 was observed lying in bed, A Pocket-talker was observed on the resident ' s night stand. No device was visible in either ear. The resident was unresponsive to verbal stimuli when observed. The resident was again observed at approximately 11:00AM on November 2, 2010 without the hearing devices. At approximately 4:30 PM another observation was made in the presence of Employee #6. The employee acknowledged that the resident was not wearing any hearing devices and added, "He/she refuses to wear the hearing aid. Whenever we put the hearing aid in his/her ear he/she takes it out. We keep it locked in the medication cart for safety. We use the pocket talker along with the hearing aid." The hearing aid was removed from the cart and observed in it's case. A review of the care plans in the resident's clinical record failed to reveal any evidence indicating that the facility staff care planned the resident's refusal to wear the hearing aid. A review of a report of an audiology follow-up dated March 25, 2010 revealed the following: "Resident #6 (name) was very unresponsive today. He/she did not wear hrg (hearing) aid to his/her appt. (appointment)." Recommendation: "Use of some form of amplification." The audiologist continued: "(Name) was seen at the (facility) for a follow-up appt. for a previously issued hearing-aid. (Name) appeared very sluggish and unresponsive to questions today. He/she was much more responsive during his/her previous au… | 2014-03-01 | ||
| 2542 | 2542 | STODDARD BAPTIST NURSING HOME | 95020 | 1818 NEWTON ST. NW | WASHINGTON | DC | 20010 | 2010-11-03 | 281 | D | JV5O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview of one (1) of 24 sampled residents, and six (6) of 14 supplemental records, it was determined that facility staff failed to meet professional standards of quality by not measuring the apical pulse for 1 minute prior to the administration of [MEDICATION NAME] for one (1) resident; the facility staff failed to identify parameters and landmarks for assessing the heart rate (apical pulse) for residents prior to the administration of [MEDICATION NAME] for one (1) of 24 sampled residents and six (6) supplemental residents; and the dietitian failed to utilize the Resident's weight in his/her nutritional risk assessments. Supplemental Residents #1, 11, S1, S2, S3, S4, S5, and S6. The findings include: 1. Facility staff failed to meet professional standards of quality by not measuring the apical pulse for 1 minute prior to the administration of [MEDICATION NAME] for one (1) resident for Resident #11. Review of the " Physicians Orders " dated and signed October 19, 2010 for Resident #11 directed " [MEDICATION NAME] 0.125mg tab ...Give 1 tab by mouth every day for [MEDICAL CONDITIONS]. " A medication pass observation of Employee #18 was conducted on October 27, 2010 at approximately 10:00 AM. He/she failed to measure the apical pulse for 1 minute prior to the administration of [MEDICATION NAME] (used to treat [MEDICAL CONDITION] and heart rhythm problems). Resident #11 was observed sitting in his/her room in a wheelchair. Employee # 18 indicated that he/she would administer his/her medications. Employee #18 obtained the blood pressure and pulse using the electronic cuff applied to the left upper arm. Employee #18 proceeded to give all medications to Resident #11 by mouth. At this point the State Agency (SA) representative stopped the medication administration process. The SA queried Employee #18 about the process taken prior to the administration of [MEDICATION NAME]. Employee #18 replied, " I am … | 2014-03-01 | ||
| 2543 | 2543 | STODDARD BAPTIST NURSING HOME | 95020 | 1818 NEWTON ST. NW | WASHINGTON | DC | 20010 | 2010-11-03 | 309 | G | JV5O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for six (6) of 24 sampled resident and two (2) of 13 supplemental residents, it was determined that facility staff failed to follow up with one (1)resident's weight loss, failed to consistently obtain monthly weights for one (1) resident in accordance with physician orders [REDACTED]. [REDACTED]. and failed to allow sufficient nursing time to obtain weights in accordance with the facility's policy for one (1) resident on isolation. Residents # 6, 1, 7, 10, 11, 16, F1 and F5. The findings include: 1. Facility staff failed to follow-up with Resident #6's weight loss. A review of the Treatment Administration Record for Resident #6 revealed the following daily weights. Date Weight October 20, 2010 171 pounds October 21, 2010 172 pounds October 22, 2010 164.5 pounds October 23, 2010 164 pounds October 24, 2010 162 pounds October 25, 2010 160 pounds October 26, 2010 160 pounds October 27, 2010 160.5 pounds October 28, 2010 159 pounds October 29, 2010 159.4 pounds October 30, 2010 158 pounds October 31, 2010 159.5 pounds According to the documentation of weights on the Treatment Administration Record (TAR) the resident lost 7.5 pounds between October 21 and 22, 2010 and an additional 5 pounds between October 22 and 31, 2010 (total of 12.5 pounds). Review of the resident's clinical record failed to reveal any documentation that addressed the resident's weight loss of 12.5 pounds. The facility has no policy for daily weight. The facility's "Monthly Weight" Policy was last reviewed on November 15, 2002. Under the headings of Procedure and Nursing: Item #1 stated, "Residents will be weighed monthly, unless more frequent monitoring is requested." Review of the record revealed that the resident returned to the facility with the following order on October 19, 2010, "Daily weight till the next [MEDICAL CONDITIONS] appointment. Send weight record with resident for the next [MEDICAL CONDITION] appointment." Per the d… | 2014-03-01 | ||
| 2544 | 2544 | STODDARD BAPTIST NURSING HOME | 95020 | 1818 NEWTON ST. NW | WASHINGTON | DC | 20010 | 2010-11-03 | 157 | D | JV5O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 24 sampled records, it was determined that facility staff failed to inform the physician/responsible party of Resident's #6's weight loss. The findings include: The admission order sheet and physician plan of care signed and dated by the physican on October 19, 2010, directed, "Daily weight til the next [MEDICAL CONDITION] appointment. Send weight record with resident for the next [MEDICAL CONDITION] appointment." According to the Treatment Administration Record Resident #6's daily weighs were as follows: Date Weight October 20, 2010 171 pounds October 21, 2010 172 pounds October 22, 2010 164.5 pounds October 23, 2010 164 pounds October 24, 2010 162 pounds October 25, 2010 160 pounds October 26, 2010 160 pounds October 27, 2010 160.5 pounds October 28, 2010 159 pounds October 29, 2010 159.4 pounds October 30, 2010 158 pounds October 31, 2010 159.5 pounds According to the documentation of weights on the Treatment Administration Record (TAR) the resident lost 7.5 pounds between October 21 and 22, 2010. There was no evidence in the nurses' notes and the physicians' notes that the physician/responsible party was notified of the resident's weight loss. A face-to-face interview was conducted with Employee #6 at approximately 11:00 AM on November 1, 2010. He/she acknowledged that neither the physician nor the responsible party was ever notified of the resident's weight loss. The employee added, "We did not notify the doctor or the responsible party of the weight loss because the resident had an order for [REDACTED]." The record was reviewed on October 29, 2010. | 2014-03-01 | ||
| 2545 | 2545 | STODDARD BAPTIST NURSING HOME | 95020 | 1818 NEWTON ST. NW | WASHINGTON | DC | 20010 | 2010-11-03 | 431 | D | JV5O11 | Based on observations, record review and staff interview of one (1) of three (3) emergency crash cart medication boxes and two (2) of three (3) narcotic reconciliation forms, it was determined that facility staff failed to ensure that one (1) of three (3) emergency crash cart boxes had appropriate medication par level(s) of Vitamin K and facility staff failed to consistently provide two (2) signatures on the narcotic reconciliation forms for two (2) of three (3) units. The findings include: 1. On November 1, 2010 at approximately 10:50 AM a review of third floor emergency crash cart revealed that the emergency medication box did not have the required number of ampoules of vitamin K as listed on the pharmacy provided inventory list. The pharmacy inventory list reveals all mediction(s) in the emergency medication box and the number of each medication . The box contained one (1) ampoule instead of two (2) ampoules as listed on the pharmacy provided inventory list. The facility staff failed to ensure the appropriate par levels of vitamin K for the crash cart medication boxes. A face-to-face interview was conducted with Employee #19 at the time of the observation. He/she acknowledged the finding and proceeded to alert pharmacy services of the error. The observation was made November 1, 2010. 2. Facility staff failed to consistently provide two (2) signatures to reconcile the narcotics sign-in sheets for two (2) of three (3) units for the month of August 2010. A review of the Narcotic Reconciliation book was conducnted on October 29, 2010 at approximately 10:30 AM on the 2nd floor Cart B. It was determined that on August 19, 2010 on the 7:00 AM to 3:30 PM shift, there was no off going signature for the nurse. A face-to-face interview was conducted with Employee #15 at the time of the observation and after review of the forms he/she acknowledged the findings. The observation was made on October 29, 2010. A review of the Narcotic Reconciliation book was conducnted on October 29, 2010 at approximately 11:15 AM on the 3nd … | 2014-03-01 | ||
| 2546 | 2546 | STODDARD BAPTIST NURSING HOME | 95020 | 1818 NEWTON ST. NW | WASHINGTON | DC | 20010 | 2010-11-03 | 155 | D | JV5O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 24 sampled residents, it was determined that facility staff failed to meet with Resident #9 ' s family and discuss Advance Directives as directed by the physician. The findings include: The social worker failed to meet and discuss Advance Directives with Resident #9 ' s family as directed by the physician. A review of a physician's order [REDACTED]. " A review of the resident ' s clinical record failed to reveal any evidence that the social worker had a meeting with the family during which the physician was called for a discussion of Advanced Directives. A face-to-face interview was conducted with Employee #14 at approximately 1:40PM on October 29, 2010. He/she acknowledged that no meeting was held with the resident ' s family. He/she stated, " I placed a call to the family and told them the facility needed to talk to them. I felt that was the end of my responsibility. My concentration right now is on MDS 3.0. I have to talk to residents, 27 people by Friday. That was my priority. " The record was reviewed on October 29, 2010. | 2014-03-01 | ||
| 2547 | 2547 | STODDARD BAPTIST NURSING HOME | 95020 | 1818 NEWTON ST. NW | WASHINGTON | DC | 20010 | 2010-11-03 | 278 | D | JV5O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for three (3) of 24 sampled residents, it was determined that facility staff failed to code the Minimum Data Set (MDS) for: the use of diuretics for one (1) resident; pressure ulcers for one (1) resident; and " input " for one (1) resident. Residents # 11, 16 and 24. The findings include: 1. Facility staff failed to code the annual MDS dated [DATE] for "Diuretics" under Section N (Medications) for Resident #11. A review of the physician's order [REDACTED]. " According to the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The facility failed to code diuretics on the annual MDS completed September 28, 2010 Assessment Reference Date of October 13, 2010. A review of the annual MDS dated [DATE] revealed that Section N (Medications ) was not coded for "Diuretics". A face-to-face interview was conducted with Employee #7 on November 1, 2010 at approximately 2:00 PM. He/she acknowledged that diuretic was not coded on the annual MDS. The record was reviewed November 1, 2010. 2. Facility staff failed to accurately code Section M (Skin) on the significant change MDS (Minimum Data Set) for Resident #16. Review of the Admissions MDS completed on September 21, 2010 with an ARD (Assessment Reference Date) of September 17, 2010 revealed that in Section M (Skin Condition) the resident was coded for one (1) stage I ulcer and three (3) stage II ulcers. Review of the Significant Change MDS with an ARD of October 15, 2010 revealed that Sections M0300 and M0900 lacked coding. Review of the skin " Assessment Sheets " dated October 25, 2010 revealed that Resident #16 had a Right buttock, Left buttock and a Sacral stage III skin alteration (wound type not identified) and a Right hip stage II skin alteration (wound type not identified). Review of the skin " Assessment Sheets " dated October 29, 2010 revealed that Resident #16 had no change in a right and left buttock and sacral pressure s… | 2014-03-01 | ||
| 2548 | 2548 | STODDARD BAPTIST NURSING HOME | 95020 | 1818 NEWTON ST. NW | WASHINGTON | DC | 20010 | 2010-11-03 | 514 | D | JV5O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record and staff interview for one (1) of 24 sampled residents, it was determined that facility staff failed to accurately document the administration the pneumococcal vaccine on the facility immunization record for Resident #24. The findings include: A review of Resident #24 ' s record revealed that a permission slip signed and dated September 16, 2010 which indicated that the resident ' s next of kin/point of contact gave the facility permission to administer the Influenza Vaccine and the Pneumococcal Vaccine. A physician's order [REDACTED]. The September 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of the " Stoddard Baptist Nursing Home Immunization Record " revealed that facility staff documented that the resident was given the Influenza Vaccine in the left deltoid on September 22, 2010. There was no evidence that facility staff documented the administration of the pneumococcal vaccine on the line identified for the administration of the pneumococcal vaccine. A face-to-face interview was conducted with Employee # 5 on November 1, 2010 at 12:07 PM. He/she acknowledged that the pneumococcal vaccine was documented on the line which indicated that the Influenza Vaccine was administered. The record was reviewed on November 1, 2010. | 2014-03-01 | ||
| 2549 | 2549 | STODDARD BAPTIST NURSING HOME | 95020 | 1818 NEWTON ST. NW | WASHINGTON | DC | 20010 | 2010-11-03 | 387 | D | JV5O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 24 sampled residents, it was determined that the physician failed to visit every 30 days for the first 90 days for one (1) resident for Resident #5. The findings include: The physician failed to visit Resident #5 every 30 days for the first 90 days after admission. A review of Resident #5's record revealed that the resident was admitted to the facility on [DATE]. An admission history and physical examination [REDACTED]. The next written and dated physician progress notes [REDACTED]. There was no evidence in the record to indicate that the physician had seen the resident and wrote a progress every 30 days after for the first 90 days of admission since January 27, 2010. A face-to-face interview was conducted with Employee #5 on October 29, 2010 at 1:15 PM. After a review of the clinical record, he/she acknowledged that the physician did not visit the resident every 30 days for the first 90 days after the resident ' s admission. The record was reviewed October 29, 2010. | 2014-03-01 | ||
| 2550 | 2550 | STODDARD BAPTIST NURSING HOME | 95020 | 1818 NEWTON ST. NW | WASHINGTON | DC | 20010 | 2010-11-03 | 285 | D | JV5O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 24 sampled residents, it was determined that facility staff failed to provide a completed MI/MR PASRR (Pre-Admission Screen/Resident Review) screening for Resident #3. The findings include: A review of the clinical record for Resident #3 revealed that he/she was admitted to the facility on [DATE] and all the requird sections of the MI/MR PASRR screening on the record were not completed. A review of the Pre-Admission Screen/Resident Review for Mental Illness and/ or Mental [MEDICAL CONDITION] form signed and dated September 14, 2010 for Resident #3 revealed that Part A (Extempting Critiria) was completed with the first two questions marked with a check and the third question remained blank. A face-to-face interview was conducted on October 28, 2010 at 10:20 AM with Employees #42 and #44. Both stated that the MI/MR was not completed because the resident was still on rehab (rehabilitation) admission which allowed exemption of up to 100 days for the completion of the MI/MR PASRR screening. After the resident follow up visit at the hospital the MI/MR PASRR screening would then be completed. A further face-to-face interview was conducted on October 29, 2010 at 12:35 PM with Employees #42 and #43 it was revealed that if the physician checked all three areas in Part A of the Pre-Admission Screen/Resident Review for Mental Illness and/ or Mental [MEDICAL CONDITION] form it would exempt completion of MI/MR screening. The third line was not checked the facility should have completed the MI/MR PASRR screening. The record was reviewed on October 29, 2010. | 2014-03-01 | ||
| 2551 | 2551 | STODDARD BAPTIST NURSING HOME | 95020 | 1818 NEWTON ST. NW | WASHINGTON | DC | 20010 | 2010-11-03 | 325 | D | JV5O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 24 sampled residents, it was determined that the dietitian failed to utilize the Resident's weight in his/her nutritional risk assessments for Resident #1. The findings include: According to the " Admitting Evaluation and History (History and Physical), " Resident #1 was admitted to the facility on [DATE]. Chief Complaint: ..[MEDICAL CONDITIONS], Dementia, Stage IV Sacrum (Decubitus); Physical Examination: Weight was " 110 1bs (pounds)." A review of Resident # 1's record revealed physician's order [REDACTED]." A nurse ' s progress note dated April 16, 2010 at 10:45 PM revealed, " Weight 110 lbs. Pt (patient) stable." The " Nursing Monthly Summary " reports revealed the following weights: April 20, 2010 --- 110 (pounds) May 20, 2010 --- Wt (weight) ... Isolation June 20, 2010 ---- Wt ... Isolation July 26, 2010 --- Wt ... Isolation August, 2010- no weight documented September 2010 - no weight documented According to the monthly weight log sheet the following was revealed: April------ no weight documented May --- Isolation June --- no weight documented July --- no weight documented August, 2010- no weight documented September 2010 - no weight documented There was no evidence in the record that the resident had monthly weights consistently obtained from April to September 2010. A " Nutrition Risk Assessment " dated April 22, 2010 revealed, "Weight: 110 lbs " . Dietary progress notes dated May 26, 2010 revealed, " Resident on contact isolation, so no (weight) obtained. " The " Nutrition Progress/Quarterly Review " signed and dated July 7, 2010 revealed, " Weight: isolation ... no weight. " There was no evidence that the dietitian utilized the resident ' s body weight in his/her assessment of the resident ' s nutritional status. An attending physician note dated August 17, 2010 revealed, " He/she has improved significantly since admission and since he/she gets adequate nutrition; we are una… | 2014-03-01 | ||
| 2552 | 2552 | STODDARD BAPTIST NURSING HOME | 95020 | 1818 NEWTON ST. NW | WASHINGTON | DC | 20010 | 2010-11-03 | 504 | D | JV5O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 24 sampled residents, it was determined that the physician failed to obtain laboratory services only when ordered by the attending physician for Resident #19. The findings include: A review of the clinical record revealed an interim physician's orders [REDACTED]." A physician ' s progress note dated August 7, 2010 revealed, " Patient has frequent micturation, currently a febrile, will order UA C/S and [MEDICATION NAME], if culture higher ...risk of [MEDICATION NAME] minimal, monitor BP (blood pressure). " Resident #19 ' s laboratory results received between August 7, 2010 and October 28, 2010 were reviewed. There was no evidence that results for the UA C/S specimen collected on August 8, 2010 was received/obtained. The record lacked evidence that the C/S results were obtained prior to the administration of [MEDICATION NAME] and in accordance with the physicians order. The record lacked evidence that facility staff followed up on the request for the resident ' s C/S laboratory results. A face-to-face interview was conducted with Employee # 19 on October 28, 2010 at 11:24 AM. After Employee #3 reviewed the clinical record, he/she acknowledged that the aforementioned laboratory studies were not obtained in accordance to the above orders. The record was reviewed on October 28, 2010. | 2014-03-01 | ||
| 2553 | 2553 | STODDARD BAPTIST NURSING HOME | 95020 | 1818 NEWTON ST. NW | WASHINGTON | DC | 20010 | 2010-11-03 | 490 | F | JV5O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for four (4) of 24 sampled resident and two (2) of 13 supplemental residents, it was determined that Administration failed to provide necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care as evidenced by failure to develop and implement policies for weighing residents that address the following: assessment of residents receiving daily weights, a re-weight policy that obtains a reweight in less than for five days for residents requiring re-weights, obtaining weights for residents that are on isolation and reconciliation ofdifferences between weights obtained at the [MEDICAL TREATMENT] center with weights obtained in the facility. Residents # 6, 1, 10, 16, F1 and F5. The findings include: 1. Facility staff failed to follow-up with Resident #6's weight loss. A review of the Treatment Administration Record for Resident #6 revealed the following daily weights. Date Weight October 20, 2010 171 pounds October 21, 2010 172 pounds October 22, 2010 164.5 pounds October 23, 2010 164 pounds October 24, 2010 162 pounds October 25, 2010 160 pounds October 26, 2010 160 pounds October 27, 2010 160.5 pounds October 28, 2010 159 pounds October 29, 2010 159.4 pounds October 30, 2010 158 pounds October 31, 2010 159.5 pounds According to the documentation of weights on the Treatment Administration Record (TAR) the resident lost 13.4 pounds between October 20 and 31, 2010. Review of the resident's clinical record failed to reveal any documentation that addressed the resident's weight loss. The facility has no policy for daily weight. The facility's "Monthly Weight" Policy was last reviewed on November 15, 2002. Under the headings of Procedure and Nursing: Item #1 stated, "Residents will be weighed monthly, unless more frequent monitoring is requested." Review of the record revealed that the r… | 2014-03-01 | ||
| 2554 | 2554 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2010-10-26 | 203 | D | Z7J711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews for Resident #1, it was determined that facility staff failed to notify the resident 30 days prior to discharge and failed to identify a location that he/she would be discharged to safely. The findings include: A review of Resident #1 ' s record revealed that he/she was born on February 6, 1949 and was admitted to the facility on [DATE]. According to the quarterly Minimum Data Set (MDS) assessment completed August 5, 2010, he/she was assessed with [REDACTED]. He/she was assessed as requiring supervision for all Activities of Living in Section G (Physical Function and Structural Problems). Disease [DIAGNOSES REDACTED]. The nurses ' notes were reviewed from May 11, 2010 (date of admission) to September 24, 2010 (resident transferred to hospital). The following was noted: The resident struck other residents or staff on June 24, 2010, August 2, 23, and 31, 2010, September 13, 22, 23 and 24, 2010. The resident was hospitalized for [REDACTED]. The psychiatrist visited the resident on May 14, June 24, July 18 and September 12, 2010. The psychiatrist ' s recommendations of the visits conducted June 24, July 18 and September 12, 2010 were: " Recommend trying to place (Resident #1) in a more secure setting given his/her [MEDICAL CONDITION] and threatening behaviors. " The resident ' s antipsychotic medications were adjusted seven (7) times from May 14, 2010 through August 30, 2010. A face-to-face interview was conducted on October 26, 2010 at 12:30 PM with Employee #1. He/she stated, " Resident #1 was not a good fit for our home. He/she was [MEDICAL CONDITION] unpredictable .... He/she did hurt some staff members and hit other residents. When (Resident #1) was sent to the (hospital) (on September 24, 2010), I told the discharge planner (at the hospital) that we would not be able to take him/her back. I sent all the paper work to let them know they needed to start with looking for a place for him/her right awa… | 2014-02-01 | ||
| 2555 | 2555 | WASHINGTON CTR FOR AGING SVCS | 95014 | 2601 18TH STREET NE | WASHINGTON | DC | 20018 | 2010-10-29 | 281 | G | RQEZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for Resident #1, it was determined that facility staff failed to monitor and document assessments for bruising and/or bleed for a resident receiving [MEDICATION NAME]. The findings include: Resident #1 was born on May 18, 1939 and was admitted to the facility on [DATE]. According to the admission Minimum Data Set assessment completed September 21, 2010, he/she was assessed with [REDACTED]. He/she was assessed as being totally dependent for bed mobility, transfers, dressing, toilet use, requiring extensive assistance for personal hygiene and bathing and independent for eating in Section G (Physical Functioning and Structural Problems). Disease [DIAGNOSES REDACTED]. According to the physician ' s admission orders [MEDICATION NAME] ([MEDICATION NAME]) 5 mg po q HS (orally at bedtime). " A PT/INR ([MEDICATION NAME] Time/ International Normalized Ratio) laboratory result dated September 10, 2010 was 58.7 (normal range 12 - 15 seconds). The physician ordered " [MEDICATION NAME] 5 mg po q HS. Hold x 2 days Resume when INR therapeutic " on September 10, 2010. Therapeutic range was defined as between 2 and 3 seconds as per the standards printed on the laboratory report. The therapeutic range for INR remained above 2 to 3 seconds from September 10 through 21, 2010. On September 21, 2010, the INR was 2.38. According to the September and October 2010 Medication Administration Record, [REDACTED]. Entries in the " [MEDICATION NAME] Management and Monitoring Record " for September 13, 14 and 16, 2010 noted the resident had no signs or symptoms of bruising or bleeding. There was no evidence in the " [MEDICATION NAME] Management and Monitoring Record " or the nurses ' noted from September 22 through October 4, 2010 that facility staff assessed Resident #1 for bruising or bleeding while he/she was receiving [MEDICATION NAME]. Upon admission, the physician's order [REDACTED].e. bruises, scratches, skin breakdown or dis… | 2014-02-01 | ||
| 2556 | 2556 | WASHINGTON CTR FOR AGING SVCS | 95014 | 2601 18TH STREET NE | WASHINGTON | DC | 20018 | 2010-10-29 | 329 | G | RQEZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for Resident #1, it was determined that the physician failed to adequately monitor the PT/INR values for a resident receiving [MEDICATION NAME]. The findings include: Resident #1 was admitted to the facility on [DATE]. According to the physician ' s admission orders [MEDICATION NAME] ([MEDICATION NAME]) 5 mg po q HS (orally at bedtime). " A PT/INR ([MEDICATION NAME] Time/ International Normalized Ratio) laboratory result dated September 10, 2010 was 58.7 (normal range 12 - 15 seconds). The physician ordered " [MEDICATION NAME] 5 mg po q HS. Hold x 2 days Resume when INR therapeutic " on September 10, 2010. Therapeutic range was defined as between 2 and 3 seconds as per the standards printed on the laboratory report. The therapeutic range for INR remained above 2 to 3 seconds from September 10 through 21, 2010. On September 21, 2010, the INR was 2.38. On September 21, 2010, the physician ordered, " [MEDICATION NAME] 4.5 mg po at 6 PM. PT/INR in two weeks. " According to the September and October 2010 Medication Administration Record, [REDACTED]. According to the pack insert for [MEDICATION NAME]: " Laboratory Control: The PT should be determined daily after the administration of the initial dose until PT/INR results stabilize in the therapeutic range ...To ensure adequate control, it is recommended that additional PT tests be done ...whenever other medications are initiated, discontinued or taken irregularly ... " (http://packageinserts.bms.com) " The resident had not received [MEDICATION NAME] from September 9 through September 21, 2010, a total of 12 days. There was no evidence that the physician ordered daily PT/INR laboratory tests after the medication was initiated on September 21, 2010 as per the manufacturer ' s recommendations. The resident was hospitalized on [DATE] for [MEDICAL CONDITION]. He/she returned to the facility on the same day. A urinalysis was completed while the resident was in t… | 2014-02-01 | ||
| 2557 | 2557 | BRINTON WOODS HEALTH & REHAB CENTER AT DUPONT CIRC | 95031 | 2131 O STREET NW | WASHINGTON | DC | 20037 | 2010-12-30 | 225 | D | MPGV11 | Based on record review and staff and resident interview for one (1) of 26 sampled residents, it was determined that facility staff failed to investigate and to report to the State Agency an allegation of one resident's sexually inappropriate behavior towards an employee. Resident #6. The findings include: Facility staff failed to investigate and report an allegation of one resident's sexually inappropriate behavior towards an employee to the State Agency. A face-to-face interview was conducted with Employee #14 at approximately 2:00 PM on December 29, 2010. The employee stated, " I was on the elevator with the resident on October 6,2011. Without any warning the resident grasped and squeezed both of my breasts with his/her two hands. He/she squeezed my breasts so hard that they were bruised for several weeks. His/her action was totally unexpected and it scared me. " A face-to-face interview was conducted with Resident #6 at approximately 10:30AM on December 28, 2010. The resident was queried whether he/she had committed the act of touching and squeezing the employee ' s breasts. The resident laughed aloud and said, "I don ' t know why I did it but it felt good. " A face-to face interview was conducted with Employee #2 at approximately 3:00PM on December 28, 2010. The employee acknowledged that there was no documentation of the incident and that no report of the incident or the investigation was ever sent to the State Agency. Facility staff failed to investigate and report an allegation of one resident ' s sexually inappropriate behavior towards an employee to the State Agency. The record was reviewed on December 28, 2010. | 2014-02-01 | ||
| 2558 | 2558 | BRINTON WOODS HEALTH & REHAB CENTER AT DUPONT CIRC | 95031 | 2131 O STREET NW | WASHINGTON | DC | 20037 | 2010-12-30 | 371 | E | MPGV11 | Based on observations that were made during a tour of the dietary services on December 27, 2010, it was determined that the facility failed to prepare and serve food under sanitary conditions as evidenced by low wash and rinse dishwashing machine water temperatures, three (3) of three (3) soiled, cracked and torn dishwashing machine curtains, one (1) of one (1) temperature gauge on the steamer that was not visible and expired foods such as four (4) of four (4) half-gallon of eggnog that expired as of 12/26/2010 and one (1) of four (4) packs of hamburger rolls that expired as of 12/26/2010. The findings include: 1. Dishwashing machine temperatures did not meet the manufacturer 's recommended minimum limit. Wash temperature was 140 degrees Fahrenheit (F) and 150 degrees F is recommended while rinse temperature did not exceed 136 degrees F and 160 degrees F is suggested. However, final rinse temperature was above the set range of 180 degrees F and reached 184 degrees F. 2. Dishwashing machine curtains were soiled, cracked, torn and needed to be replaced. 3. The temperature gauge on the steamer was hazy and the numbers could not be seen or read. 4. The following food items were stored beyond their expiration date: four (4) half- gallons of eggnog (12/26) and one (1) pack of hamburger rolls (12/26). These observations were made in the presence of employee # 11 who acknowledged these findings during the survey. | 2014-02-01 | ||
| 2559 | 2559 | BRINTON WOODS HEALTH & REHAB CENTER AT DUPONT CIRC | 95031 | 2131 O STREET NW | WASHINGTON | DC | 20037 | 2010-12-30 | 253 | D | MPGV11 | Based on observations made during the environmental tours of the facility between December 28 and December 30, 2010, it was determined that the facility failed to provide effective maintenance services in residents rooms as evidenced by: loose cubicle curtain tracks in three (3) of 48 resident 's rooms and damaged floor tiles on the first floor. The findings include: 1. Cubicle curtains tracks were loose in rooms #405, 412 and 421. 2. Approximately 26 floor tiles were damaged in the east wing hallway on the first floor. These observations were made in the presence of Employee's #12 and #13 who acknowledged the findings. | 2014-02-01 | ||
| 2560 | 2560 | BRINTON WOODS HEALTH & REHAB CENTER AT DUPONT CIRC | 95031 | 2131 O STREET NW | WASHINGTON | DC | 20037 | 2010-12-30 | 323 | D | MPGV11 | Based on observations made during the environmental tours of the facility on December 28 thru December 30, 2010, it was determined that the facility failed to provide an environment that is free from accident hazards as evidenced by one (1) of two (2) oxygen tanks that was left on top of a cabinet in the clean linen room on the third floor and three (3) of three (3) surge protectors that were observed on the floor in the rehabilitation area and one (1) room was observed without signage to indicate that Oxygen was in continuous use within the room. The findings include: 1. An oxygen tank was stored upright and unsecured on top of a cabinet in the clean linen room on the third floor. 2. Three surge protectors were in use, on the floor, and were not secured to the wall in the rehabilitation center on the 5 th floor. These observations were made in the presence of Employee's #12 and # 13 who acknowledged the findings. 3. Facility staff failed to post signage outside the room of one (1) resident ' s room to indicate that Oxygen was in use continuously. Resident #12. During a tour of the facility at approximately 9:00AM on December 27, 2010 Resident #12 was observed lying in bed with Oxygen infusing via nasal cannula. There is no signage outside of the room to indicate that Oxygen was in use. The observation was made in the presence of Employee #7 who was accompanying the surveyor on the tour. The employee acknowledged the finding and stated, " I have the sign in my office. I forgot to put it outside of the room. " | 2014-02-01 | ||
| 2561 | 2561 | BRINTON WOODS HEALTH & REHAB CENTER AT DUPONT CIRC | 95031 | 2131 O STREET NW | WASHINGTON | DC | 20037 | 2010-12-30 | 469 | D | MPGV11 | Based on observations made during the environmental tour of the facility on December 28 thru December 30 2010, it was determined that the facility failed to maintain an effective pest control program as evidenced by flying insects seen on three (3) of five (5) floors during the survey. The findings include: Flying insects were observed in rooms # 103, 401 and the kitchen dining room during the survey period. These observations were made in the presence of Employee's # 12 and # 13 who were present at the time of observation. | 2014-02-01 | ||
| 2562 | 2562 | BRINTON WOODS HEALTH & REHAB CENTER AT DUPONT CIRC | 95031 | 2131 O STREET NW | WASHINGTON | DC | 20037 | 2010-12-30 | 492 | D | MPGV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview of one (1) of 26 sampled residents, it was determined that facility staff failed to ensure that a physical examination was performed at least once every 12 months for one resident. Resident #13. The findings include: In accordance with Title 22 DCMR (District of Columbia Municipal Regulations) 3207.11 " Each resident shall have a comprehensive medical examination and evaluation of his or her health status at least every twelve (12) months, and documented in the resident ' s medical record. A review of Resident #13 ' s clinical record revealed an admissions date of June 7, 2004. Further review of the clinical record revealed that the last " History and Physical " was conducted on July 6, 2009. The record lacked evidence that a comprehensive history and physical evaluation had been done since July 6, 2009. A face-to-face interview was conducted with Employee #5 on December 28, 2010 at 1:30 PM. After review of the clinical record he/she acknowledged the findings and indicated that he/she would check further for the document. Employee #5 failed to produce a history and physical examination [REDACTED]. The record was reviewed on December 28, 2010. | 2014-02-01 | ||
| 2563 | 2563 | BRINTON WOODS HEALTH & REHAB CENTER AT DUPONT CIRC | 95031 | 2131 O STREET NW | WASHINGTON | DC | 20037 | 2010-12-30 | 278 | D | MPGV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for three (3) of 26 sampled residents, it was determined that facility staff failed to accurately code the Minimum Data Set (MDS) for one (1) resident for Urinary Tract Infection [MEDICAL CONDITION], one (1) resident for an ostomy, and feeding tube, and one(1) resident with a history of falls, . Residents #2, 4, and 7. The findings include: 1. Facility staff failed to code Resident #2 annual MDS 3.0 with Assessment Reference date of December 10, 2010 and Assessment completion date of December 16, 2010 for "Urinary Tract Infection [MEDICAL CONDITION]" under Section I (Infections). A review of the physician's order [REDACTED].O. BID times ten days for UTI " . A review of the Nurse's Progress Note dated December 1, 2010 reveals a note that stated. " Foley catheter was placed for wound healing at request of wound care team, drainage of thick bloody urine with pyuria (pus in urine) now noted in bag." A review of the annual MDS 3.0 on December 28, 2010 revealed that Section I (Infections) was not coded for "UTI". A face-to-face interview was conducted with Employee #9 on December 28, 2010 at approximately 9:00 AM. He/she acknowledged that "UTI" was not coded on the annual MDS 3.0. The record was reviewed December 28, 2010. 2. Review of Resident #4 ' s quarterly MDS (Minimum Data Set) assessment with an ARD (assessment reference date) of October 15, 2010 revealed that the resident's feeding tube was mis- coded as "ostomy" in Section H Bladder and Bowel h0100: (c) Appliances and not coded in Section K Swallowing/Nutritional Status k0500; facility staff also failed to code the percent of intake by artificial Route in Section k0700: Section A. According to the CMS ' s (Center for Medicaid and Medicare) RAI Version 3.0 Manual page H-2 under " Coding Tips and Special Populations: do not code gastrostomies or other feeding ostomies in this section. Only appliances used for elimination are coded here. " Review of … | 2014-02-01 | ||
| 2564 | 2564 | BRINTON WOODS HEALTH & REHAB CENTER AT DUPONT CIRC | 95031 | 2131 O STREET NW | WASHINGTON | DC | 20037 | 2010-12-30 | 334 | D | MPGV11 | Based on record review and staff interview of one (1) of 26 sampled residents it was determined that facility staff failed to provide documentation that identified that the resident was offered an influenza immunization.annually or that the legal representative received education regarding the benefits and potential side effects of the immunization. Resident # 4 The findings include: Review of the clinical record revealed that the last time that Resident #4 was offered the influenza immunization was October 29, 2009. A query was made on December 28, 2010 at 11:30 AM to Employees #7 of the documentation for the year 2010 that identified that the resident was offered the immunizations and the documentation that identified that the legal representative received information about the benefits and potential side effects of the immunization. Employee #7 indicated that the relative signed the consent for the resident to receive the immunization. Employee #7 was unable to provide current documentation of the above immunizations. Facility staff failed to provide current documentation that Resident #4 was offered the above immunization or that the legal representative received documentation about the above mentioned immunization. The record was reviewed on December 28, 2010. | 2014-02-01 | ||
| 2565 | 2565 | BRINTON WOODS HEALTH & REHAB CENTER AT DUPONT CIRC | 95031 | 2131 O STREET NW | WASHINGTON | DC | 20037 | 2010-12-30 | 276 | D | MPGV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 26 sampled residents, it was determined that the facility staff failed to complete a a quarterly review assessment for the resident.. Resident #14. The findings include: A review of the Clinical Records on December 28, 2010 at approximately 2:00 PM revealed that the last MDS (Minimum Data Set) on the chart was an annual MDS dated [DATE]. There was no quarterly MDS assessment dated for October 2010 found on Resident #14 ' s Clinical Record. A face-to-face interview was conducted with Employee #9 on December 28, 2010 at approximately 2:30 PM. He/she acknowledged the above findings. The record was reviewed December 28, 2010. | 2014-02-01 | ||
| 2566 | 2566 | BRINTON WOODS HEALTH & REHAB CENTER AT DUPONT CIRC | 95031 | 2131 O STREET NW | WASHINGTON | DC | 20037 | 2010-12-30 | 309 | D | MPGV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for three (3) of 26 sampled residents, it was determined that the facility failed to follow up on a psychiatric consult for one (1) resident; failed to follow up on resident's consultation report from an orthopedic appointment for one(1) resident; and failed to call the attending physician when the resident's blood sugar was less than 80 for one (1) resident. Residents #7, #19 and #22. The findings include: 1.Facility staff failed to follow up on a psych (psychiatric) consult for Resident #7. A review of the interum orders revealed the following: September 9, 2010 at 3:00 PM, " s/p (status [REDACTED]. September 23, 2010 at 12:30 PM, " s/p fall medications review...Psych consult. " A further review of the record revealed that a psychiatric evalution was completed on October 13, 2010. The record revealed that the psychiatric evaluation was done 34 days after the initial directive (from the physician) on September 9, 2010 s/p Resident #7 ' s fall. A face-to-face interview was conducted on December 30, 2010 at 10:00 AM with Employee # 4. He/she acknowledged that the psychiatric evaluation was done 34 days after the initial directive (from the physician) on September 9, 2010 s/p Resident #7 ' s fall. The record was reviewed December 30, 2010. 2. Facility staff failed to follow-up on Resident #19's consultation report from an orthopedic appointment. A review of the nurse's note dated July 14, 2010 acknowledged that Resident #19 was scheduled for an orthopedic appointment on July 23, 2010 for shoulder pain. The nurse's note dated July 23, 2010 acknowledged that the resident went to his/her appointment and returned to the facility. There was no evidencein the clinical record that a follow-up report regarding the resident ' s outcome of the consultation was present. Additionally, there were no progress note(s) from the physician or the nursing staff that address the outcome of the consultation. On December 30… | 2014-02-01 | ||
| 2567 | 2567 | BRINTON WOODS HEALTH & REHAB CENTER AT DUPONT CIRC | 95031 | 2131 O STREET NW | WASHINGTON | DC | 20037 | 2010-12-30 | 279 | D | MPGV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident and staff interview for one (1) of 26 sampled residents, it was determined that facility staff failed to initiate a care plan with goals and approaches for shoulder pain for Resident #19. The findings include: A face-to-face interview was conducted on December 28, 2010 at approximately 3:00 PM with Resident #19. He/she stated, " I have shoulder pain. " A review of the Resident #19's record revealed that he/she was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of the nurse's notes on July 14, 2010 acknowledged that the resident is scheduled for an orthopedic appointment on July 23, 2010 for shoulder pain. The nurse ' s notes on November 17, 2010 and on December 28, 2010 revealed that the resident complained of pain of the right shoulder. According to the December 2010 Medication Administration Record, [REDACTED]. A review of the care plan section of the record, lacked evidence that a care plan for shoulder pain was initiated with goals and approaches to address Resident #19's shoulder pain. A face-to-face interview was conducted on December 30, 2010 at approximately 10:00 AM with Employee #5. He/she acknowledged that a care plan for shoulder pain was not initiated. The record was reviewed on December 30, 2010. | 2014-02-01 | ||
| 2568 | 2568 | BRINTON WOODS HEALTH & REHAB CENTER AT DUPONT CIRC | 95031 | 2131 O STREET NW | WASHINGTON | DC | 20037 | 2010-12-30 | 514 | D | MPGV11 | Based on record review and staff interview for one (1) of 26 residents reviewed, facility staff failed to accurately document the history of falls for Resident #7. The findings include: A review of the nursing notes revealed that Resident #7 was observed sitting on the floor in the social room on September 8, 2010. The " Fall Risk Assessment " dated October 11, 2010 was scored as zero in Section B for the history of falls in the past three (3) months. The record lacked evidence that the " Fall Risk Assessment " was accurately documented in Section B for the history of falls in the past three (3) months. A face-to-face interview was conducted on December 30, 2010 at 10:00 AM with Employee #4 who acknowledged that the " Fall Risk Assessment " was inaccurately coded. The record was reviewed on December 30, 2010. | 2014-02-01 | ||
| 2569 | 2569 | BRINTON WOODS HEALTH & REHAB CENTER AT DUPONT CIRC | 95031 | 2131 O STREET NW | WASHINGTON | DC | 20037 | 2010-12-30 | 431 | D | MPGV11 | Based on observations, record review and staff interviews, it was determined that facility staff failed to accurately reconcile a controlled substance medication for one (1) of 26 residents and failed to discard one (1) of one (1) bottle of Humalog insulin stored beyond expiration date. Resident #12 The findings include: 1. Facility staff failed to accurately reconcile a controlled substance medication for Resident #12 receiving morphine. On December 28, 2010 at approximately 11:00 AM one (1) of one (1) bottle of Morphine Concentrate was observed with 20 mls of medication remaining in the bottle. A review of the " Controlled Drug Receipt/Record/Disposition Form " revealed that on December 28, 2010 at 9:00 AM 0.25mls of morphine concentrate was administered to the resident and the amount remaining was 15.50 mls. There was no evidence that facility staff accurately reconciled the amount of Morphine Concentrate that remained in the bottle with the disposition form. This observation was made in the presence of Employee # 7 who acknowledged the aforementioned findings. 2. Facility staff failed to discard one (1) of one (1) vial of Humalog stored beyond the expiration date. On December 28, 2010 at approximately 10:45 AM one (1) of one (1) vial of Humalog 100 was observed stored in the 4th floor medication refrigerator. The open date was documented as November 20, 2010 with an expiration date of December 28, 2010. The vial of Humalog was available for use to be administered to the resident for 38 days, eight (8) days past the expiration date. This observation was made in the presence of Employee # 7 who acknowledged the aforementioned findings. | 2014-02-01 | ||
| 2570 | 2570 | BRINTON WOODS HEALTH & REHAB CENTER AT DUPONT CIRC | 95031 | 2131 O STREET NW | WASHINGTON | DC | 20037 | 2010-12-30 | 157 | D | MPGV11 | Based on record review and staff interview for one (1) of 26 sampled residents, it was determined that facility staff failed to notify the physician when Resident #1 had a significant weight loss. The findings include: A review of the December 2010 weights for Resident #1 revealed the following: December 2, 2010 226.5 pounds December 4, 2010 225.5 pounds December 8, 2010 224.6 pounds December 15, 2010 203.6 pounds The review of the weights revealed that Resident #1 lost 21 pounds within seven (7) days. A review of the physician, nursing and dietary progress notes, revealed that the physician and the responsible party were not notified of the 21 pound weight loss by Resident #1 that occured within seven (7) days. A face-to-face interview was conducted on December 28, 2010 at 10:25 AM with Employee # 6. He/she acknowledged that the physician and the responsible party were notified of the weight loss. The record was reviewed December 28, 2010. | 2014-02-01 | ||
| 2571 | 2571 | BRINTON WOODS HEALTH & REHAB CENTER AT DUPONT CIRC | 95031 | 2131 O STREET NW | WASHINGTON | DC | 20037 | 2010-12-30 | 325 | D | MPGV11 | Based on record review and staff interveiw for one (1) of 26 sampled residents, it was determined that facility staff failed to complete an assessment for Resident#1 with a significant weight loss. The findings include: A review of the December 2010 weights for Resident #1 revealed the following: December 2, 2010 226.5 pounds December 4, 2010 225.5 pounds December 8, 2010 224.6 pounds December 15, 2010 203.6 pounds The review of the weights revealed that Resident #1 lost 21 pounds within seven (7) days. A review of the clinical record revealed that the dietitian failed to assess Resident #1 ' s 21 pound weight loss. A face-to-face interview was conducted on December 28, 2010 at 10:25 AM with Employee # 6. He/she acknowledged that the dietitian did not assess Resident #1's 21 pound weight loss that occured with in seven days. The record was reviewed December 28, 2010. | 2014-02-01 | ||
| 2572 | 2572 | BRINTON WOODS HEALTH & REHAB CENTER AT DUPONT CIRC | 95031 | 2131 O STREET NW | WASHINGTON | DC | 20037 | 2010-12-30 | 176 | D | MPGV11 | Based on record review and staff interview for one (1) of 26 sampled residents, it was determined that facility staff failed to utilize the interdisciplinary team to determine if the resident was able to self administer medications. Resident #10. The findings include: During a tour of Unit Two at approximately 9:30AM on December 27, 2010 (2) bottles of Magic Mouth Wash were observed on the resident ' s bedside table. One bottle was completely filled (8oz) and the other was partially filled (approximately 6oz). The bottles had labels from an area hospital and had the following directions; " Rinse mouth with two (2) tablespoons of liquid three to four (4) times a day before meals. Do not swallow. " Both bottles were dated December 20, 2010. A face-to-face interview was conducted with the resident at approximately 9:45AM on December 27, 2010 in the presence of Employee #7. When queried about the use of the mouth wash the resident stated, " They gave it to me in the hospital and told me to use it before I eat. I use it about three (3) times a day. " Employee #7 informed this surveyor that the resident had recently returned to the facility from a short stay in an area hospital. The employee acknowledged that no Interdisciplinary Team Meeting (IDT) was held to determine whether the resident was capable of administering his/her medications. He/She stated, " I will remove the mouth wash right now. " The facility staff failed to utilize the interdisciplinary team to determine if the resident was able to self administer medications before allowing him/her to do so. | 2014-02-01 | ||
| 2573 | 2573 | BRINTON WOODS HEALTH & REHAB CENTER AT DUPONT CIRC | 95031 | 2131 O STREET NW | WASHINGTON | DC | 20037 | 2010-12-30 | 389 | D | MPGV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 26 sampled residents, it was determined that facility staff failed to obtain emergency psychiatric evaluation in a timely manner for a resident after that resident's inappropriate sexual behavior towards an employee. Resident #6. The findings include: Facility staff failed to obtain emergency psychiatric evaluation in a timely manner for a resident after an allegation of sexually inappropriate behavior towards an employee of the facility. A review of the resident's history and physical report which was completed in July, 201The resident has a history of Substance Abuse, Cognitive Impairment., Behavior Issues, [MEDICAL CONDITION] and Dementia. He/she was being treated with [MEDICATION NAME] for Mood Disorder and [MEDICATION NAME] for [MEDICAL CONDITION] with aggression. A review of the resident ' s clinical record revealed a physician ' s telephone order dated October 6, 2010 which directed the following, " Psych (Psychiatric) consult (emergency) to evaluate capacity to make decisions, inappropriate sexual behavior and touching of female. " A review of a Psychiatric consultation Report in the Progress Notes revealed that the documentation was made on October 11, 2010 (five days after the psych consult was ordered). After his/her examination of the resident the psychiatrist wrote, " He/she is not able to engage in any cognitive exercise due to his/her memory loss. ... Plan (1) Add [MEDICATION NAME] 40 mg PO (by mouth) q am (every morning) (2) Possible transfer to all male group home if no improvement and if available. " A face-to-face interview was conducted with Employee #1 at approximately 11:00AM on December 29, 2010. The employee acknowledged that the psychiatric consultation should have been completed sooner than five (5) days. The employee added, " One reason for the delay was that there was a weekend within those five (5) days. We have taken steps to ensure that all future emergen… | 2014-02-01 | ||
| 2574 | 2574 | UNITED MEDICAL NURSING HOME | 95039 | 1310 SOUTHERN AVENUE, SE, SUITE 200 | WASHINGTON | DC | 20032 | 2010-10-28 | 514 | D | 9QIW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) resident, it was determined that the Resident Care Aides (RCA) failed to consistently document the percentage of a meal consumed. Resident #1. A review of Resident #1 ' s record revealed that he/she was born on March 7, 1963 and was admitted to the facility on [DATE]. According to the quarterly Minimum Data Set (MDS) assessment completed June 18, 2010, he/she was assessed with [REDACTED]. He/she was assessed as requiring total assistance for bed mobility and transfers and extensive assistance for toileting, personal hygiene and bathing in Section G (Physical Functioning and Structural Problems). Disease [DIAGNOSES REDACTED]. A " Meal Percentages " book records the amount of food eaten at a meal by each resident. This activity is to be completed by the RCAs. A review of the " Meal Percentages " book revealed that there was no percentage of meal intake as follows: Date Number of residents with no meal percentage intake. Total census 21. October 18, 2010 Breakfast: 12/21 Lunch: 12/21 Dinner: 0/21 October 19, 2010 Breakfast: 0/21 (charting on all residents) Lunch: 0/21 (charting on all residents) Dinner: 13/21 October 20, 2010 Breakfast: 1/21 Lunch: 0/21 (charting on all residents) Dinner: 1/21 October 21, 2010 Breakfast: 0/21 (charting on all residents) Lunch: 0/21 (charting on all residents) Dinner: 21/21 (no charting on any resident October 22, 2010 Breakfast: 1/21 Lunch: 14/21 Dinner: 21/21 (no charting on any resident) October 23, 2010 Breakfast: 7/21 Lunch: 7/21 Dinner: 21/21 (no charting on any resident) October 24, 2010 Breakfast: 21/21 (no charting on any resident) Lunch: 21/21 (no charting on any resident) Dinner: 21/21 (no charting on any resident) Face-to-face interviews were conducted on October 28, 2010 from 10:55 AM through 11:15 AM with the three (3) RCAs on duty, Employees #1, #2 and #3. The three (3) RCAs acknowledged that it is the responsibility of the RCA to enter the mea… | 2014-02-01 | ||
| 2575 | 2575 | UNITED MEDICAL NURSING HOME | 95039 | 1310 SOUTHERN AVENUE, SE, SUITE 200 | WASHINGTON | DC | 20032 | 2010-10-28 | 425 | D | 9QIW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined for Resident #1 that the facility failed to develop a system that ensured routine C2 medication orders were consistently signed by the physician and that the medication was provided to the resident on a timely basis. Resident #1 The findings include: A review of Resident #1 ' s record revealed a physician's order [REDACTED]. " The facility identified that the Oxycontin was to be administered at 6:00 AM and 6:00 PM. Reviews of the October 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The reason written on the reverse side of the October 2010 MAR indicated [REDACTED]. " A face-to-face interview was conducted with Employee #4, on October 28, 2010 at 9:30 AM. He/she stated, " The pharmacy delivery person brings us the green forms that are the renewal forms for the C2 drugs. Those get put into the resident ' s record for the doctors to sign. The problem is that the doctors don ' t come on a regular basis. They come whenever. So the forms don ' t always get signed on time. I know that this way does not work to get the C2 forms signed on time. There is no tracking system for the green forms after they are placed in the resident ' s record. When I came in Tuesday morning (October 26, 2010) I called the pharmacy and asked what the problem was for Resident #1. The pharmacy told me that the prescription had expired so I called the doctor and got the C2 form signed, faxed it to the pharmacy and called the pharmacy to ensure that we would get the Oxycontin on time. " The resident received Oxycontin 20 mg at 6:00 PM on October 26, 2010. The record was reviewed October 28, 2010. | 2014-02-01 | ||
| 2576 | 2576 | WASHINGTON NURSING FACILITY | 95022 | 2425 25TH STREET SE | WASHINGTON | DC | 20020 | 2010-09-07 | 223 | D | NOSV11 | Based on record review and staff and resident interviews for one (1) of three (3) sampled residents, it was determined that facility staff failed to ensure that one (1) resident was free from physical abuse. The findings include: A review of an incident report received on August 16, 2010 revealed that a family member wrote a letter and identified Employee #1 as abusing Resident #1 while in the hallway of the facility. There is a camera mounted in the hallway that recorded the incident and was viewed during this investigation. The recording showed Employee #1 standing over Resident #1, seated in a wheelchair, in the hallway. Employee #1 pointed towards the direction of Resident #1 ' s room. Resident #1 did not turn around. Employee #1 tried to turn Resident #1 around, but he/she put his/her feet flat on the floor and the wheelchair could not be moved. Employee #1 tipped the wheelchair back resting on the back two wheels and raising the front two wheels off the floor, in an attempt to turn the chair around as Resident #1 hung onto the hallway hand rail. Employee #1 dropped the chair back onto the floor and walked away from Resident #1 throwing his/her arms up in the air. The recording had no sound. A face-to-face interview was conducted with Employee #1 on September 3, 2010 at 11:15 AM. Employee #1 acknowledged that tipping Resident #1 in the wheelchair onto the back wheels was, " not right. " Employee #1 stated, " I see now that I should not have done that. That was wrong. " Facility staff failed to ensure that Resident #1 was free from physical abuse. The record was reviewed August 18, 2010. | 2014-01-01 | ||
| 2577 | 2577 | CAPITOL HILL NURSING CENTER | 95027 | 700 CONST. AVE. NE | WASHINGTON | DC | 20002 | 2010-08-23 | 279 | E | 3GVT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview for six (6) of 23 sampled residents, it was determined that facility staff failed to initiate care plans for communication for two (2) residents, activities for one (1) resident, , incontinence for one (1) resident, [MEDICAL CONDITION] for one (1) resident, decreased range of motion for one (1) resident, lip biting and post-op lip repair for one (1) resident, altered skin integrity for one (1) resident, pain for one (1) resident, hypercalcemia for one (1) resident, and hypertension for one (1) resident. Residents #1, 2, 10, 12, 14 and 19. The findings include: 1. Facility staff failed to develop a care plan for incontinence and communication for Resident #1. According to the resident ' s annual Minimum Data Set (MDS) assessment completed June 16, 2010 the resident was coded in Section C " Communication/Hearing patterns " C 4, 5 and 6 " Making self understood ", " Speech clarity " and " Ability to understand others" as "Rarely/never understood ", " No speech: absence of spoken words " and " Rarely/never understands. " The resident ' s annual MDS assessment completed on June 16, 2010 revealed that " Urinary incontinence and indwelling catheter and Communication was triggered in Section V " Resident assessment protocol summary " (RAPs). A further review of the resident ' s clinical record revealed a "MDS Footnote Form" that indicated that a care conference was conducted on June16, 2010. A review of the resident ' s care plans lacked evidence that facility staff initiated care plans with appropriate goals and approaches for incontinence and communication when the resident ' s care conference was conducted. A face-to-face interview was conducted on August 19, 2010 at approximately 10:30 AM with Employee #12. After a review of the resident ' s clinical record and an observation of the resident, he/she acknowledged the aforementioned findings. The record was reviewed on August 19, 2010. 2. Facility … | 2014-01-01 | ||
| 2578 | 2578 | CAPITOL HILL NURSING CENTER | 95027 | 700 CONST. AVE. NE | WASHINGTON | DC | 20002 | 2010-08-23 | 309 | G | 3GVT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview for 12 of 23 sampled residents and three (3) supplemental residents, it was determined that facility staff failed to: failed to reassess pain during removal of a dressing from the scalp for one (1) resident, follow-up with the physician's orders [REDACTED]. [REDACTED]. [REDACTED]. Residents # 1, 3, 4, 5, 6, 8, 9, 10, 11, 13, 17, and 21. The findings include: The facility staff failed to stop a wound care treatment and reassess Resident #11 for pain when he/she grimaced and flailed his/her arms during the removal of an old dressing. During an observation of a wound care treatment for [REDACTED].#18 was going to perform a dressing change to the resident occipital area. The second nurse (Employee #14) held Resident #11 on his /her left side and held the resident's head stable so that Employee #18 could remove the old dressing. As Employee #18 began pulling/removing the old dressing from the occipital area, Resident #11 ' s hair was being pulled from his/her scalp. Resident #11 flailed his/her arms and grimaced throughout the entire process of removing the old dressing. Employee #14 stated to Resident #11, "I ' m sorry. Do you want to hold my hand? We are almost done. Okay. It ' s almost over. Sorry for that." Employee #18 continued to remove the old dressing and never stopped to reassess Resident #11 for pain. Once the old dressing was removed Resident #11 stopped grimacing and flailing his/her arms. A review of the August 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]' s order dated July 29, 2010. The " Wound and Skin Care Progress " note dated August 12, 2010 revealed, " Wound #2 ...Location: Occipital Scalp ...Characteristics: Stage II; 3x4x0.0 cm ...No drainage ...Treatment: Add protective form (foam) dressing qd (every day) and PRN " The interim order dated August 12, 2010 " Occipital Scalp: Cleanse with NS (normal saline), Pat dry, Apply cov… | 2014-01-01 | ||
| 2579 | 2579 | CAPITOL HILL NURSING CENTER | 95027 | 700 CONST. AVE. NE | WASHINGTON | DC | 20002 | 2010-08-23 | 281 | D | 3GVT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations during the medication pass conducted on August 17, 2010 at 10:30 AM, it was determined that facility staff failed to use appropriate standard of care technique while administering medication via gastrostomy tubing ([DEVICE]) for one (1) resident. Resident MS1. The findings include: During medication pass observation conducted on August 17, 2010 at 10:30 AM on 4th floor, Employee #30 washed his/her hands and donned a pair of gloves then spread strips of paper towels across Resident MS1's thighs for a protective barrier. He/she disconnected the [DEVICE] from feeding tube and clamped off the feeding tube portion. Employee #30 checked for [DEVICE] placement and residual then flushed the [DEVICE]. After Employee #30 completed flushing the [DEVICE] it was observed that the y- connector was not at the end of the G-tubing. Employee #30 then tied a loose knot in [DEVICE] and laid it on the strips of paper towels. At this time the fluid content within the G- tubing seeped out of the tubing and on to the paper towels, soaking through the paper towels and wetting the resident ' s bed linen before the administration of medication via [DEVICE]. According to Medpass .com " ...Disconnect plunger from 60cc syringe and connect syringe to clamped tubing. Put 15-30 cc of water in syringe and flush tubing with gravity flow. Clamp tubing after the syringe is empty, allowing water to stay into tubing. Pour dissolved/diluted medication into syringe and unclamped tubing, allowing medication to flow by gravity. Flush tubing with 15-30 cc of water, or prescribed amount. Allow water to remain in tubing. Clamp tubing and detached syringe. Restart continuous feeding " . Facility staff failed to use appropriate standard of care technique when he/she failed to clamp G-tubing while administering resident medication via [DEVICE]. A face-to-face interview was conducted on August 17, 2008 at 10:35 AM with Employee #30. He/she acknowledged the findings when… | 2014-01-01 | ||
| 2580 | 2580 | CAPITOL HILL NURSING CENTER | 95027 | 700 CONST. AVE. NE | WASHINGTON | DC | 20002 | 2010-08-23 | 441 | F | 3GVT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for four (4) of 23 sampled residents and one (1) supplemental residents and observations made during the environmental tour of the facility made on August 19 and 20, 2010, it was determined that the facility failed to provide a clean barrier prior to a wound treatment for one (1) residents, to clean resident side table after wound care procedure for one (1) resident, wash hands upon entering a residents room and between cleaning a dirty wound and application of clean gloves for one (1) resident, failed to clean scissors between dirty and clean use and placing the scissors on the clean barrier during a wound treatment for one (1) resident, failed to clean stethoscope after use and failed to clean the 60cc syringe after use for one (1) resident, failed to clean and provide a safe, sanitary and comfortable environment as evidenced by drain lines that were improperly installed on three (3) of three (3) ice machines and linen that were uncovered on three (3) of three (3) observations. Residents #4, 5, 11, 14, and MS1. The findings include: 1. Facility staff failed to clean resident side table after wound care procedure for Resident # 4. After wound care observation conducted on August 19, 2010 at 10:30 AM on 4th floor, the facility staff washed his/her hands and donned a pair of gloves, then removed remaining wound care treatments, ointment, and bandages from the treatment cart and soiled old bandages and trash to the biohazard container he/she return to resident room and put the side table away without cleaning it. A face-to-face interview was conducted on August 19, 2010 at 10:30 AM with Employee # 18 at the time of the observation. He/she acknowledged to findings when he/she cleaned resident side table. 2. Facility staff failed to maintain appropriate infection control practices during wound care treatment for Resident #5. A review Resident ' s 5 ' s record revealed a physician's order [REDACTED]. " A … | 2014-01-01 | ||
| 2581 | 2581 | CAPITOL HILL NURSING CENTER | 95027 | 700 CONST. AVE. NE | WASHINGTON | DC | 20002 | 2010-08-23 | 323 | D | 3GVT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Based on observations made during the environmental tour of the facility on August 19 and 20, 2010, it was determined that the facility failed to provide an environment that is free from accident hazards as evidenced by a damaged lock on the access door to one (1) of one (1) medical gas storage room and an unsecure oxygen cylinder on one (1) of three (3) residents floors. The findings include: 1. The door was unlocked and the lock was damaged in the medical gas storage room. 2. One (1) of thirteen oxygen cylinders stored in the oxygen room on the 6th. Floor was stored directly on the floor. These findings were acknowledged by Employee # 5 who was present at the time of observation. B. Based on record review and interview of one (1) of 23 residents reviewed, it was determined that facility staff failed to ensure window blinds were secured as to prevent injury. Resident #17. The findings include: Facility staff failed to ensure that window blinds were secured as to prevent injury. A review of the facility ' s Incident Report Form dated July 10, 2010 revealed Resident #17 was struck on the head by a window blind that fell from its mounting when the resident pulled on it. The resident was struck on the right temporal side of his/her head and subsequently developed a " small lump " at the sight of injury. The " action taken " by the facility included, " assess the sturdiness of window blind panels in all the rooms. " The Nurse Practitioner ' s progress report dated July 10, 2010 at 4:00 PM revealed, " ...(resident) hit head by falling plastic window blinds, complained of soreness on right temporal scalp, small lump developed. " physician's order [REDACTED]." A subsequent Nurse Practitioner ' s note dated July 13, 2010 revealed the skull x-ray was negative for fracture and the scalp injury was resolving. Resident #17 sustained a head injury from a window blind that fell from its mounting when the resident attempted to operate it. Facility staff … | 2014-01-01 | ||
| 2582 | 2582 | UNITED MEDICAL NURSING HOME | 95039 | 1310 SOUTHERN AVENUE, SE, SUITE 200 | WASHINGTON | DC | 20032 | 2010-09-21 | 514 | D | 2N2P11 | Based on record review and staff and resident interviews for one (1) resident, it was determined that the Resident Care Aides (RCA) failed to consistently document on the " RCA Resident Daily Record " for Resident #1. The findings include: A review of the " Daily Staffing Assignment " sheets for August 2010 revealed that a " Bed Bath/Shower " for Resident #1 was scheduled on Tuesdays and Thursdays for the day shift. A review of the August 2010 " RCA Resident Daily Record " under " Bathing " revealed the following Resident Care Aide charting: Tuesday, August 3 - blank Thursday, August 5- blank Tuesday, August 10 - blank Thursday, August 12 - blank Tuesday, August 17 - " Shower " was checked Thursday, August 19 - blank Tuesday, August 24 - blank Thursday, August 26 - blank A face-to-face interview with Employee #2 was conducted on September 9, 2010 at 8:20 AM. When queried about the lack of consistent charting on Resident #1 ' s " RCA Resident Daily Record " under " Bathing, " Employee #2 stated, " I thought I completed all the charting before I left each time I worked. I guess I missed the bathing part. " The Resident Care Aides failed to consistently chart the type of " Bathing " care given to Resident #1 on his/her scheduled shower days. The record was reviewed August 26, 2010. | 2014-01-01 | ||
| 2583 | 2583 | UNITED MEDICAL NURSING HOME | 95039 | 1310 SOUTHERN AVENUE, SE, SUITE 200 | WASHINGTON | DC | 20032 | 2010-09-21 | 226 | D | 2N2P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and resident interviews for one (1) resident, it was determined that facility staff failed to document and report to the state agency an alleged abusive incident for Resident #1. The findings include: According to the facility ' s " Resident Abuse, Neglect and Mistreatment: Staff to Resident " policy No; SNS 51, effective date December 15, 2008, page 1, paragraph two (2): " Purpose ...The facility will report all cases of possible abuse as soon as reasonably practicable to the appropriate jurisdictional authorities, (facility), Department of Health, and to the resident ' s responsible party, responsible relative or proxy relative. A prompt and thorough investigation will be conducted immediately. Employees suspected of abuse will be suspended pending the outcome of such investigations. If allegations of resident abuse are substantiated, the facility will take appropriate remedial measures in a timely fashion. " " B. Reporting Possible Abuse: a. All incidents of possible abuse, neglect or mistreatment, including injuries that suggest abuse, neglect or mistreatment of [REDACTED]. i. An " Occurrence Report " will be completed consistent with the policies and procedures pertaining to the occurrence reports ... " D. Treating Suspected Abuse: Residents, who are the suspected object of abuse, neglect or mistreatment should: a. Be physically examined immediately by a registered nurse to determine whether the resident has suffered symptoms of physical harm ... " E. Investigating Suspected Abuse: ...b. The employee who is suspected of abusing, neglecting or mistreating a resident will be suspended immediately pending the outcome of the investigation. c. The resident who has been the object of the suspected abuse, neglect or mistreatment will be protected from further abuse while the investigation is in process. " On August 24, 2010, the state agency received an incident report that alleged physical abuse towards Residen… | 2014-01-01 | ||
| 4 | 4 | WASHINGTON CTR FOR AGING SVCS | 95014 | 2601 18TH STREET NE | WASHINGTON | DC | 20018 | 2019-07-30 | 584 | E | 0 | 1 | BMNI11 | Based on observations and interview, the facility failed to provide housekeeping services necessary to maintain a safe, clean, comfortable environment as evidenced by soiled bathroom vents in four (4) of 65 residents' rooms and ten (10) of ten (10) containers of Boost nutritional drinks that were stored for use beyond their expiration date. Findings included . During an environmental tour of the facility on (MONTH) 18, 2019 between 10:00 AM and 3:30 PM the following observations were made: 1. Bathroom vents in Resident rooms' #159, #160, #208 and #237 were soiled with dust, four (4) of 65 resident's rooms. 2. Ten (10) of ten (10) eight-ounce carton containers of Boost nutritional supplement drinks, stored in the pantry on Unit 2 Blue, were expired as of (MONTH) 30, 2019. Employee #9 acknowledged the above findings during a face-to-face interview on (MONTH) 18, 2019 at approximately 3:00 PM. | 2020-09-01 |
| 6 | 6 | WASHINGTON CTR FOR AGING SVCS | 95014 | 2601 18TH STREET NE | WASHINGTON | DC | 20018 | 2019-07-30 | 641 | D | 0 | 1 | BMNI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview for one (1) of 56 sampled residents, facility staff failed to accurately code the Comprehensive Minimum Data Set (MDS) for one (1) resident with a [DIAGNOSES REDACTED]. Findings included . Resident #175 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Comprehensive Minimum Data Set ((MDS) dated [DATE] showed Resident #175 is cognitively intact as evidenced by a Brief Interview for Mental Status score of 15. Review of the physician's orders [REDACTED]. Further review of the MDS showed Section I Active Diagnoses: [REDACTED]. Facility staff failed to accurately code the MDS to include resident's active [DIAGNOSES REDACTED]. During a face-to-face interview on 7/29/19 at 11:30 AM Employee #12 acknowledged the finding and stated yes, the resident has [MEDICAL CONDITION] I will make the change now. | 2020-09-01 |
| 7 | 7 | WASHINGTON CTR FOR AGING SVCS | 95014 | 2601 18TH STREET NE | WASHINGTON | DC | 20018 | 2019-07-30 | 645 | D | 0 | 1 | BMNI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 56 sampled residents, it was determined that facility staff failed to ensure that the resident on admission was referred to the appropriate state-designated authority for a Level II Pre-Admission Screen/Resident Review for Mental Illness and or Mental [MEDICAL CONDITION] evaluation and determination. Resident #7. Findings included . A review of the Pre-Admission Screening/Resident Review for Mental Illness and or Mental [MEDICAL CONDITION] Level I (PASRR) screen, signed as completed by the facility staff on (MONTH) 31, 2014, revealed that Resident #7 was identified as positive for major mental disorder [MEDICAL CONDITION], and a Level II screen is required. There is no evidence that the facility staff completed the Level II Pre-Admission Screening/Resident Review as indicated from the level I screening. Facility staff failed to ensure that the Level 2 Pre-Admission Screen/Resident Review for Mental Illness and or Mental [MEDICAL CONDITION] for Resident #7 who had a [DIAGNOSES REDACTED]. A face-to-face interview was conducted with Employee #11 (SW) on 7/25/2019 at 9:00 AM. After a review of the findings she acknowledged that the level II screening was not done. | 2020-09-01 |
| 8 | 8 | WASHINGTON CTR FOR AGING SVCS | 95014 | 2601 18TH STREET NE | WASHINGTON | DC | 20018 | 2019-07-30 | 655 | E | 0 | 1 | BMNI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 56 sampled residents, facility staff failed to ensure that a baseline care plan included goals and approaches needed to provide effective and person-centered care for one (1) resident who has [MEDICAL CONDITION] to the right arm. Resident # 235 Findings included . Facility staff failed to ensure that Resident #235 who has a [DIAGNOSES REDACTED]. Resident #235 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. 5) Elevate r (right) arm with pillow to reduce [MEDICAL CONDITION]. Review of the facility's 48-hour baseline care plan showed the care plan was initiated on 6/20/19; however, there are no goals or approaches to address the care or the resident's right arm. During a face-to-face interview conducted on 7/25/19 at 3:28 pm, with Employee #16, she acknowledged the findings. | 2020-09-01 |
| 9 | 9 | WASHINGTON CTR FOR AGING SVCS | 95014 | 2601 18TH STREET NE | WASHINGTON | DC | 20018 | 2019-07-30 | 656 | D | 0 | 1 | BMNI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1 ) of 56 sampled residents, facility staff failed to develop a care plan with goals and approaches to properly care for one (1) resident who has a negative pressure dressing/device on her right knee. Resident # 545. Findings included . Facility staff failed to ensure that Resident #545 had a care plan to address the use of a negative pressure dressing and device. Resident #545 was admitted to the facility on (MONTH) 12, 2019, with diagnoses, which included Presence of right artificial knee joint, obesity, and [MEDICAL CONDITION] disorder. The physician's orders [REDACTED]. Monitor site for drainage and signs of infection (every) shift. On (MONTH) 18, 2019 at approximately 9:40 AM, Resident #545 was observed sitting in a wheelchair in her room with the negative pressure dressing/device placed over her right knee. Review of Resident #545's care plan lacked evidence of problem/focus area with goals and approaches to address the care of treatment of [REDACTED]. The findings were acknowledged during a face-to-face interview with Employee #16 on (MONTH) 22, 2019 at approximately 3:40 PM. | 2020-09-01 |
| 10 | 10 | WASHINGTON CTR FOR AGING SVCS | 95014 | 2601 18TH STREET NE | WASHINGTON | DC | 20018 | 2019-07-30 | 657 | E | 0 | 1 | BMNI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review for three (3) of 56 sampled residents, facility staff failed to revise care plan for one (1) resident diagnosed with [REDACTED]. Residents' #58, #155 and #182 Findings included 1. Facility staff failed to update/revise the care plan with resident-centered goals and approaches for care of Resident #58 with an indwelling Foley catheter who developed an penile injury. Resident #58 was admitted to facility on 1/27/15, with [DIAGNOSES REDACTED]., Depression, [MEDICAL CONDITION]. A review of the Quarterly MDS (Minimum Data Set) dated 4/16/19 showed, Section C (Cognitive) - BIMS score 05 indicating resident has severe cognitive impairment. Section G Functional Status the resident was coded as needing total assistance with one to two person support and care under toileting. Section H Bladder/Bowel - Appliances was coded to indicate resident has indwelling urinary draining device. A review of NP (Nurse Practitioner) progress note dated 5/31/2019 revealed, .10:36 PM Pt with UR, observed during day, unable to pee, Foley reinserted able to drain urine. Penis lacerated from previous Foley catheter with ulcer at glans Pt states pain burning at penis. Purulent drainage from penis . Foley inserted attached to right leg to avoid further laceration at left side Avoid diaper when patient has Foley (to lacerate penis). There was no evidence facility staff revised care plan to include care of penile laceration and erosion. The findings were acknowledged during a face-to-face interview with Employee #3 (Unit Manager) on (MONTH) 29, 2019 at 11:00 AM. 2. Facility staff failed to update/revise the care plan with resident-centered goals and approaches for care of Resident #155 percutaneous endoscopic gastrostomy (PEG) tube. Resident #155 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] showed resident Brief Interview for Mental Status (BIMS) is coded as 6… | 2020-09-01 |
| 11 | 11 | WASHINGTON CTR FOR AGING SVCS | 95014 | 2601 18TH STREET NE | WASHINGTON | DC | 20018 | 2019-07-30 | 658 | D | 0 | 1 | BMNI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Medpass observation and interview for one (1) of 56 sampled residents, the facility staff failed to provide care in accordance with professional nursing standards as evidenced by the staff was observed using the blood pressure machine incorrectly to measure one (1) resident's blood pressure. Resident #14. Findings included . According to the American Heart Association: Accurate measurement of blood pressure is essential to classify individuals, to ascertain blood pressure-related risk, and to guide management. Selection of the correct cuff size, and proper patient positioning if accurate blood pressures are to be obtained . In view of the consequences of inaccurate measurement, regulatory agencies should establish standards to ensure the use of validated devices, routine calibration of equipment, and the training and retraining of manual observers. Retrieved from: www.ahajournals.org/doi/full/10.1161/01.HYPXXX XXX .8e Resident #14 was admitted to the facility on (MONTH) 27, (YEAR), with diagnoses, which include [MEDICAL CONDITION], Neoplasm of Prostate, Cardiomegaly, Hypertension, [MEDICAL CONDITION], and Coronary [MEDICAL CONDITION]. A review of the Quarterly Minimum Data Set (MDS) dated (MONTH) 3, 2019, Section C0500 (BIMS (Brief Interview for Mental Status) Summary Scores) of 12 Moderately impaired which indicates, Resident unable to make decisions. During Med pass observation on (MONTH) 23, 2019, at 8:55 AM, Employee #10 was observed using the blood pressure machine incorrectly to measure Resident # 14's blood pressure and to walk away out of the room, leaving the resident's medication at the bedside prior to administering the resident his medication. The employee used an automatic digital blood pressure machine provided by the facility for measuring residents blood pressure. Observation showed the blood pressure machine had a problem measuring Resident #14's blood pressure. Employee#17 removed and reapplied the digital upper arm… | 2020-09-01 |
| 12 | 12 | WASHINGTON CTR FOR AGING SVCS | 95014 | 2601 18TH STREET NE | WASHINGTON | DC | 20018 | 2019-07-30 | 684 | D | 0 | 1 | BMNI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 56 sampled residents facility's staff failed to ensure the resident received treatment and care in accordance with professional standards of practice as evidenced by failure to ensure that Resident #548 was seen by the orthopedic physician in a timely manner. Findings included . Resident #548 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During a face-to-face interview with Resident #548 on 7/17/19 he stated, I have not had a follow up appointment related to my fractured toe(s). When I spoke with the facility, they stated the hospital did not give them the appointment date. I have not seen the orthopedic surgeon since I have been here and I do not have an appointment. Review of the discharge summary from the hospital dated 7/10/19, showed, .(Resident #548) should remain NWB (Non weight bearing) LLE (left lower extremity) and elevate LLE when not ambulating .Follow up with (Doctor Name) in 7-10 days after discharge. Splint should remain in place and will get repeat x-rays in ortho clinic in 2 weeks. The physician's orders [REDACTED].Schedule appointment to follow up with orthopedic . The facility staff failed to schedule Resident #548 for a follow up orthopedic appointment in a timely manner. During a face-to-face interview with Employee #16 on 7/22/19, at 2:12 PM, she (nurse manager) stated the appointment has not been made. He did not come with an appointment date. Employee #16 then reviewed the discharge summary and stated, We will make the appointment today. The facility staff failed to ensure that Resident #548 was seen by the orthopedic physician within 7 -10 days after he was discharged from the hospital. | 2020-09-01 |
| 13 | 13 | WASHINGTON CTR FOR AGING SVCS | 95014 | 2601 18TH STREET NE | WASHINGTON | DC | 20018 | 2019-07-30 | 689 | G | 0 | 1 | BMNI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 56 sampled residents, facility staff failed to ensure one (1) resident who was identified as a fall risk received adequate supervision. The resident was left unattended in the solarium where he subsequently fell from his wheel chair and sustained a left Femur fracture. Resident #182 Findings included . A review of the Resident's Clinical record showed that on (MONTH) 7, 2019, at 11: 00 AM Resident #182 was left unattended in the solarium where he subsequently fell from his wheel chair and sustained a left Femur fracture. Resident #182 was admitted to the facility on (MONTH) 15, 2019, with [DIAGNOSES REDACTED]. A review of Resident #182's admission Minimum Data Set ((MDS) dated [DATE], showed Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) with a score of 11 which indicates the resident had moderate cognitive impairment. Section G (Functional Status) resident is coded as 3 extensive assistance with one (1) person physical assist for bed mobility, transfer, locomotion on the unit and locomotion off the unit. Section G 0400 Functional Limitation in Range of motion code 0 indicates No impairment. Section J I700 Fall History on Admission/entry was coded as1 to indicate that the resident had a fall 2 - 6 months prior to his admission to the facility. A review of the care plan initiated on 5/17/19 showed resident at risk for falling r/t (related) cognitive impairment, unsteady gait and [DIAGNOSES REDACTED]. resident was observe on the floor with no injury. There was no mention that Resident #182 had a fall on 7/7/19. A review of the Resident's progress note showed the following: 7/7/19/ 1:41 PM Writer (RN Supervisor) was called to unit 3 green and noted resident in a sitting position in front of his wheel chair in the solarium. Upon assessment resident denied pain or discomfort, no injury noted, denied hitting his head able to move his upper arm and lower extremities… | 2020-09-01 |
| 14 | 14 | WASHINGTON CTR FOR AGING SVCS | 95014 | 2601 18TH STREET NE | WASHINGTON | DC | 20018 | 2019-07-30 | 690 | G | 0 | 1 | BMNI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and staff interviews for one (1) of 56 sampled residents, the facility staff failed to provide appropriate and sufficient catheter care and assessments and reassessments to prevent Harm for Resident #58 who was admitted with an indwelling Foley catheter which resulted in penile erosion and laceration. Findings included . Wound, Ostomy and Continence Nurses Society. (2016). Care and management of patients with urinary catheters: A clinical resource guide. MT. Laurel: N[NAME] Author Securement Devices: .Indwelling catheters should be secured to avoid traction on the catheter, which causes irritation and trauma to the urethra(e.g., urethritis, necrosis, erosion, stricture) .monitor the urethra daily for irritation, erosion, or urine leakage and assess the skin integrity under the securement device. Resident #58 was readmitted to facility on 12/21/18, with [DIAGNOSES REDACTED]., Depression, [MEDICAL CONDITION]. A review of the Comprehensive MDS (Minimum Data Set) dated 4/16/19 showed, Section C (Cognitive) - BIMS score 05 indicating resident has severe cognitive impairment. Section G Functional Status the resident was coded as needing total assistance with one to two person support and care under toileting. Section H Bladder/Bowel - Appliances was coded to indicate resident has indwelling urinary draining device. A review of the care plan for Foley Catheter due to [MEDICAL CONDITION] showed it was initiated on 1/23/2019. Goal: resident will have catheter care managed appropriately .not exhibiting signs of urinary tract infection or urethral trauma. Approach: .report signs of UTI .manipulate tubing as little as possible during care .provide catheter care .use catheter strap .use leg bag as needed . A review of Medical Record Revealed: A physician's orders [REDACTED]. Urology consult for UR 12/10/2018. Urology Consult-1/3/2019, Diagnosis; [MEDICAL CONDITION] with chronic indwelling Foley catheter and u… | 2020-09-01 |
| 15 | 15 | WASHINGTON CTR FOR AGING SVCS | 95014 | 2601 18TH STREET NE | WASHINGTON | DC | 20018 | 2019-07-30 | 693 | D | 0 | 1 | BMNI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview for one (1) of 56 sampled residents facility staff failed to provide evidence of providing care for one (1) resident's percutaneous endoscopic gastrostomy (PEG) site. Resident #155. Findings included . Resident #155 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] showed resident Brief Interview for Mental Status (BIMS) is coded as 6 to indicate moderately impaired cognition. Further review of the MDS showed Section K (Swallowing/Nutritional Status) Nutrition Approach resident is coded as having a feeding tube. Percutaneous Endoscopic Gastrostomy (PEG) is a medical procedure in whch a tube is passed into a patient's stomach to provide a means of feeding when oral intake is not adequate. Review of the nurses note on 6/28/19 showed resident went to the emergency room via non-emergency ambulance for evaluation. Review of (Hospital name) transfer summary dated 7/3/19 showed the patient was found to have skin excoriation and some pus discharge around the PEG tube site on admission. Further review of the transfer summary showed discharge plan please continue the PEG care at the nursing home, clean the area around the PEG tube. Observation on 7/26/19 at 11:30 AM of Resident #155 PEG site showed PEG tube insertion site without a dressing in place or evidence the site was cleaned. During an interview on 7/26/19, at 11:30 AM Employee #13 was asked if nurses were providing PEG site care? Employee #13, I did not see this on the transfer summary, I will let the doctor know right away. Review of the medical record showed no documented evidence facility staff are cleaning around the PEG site. Facility staff failed to provide evidence of providing skin care to PEG site to maintain infection control practices. During a face-to-face interview on 7/26/19 at 11:30 AM, Employee #13 acknowleged the finding. | 2020-09-01 |
| 16 | 16 | WASHINGTON CTR FOR AGING SVCS | 95014 | 2601 18TH STREET NE | WASHINGTON | DC | 20018 | 2019-07-30 | 726 | E | 0 | 1 | BMNI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews for two (2) of 56 sampled residents, the facility staff failed to provide competent nursing staff to care for one (1) resident with an indwelling Foley catheter who developed an penile injury; and failed to ensure nursing staff has specific competencies and skills to assess and care for one (1) resident who is [MEDICAL TREATMENT]-dependent and has a arteriovenous (AV) fistula graft site. Residents' #58 and #175. Findings included . 1. Facility staff failed to provide competent nursing staff to care for Resident #58 with an indwelling Foley catheter who developed an penile injury. Wound, Ostomy and Continence Nurses Society. (2016). Care and management of patients with urinary catheters: A clinical resource guide. MT. Laurel: N[NAME] Author Securement Devices: .Indwelling catheters should be secured to avoid traction on the catheter, which causes irritation and trauma to the urethra(e.g., urethritis, necrosis, erosion, stricture) .monitor the urethra daily for irritation, erosion, or urine leakage and assess the skin integrity under the securement device. Resident #58 was readmitted to facility on 12/21/18, with [DIAGNOSES REDACTED]., Depression, [MEDICAL CONDITION]. A review of the Comprehensive MDS (Minimum Data Set) dated 4/16/19 showed, Section C (Cognitive) - BIMS score 05 indicating resident has severe cognitive impairment. Section G Functional Status the resident was coded as needing total assistance with one to two person support and care under toileting. Section H Bladder/Bowel - Appliances was coded to indicate resident has indwelling urinary draining device. A review of the care plan for Foley Catheter due to [MEDICAL CONDITION] showed it was initiated on 1/23/2019. Goal: resident will have catheter care managed appropriately .not exhibiting signs of urinary tract infection or urethral trauma. Approach: .report signs of UTI .manipulate tubing as little as possible during care .provide cath… | 2020-09-01 |
| 17 | 17 | WASHINGTON CTR FOR AGING SVCS | 95014 | 2601 18TH STREET NE | WASHINGTON | DC | 20018 | 2019-07-30 | 740 | E | 0 | 1 | BMNI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 56 sampled residents facility staff failed to provide the necessary behavioral health care services and antidepressant medication for Resident #63 to attain the highest practicable physical, psychosocial and mental well-being in accordance with the comprehensive assessment and plan of care. Findings included Resident #63 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Comprehensive Minimum Data Set ((MDS) dated [DATE], showed Resident #63's Brief Interview for Mental Status (BIMS) is coded as 15 to indicate she is cognitively intact. Further review of the MDS showed Section D (Mood) resident is coded as 1 to indicate the presence of the following symptoms: feeling down, depressed or hopeless, trouble concentrating on things, poor appetite, trouble falling or staying asleep .Section I (Active Diagnoses) showed Psychiatric/Mood Disorder, Depression is selected. Section N (Medications) Antidepressants is not selected to indicate resident did not receive antidepressant medication. Review of the Social Service note dated 7/19/19, showed resident stopped this social worker stating that she took [MEDICATION NAME] in the past but has not, since being admitted . During a resident interview on 7/24/19, at 4:00 PM, Resident #63 stated, I told the nurse that I was on an antidepressant and I have not been getting my medicine and I have nightmares. Resident denied wanting to harm herself or others. Review of the physician's orders [REDACTED]. During an interview on 7/24/19, at 4:30 PM with the Employee #13 stated, She is care planned for depression but no she is not on medication or seeing the psychiatrist, I will get on this right away. Observations during survey period (7/17/19 through 7/30/19) showed resident participating in activities daily and talking with other residents. Facility staff failed to provide the necessary behavioral health care and services (to in… | 2020-09-01 |
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CREATE TABLE [cms_DC] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );