cms_GA: 6659
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 6659 | LIFE CARE CTR OF LAWRENCEVILLE | 115659 | 210 COLLINS INDUSTRIAL WAY | LAWRENCEVILLE | GA | 30045 | 2016-11-04 | 282 | J | 1 | 0 | 03D012 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident and staff interview, the facility failed to follow the care plan intervention to notify the physician of changes in skin condition in a timely manner for one Resident (R) #1. In addition, the facility failed to follow the care plan related to floating heels and minimizing pressure over bony prominences for one resident (R) (#7). Ten residents were reviewed for pressure ulcers, and the sample size was 32 residents. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On [DATE] at 8:00 p.m. the facility's Divisional Vice President, Executive Director, Divisional Director of Clinical, the Director of Nursing, and the Regional Vice-President were informed of the jeopardy related to: F157:J, F281:J, F282:J, F314:J. On [DATE] at 3:43 p.m., the Executive Director was informed that Immediate Jeopardy had been identified at F223:J and F520:K in addition to F157:J, F281:J, F282:J, F314:J that were identified on [DATE]. The noncompliance related to the immediate jeopardy was identified to have existed on [DATE]. The immediate jeopardy continued through [DATE] and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the immediate jeopardy on [DATE]. The Immediate Jeopardy is outlined as follows: Resident #1 (R#1) was admitted to the facility on [DATE] with [MEDICAL CONDITION]/[MEDICAL CONDITION] after having a [MEDICAL CONDITIONS]. The resident was dependent on staff for Activities of Daily Living (ADL's) and was incontinent of bowel and bladder. The weekly Skin Integrity Data Collection document indicates that the resident had an open area to the sacrum on [DATE], and again on [DATE]. However, the physician was not notified of the open area and the resident did not receive any treatments or assessments from the wound care nurse, for this open area to the sacrum, until [DATE]. In addition to this, the resident's care plan was not updated to address any skin care problems. R#1 was transferred, from the facility, to an acute care hospital, on [DATE]. The hospital Discharge summary, for R#1, revealed that the resident was admitted to the hospital with [REDACTED]. The ulcer required debridement. The resident developed myositis with [DIAGNOSES REDACTED]. The resident suffered complications during her hospitalization , related to aspirating tube feeding, and subsequently died on [DATE]. The immediate jeopardy was related to the facility's noncompliance with the program requirements at F 157: J - 42 C.F.R. 483.10(b)(11) Notify of changes (injury/decline/room, etc), F 223:J - 42 C.F.R. 483.13(b), 483.13(c)(1)(i) Free from abuse/involuntary seclusion, F 281:J - 42 C.F.R. 483.20(k)(3)(i) Services provided meet professional standards, F 282:J - 42 C.F.R. 483.20(k)(3)(ii) Services by qualified persons/per care plan, F 314: J - 42 C.F.R. 483.25(c) Treatment / Svcs to prevent/heal pressure sores, F 520:K - 42 C.F.R. 483.75(o)(1) QAA Committee - Members/meet quarterly/plans. Additionally, Substandard Quality of Care was identified with the requirements at F 223:J - 42 C.F.R. 483.13(b), 483.13(c)(1)(i) Free from abuse/involuntary seclusion and F 314: J - 42 C.F.R. 483.25(c) Treatment / Svcs to prevent/heal pressure sores. A Credible Allegation of Compliance (AoC) was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance at a lower scope and severity as follows: and in addition to F157:D, F223:D, F281:D, F282:D, F314:D, F520:E while the facility continued management level staff oversight of notification of physician and pressure ulcer treatment to ensure the continuity of resident care. This oversight process included the analysis of facility staff's conformance with the facility's Policies and Procedures governing physician notification, initiating and implementing wound care, implementing the interventions of the residents care plans and the necessary steps to ensure continuity of care. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures. Resident records were reviewed to ensure that resident care and treatment, including physician notification and care plans were current and accurate. After Supervisory review by the State Survey Agency F223:J and F281:J were placed under the appropriate tag and the scope and severity for F520:K was lowered to F520:J. The revised tags, as related to the Immediate Jeopardy are as follows: F157: J, F282: J, F314: J, F520: J. Findings include: 1. Review of medical records revealed that R# 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the comprehensive care plan, for R#1, titled Risk for Pressure Ulcers with an onset date of [DATE] indicates that the resident is at risk for developing a pressure ulcer related to decreased mobility and incontinence with a documented goal that the resident will have intact skin through the next review date. Interventions listed, in pertinent part, include: Report changes in skin status to physician. (Licensed nurse) Review of the comprehensive care plan implemented on [DATE] and titled Impaired Skin Integrity noted the Resident is at risk for skin impairment, incontinence, weakness, s/p [MEDICAL CONDITION], physical limitations. The goal revealed the resident's disruption of skin surface will remain free from infection and show evidence of healing by next review date. Interventions listed, in pertinent part, include: Report changes in skin condition to physician. (Licensed nurse.) Review of the document titled Weekly Skin Integrity Data Collection dated [DATE], Licensed Practical Nurse (LPN )NN documented R # 1's skin was dry and there was an open area at the sacrum. Review of the medical records for R#1 revealed that there was not any evidence of any documentation that R#1's physician was notified of the open area or that a treatment order was obtained. Review of the documented titled, Weekly Skin Integrity data Collection dated [DATE], LPN CC documented an open area at R#1's sacrum. Review of the medical records for R#1 revealed that there was not any evidence of any documentation that R#1's physician was notified of the open area or that a treatment order was obtained In a Pressure Ulcer Status Record dated [DATE], LPN AA documents R#1 has an unstageable wound to the sacrum measuring 4.9 centimeters (cm) x 2.5 cm with eighty percent necrotic tissue. Interview on [DATE] at 9:45 a.m., with LPN MM (Unit Manager) revealed that weekly skin assessments are completed by nursing, and if a nurse notes a possible wound or area of pressure, she is responsible for notifying the physician and implementing treatment. She states the nurse is also responsible for notifying the responsible party. Interview and record review on [DATE] at 10:30 a.m., with Registered Nurse (RN) HH, Assistant Director of Nursing (ADON) revealed that there was not any evidence of any documentation of a physician order [REDACTED]. 2. Review of the clinical record, for resident (R) #7 (R#7), revealed that she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS), for R#7, dated [DATE], revealed that the resident had a Brief Interview for Mental Status score of 13 (a score of 13 to 15 indicates that a resident is cognitively intact), this same MDS documented that the resident needed extensive assist for bed mobility and transfers, walking in the room and corridor did not occur, was a pressure ulcer risk but had no unhealed pressure ulcers. Review of a care plan for pressure ulcer to the right heel/ankle related to immobility, for R#7, revealed that the care plan included approaches that included: float heels when in bed as resident allows, and minimize pressure over boney (sic) prominences. Review of the Pressure Ulcer Status Record, for R#7, dated [DATE] documented that the resident had an unstageable wound to the right ankle first identified on [DATE] with the appearance of a blood-filled blister Interview on [DATE] at 8:50 a.m., with R #7 revealed that she recently had a stroke, and was paralyzed on her right side. The resident further revealed that she asked the staff to put a pillow under her feet to keep her heels elevated off of the bed, as both of her feet were sore. During an observation, at this time, a pillow was observed under the resident's mid-calf to her knees, but her feet were observed to rest directly on the mattress. During further observation, at this time, the resident's right leg was observed to be turned outward so that her lateral right ankle was resting directly on the mattress. Observation on [DATE] at 9:30 a.m., revealed that R #7 was in bed with a pillow under her knee and upper part of her lower legs, but her feet were observed to be on the mattress. During further observation, at this time, the resident's right foot was observed turned outward so that her right lateral ankle was observed resting directly on the mattress. Interview on [DATE] at 9:21 a.m., with R #7 revealed that her right ankle was very tender last night, and that she had to request pain medicine for it. During observation at this time, her right foot was rotated outward and her foot and lower leg were positioned on a flat pillow, but her foot was not extended over the end of the pillow and her right lateral ankle was positioned directly on the surface of the pillow. This was verified during an interview with Licensed Practical Nurse (LPN) Treatment Nurse OO at this time, who revealed that the pillow should have been folded in half to raise the resident's foot so that it was not touching the pillow or the mattress. Observation on [DATE] at 6:45 p.m., of wound care for R #7 with LPN OO, LPN OO revealed that the blister on the resident's right ankle was directly over a pressure point, and that the area should be offloaded. Cross-refer to F 314. The facility implemented the following actions to remove the Immediate Jeopardy Patients Impacted: The facility has changed treatment nurses as of February 13, 2017. The Assistant Director of Nursing has assumed the role of facility treatment nurse until a permanent one has been hired and trained. The Assistant Director of Nursing will be provided training and given assistance by a WTA certified wound nurse x 4 weeks. All patients have had skin assessments and Braden scales completed by licensed nursing leadership team which includes the Director of Nursing, Assistant Director of Nursing, Unit Managers, Treatment Nurse, MDS Coordinator, ,[DATE] Supervisor, Restorative Nurse, LPN Business Development Director and LPN Medical Records Director. This will be completed February 14, 2017. Systemic Changes: All licensed nurses will receive in-service training on the following by the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Unit Managers and/or corporate nurse. This will be completed February 14, 2017. Performing and documenting patient skin assessments Physician and patient representative notification of skin condition changes Implementing and documenting treatment orders/TARS Pressure ulcer care planning All certified nursing assistants have received in-service training on the following by the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Unit Managers and/or corporate nurses. This will be completed February 14, 2017. Pressure ulcer prevention Reporting changes in skin condition to nursing supervisor 90% of licensed nurses have received the above training. Any licensed nurse that does not have the in service training by February 14, 2017, will receive this in-service training upon their return to work. These associates will not be able to provide direct patient care until completion of the in-service. Monitoring: During daily clinical meeting/rounds, nursing leadership will review daily scheduled skin assessments for completion, new areas identified, physician and patient representative notification and pressure ulcers care plans are completed. Upon identification of non-compliance, the Director of Nursing, Staff Development Coordinator, Unit Managers and/or corporate nurse will follow-up with the licensed nurse and provide additional education. The Director of Nursing will review the above findings with the Executive Director weekly for any additional follow-up. This will occur weekly for 3 months, and monthly for one year. The Director of Nursing will bring and present the monitoring findings from the regulatory deficiencies cited to the Pl Committee. The Committee will utilize the findings to evaluate the effectiveness of the Pl plans. The State survey agency validated the implementation of the facility's Credible Allegation of Jeopardy Removal (CAJR) as follows: Patients Impacted: Interview on [DATE] at 11:50 a.m., with the Registered Nurse (RN) Division Director of Clinical Services QQ she revealed that Licensed Practical Nurse (LPN) Treatment Nurse DD had resigned, and that LPN Treatment Nurse OO was brought in from another facility over the weekend (of [DATE]) to assist and train the Assistant Director of Nursing (ADON), who was going to temporarily do treatments. RN QQ further revealed that the facility was actively seeking a replacement for the treatment nurse position, and that LPN OO would be in the facility for at least four weeks. Review of the Allegation Of Compliance (AOC) notebook revealed that it Included a copy of LPN OO's Certified Wound Care Associate card with an expiration date of [DATE], as well as Certificate of Completions on [DATE] for an Ostomy Workshop (7 contact hours), and on [DATE] for Current Concepts in Skin Care and Wound Management (24.5 contact hours). Further review of the AOC notebook revealed that there was a Separation Notice for LPN DD effective [DATE]. Further review revealed a signed statement that as of [DATE] the facility had changed treatment nurses, and that the ADON would assume this responsibility until a permanent nurse was hired. Interview on [DATE] at 4:12 p.m., with LPN CWCA (Certified Wound Care Associate) OO she revealed that she had been asked to train the ADON and make sure she understood the pressure ulcer prevention, treatment and notification policy, and to help her with the basics of wound care such as measuring, treating and assessing. She further revealed that the ADON's training would include filling out pressure ulcer and non-pressure ulcer wound sheets correctly; notifying the physician; addressing pain; proper infection control technique including prevention of cross-contamination. She further revealed that education on staging and recognizing the difference between Stage 1 and DTI (deep tissue injury) wounds would be covered. LPN OO further revealed that she was not yet sure if she was going to be coming back to the facility on an ongoing basis for follow-up of the wound care program, but that she had been asked to be at the facility for a minimum of four weeks. She revealed that she came in the facility on Saturday [DATE] and was following up on skin assessments that had been done, and if an assessment noted a concern she helped with the assessment and staging. She further revealed that on [DATE] she started doing all the measurements on the residents found to have pressure ulcers after the skin sweep (a head to toe skin assessment of all residents in the facility). LPN OO revealed that she also reviewed and/or updated care plans for all the residents found to have pressure ulcers or non-pressure wounds. She further revealed that treatments were done for all wounds, as well as physician and family notification of the presence of a new wound and/or present status of the existing wound(s). Interview on [DATE] at 10:14 a.m., with ADON HH she revealed that she had been told to ensure that the weekly skin assessments were being done and accurate, and any follow-up implemented. She revealed that the skin assessments were now being kept in a binder on each unit instead of the treatment books, which made them more accessible, and that she was told to check in the mornings to see if there were any new skin issues. She further revealed that she was told to ensure that Braden scale scores were completed per policy, to make sure initial skin assessments were done on admission, and that she would do an actual skin assessment on the new admissions to ensure nothing was missed. She further revealed that part of her new responsibilities would be to make rounds with the wound physician, and to check the TARs (Treatment Administration Records) to ensure that the correct treatments were on them and they were being documented as done. The ADON revealed during further interview that LPN Treatment Nurse OO would be with her at least four weeks for training, and that she had actually done wound care in the facility in the past, from August to November of 2014, The ADON revealed that she was not certified in wound care, but had attended a one-day workshop on wound care in the past. The ADON further revealed that the DON said that the facility was going to hire another wound care nurse, and they would both be sent out for training to a wound care class. Review of the AOC notebook revealed that a skin sweep and Braden Scale scores were completed for 100% of the residents by [DATE]. Further review revealed that an audit form had been developed that included the resident's name and room number; if the skin assessment and Braden Scale were completed; if any new pressure ulcers were identified; if the resident was at risk for pressure ulcer development; if the physician and/or Nurse Practitioner were notified; if the treatment order was initiated; if the care plan was updated; and an area for any comments. Interview on [DATE] at 2:03 p.m., with the DON she revealed that when the 100% skin sweep was done, they identified three residents with previously unidentified wounds. She further revealed that she ensured the staff followed through with notification of the physician and responsible party. During further interview, she revealed that the treatment nurse would be providing a copy of the pressure ulcer report weekly on Tuesdays, but that any new areas of skin breakdown would be addressed as they were identified on a daily basis. She added that this weekly pressure ulcer report was just another check to ensure that the care plan was completed. Review of the sampled residents' clinical records revealed that they had skin assessments and Braden Scale scores completed on the following dates as follows: R #4: [DATE] R #5: Braden on [DATE], skin assessment on [DATE] R #7: [DATE] R #8: Braden on [DATE], skin assessment on [DATE] R #412: [DATE] R #424: [DATE] R #435: [DATE] R #529: [DATE] R #558: [DATE] Review of the facility's AOC audits revealed 105 residents had updated Braden scores. There were 103 weekly skin integrity data collection tools noted. An interview with the Regional Clinical Director on [DATE] at 12:30 p.m. revealed that skin assessments were not completed on 1 resident that was transferred to the hospital and another resident that expired. There were 14 residents noted to have skin breakdown. Pressure ulcer status records were completed on all 14 residents. Nursing notes for all 14 residents indicated the physicians and responsible parties were notified. In addition, 3 additional residents were identified as having pressure ulcers during the facility's skin assessments. All three residents had physician wound treatment orders documented and care plans for pressure ulcers initiated. Nursing progress notes revealed Responsible parties were notified on these residents. Interview on [DATE] at 3:35 p.m. with Corporate MD nurse XX. She states that 100 % of at risk residents care plans were reviewed and updated if indicated. If the care plans were current with interventions, they were not updated. Interview on [DATE] at 3:55 p.m. with RN QQ revealed that residents who were deemed at risk and above on the Braden scale were reviewed. The residents had skin assessments completed and care plans reviewed for accuracy. 14 residents were initially identified as having pressure ulcers. All 14 had documentation in the progress notes that the physician and responsible party were notified of the presence or progress of the pressure ulcer. One resident (R 424)) had orders changed, and these were noted on an order sheet. Review of a Braden score, for R#8, dated ,[DATE] documents a score of 11, indicating the resident is at high risk for pressure ulcers. A weekly skin integrity data collection dated [DATE] revealed resident has an open area to her sacrum in addition to dry skin at the left shoulder and a dressing to the left elbow. Pressure ulcer status record, for R#8, dated [DATE] documented a 2.0x1.5 unstageable wound to the sacrum; in house acquired. The wound nurse RN OO documented a superficial opening on non-blanching discolored tissue consistent with DTI. An Addendum progress note, for R#8, dated [DATE] at 10:53 p.m. by RN Staff Development Coordinator (SDC), noted the physician were updated regarding the wound. An Addendum progress note, for R#8, dated [DATE], at 10:53 p.m. by RN Staff Development Coordinator (SDC), revealed the physician was notified regarding the wound and family member was updated. Review of a care plan, for R#8, initiated [DATE], documented care review on [DATE] and notes Sacrum PU unstageable DTI. Updated interventions dated [DATE] include skin treatments as ordered, report any changes in skin condition to physician and responsible party, and pressure reduction surface area provided. Observation on [DATE] at 10:20 a.m. R#8 observed in activities sitting in wheelchair. Wheelchair pad observed to be in place. Observation on [DATE] at 3:55 p.m. R#8 observed in bed lying on side. Gel cushion noted in wheelchair with small cushion on top. Observation on [DATE] at 9:50 a.m. R#8 observed in bed lying on side. Duoderm in place to sacral wound, dated [DATE] Review of a Braden score, for R#5, dated ,[DATE]//17 documents a score of 16, indicating the resident is at risk for pressure ulcers. A skin assessment completed [DATE] documents the resident was admitted with a wound to her right heel. The wound measures 3.0x3.8 and is unstageable. A Progress note, for R#5, dated [DATE] at 10:49 p.m. by Registered Nurse (RN) HH documents MD aware of wound, and to continue with current treatment. Nursing notes, for R#5, dated [DATE] at 10:49 p.m. by RN HH documents resident updating on care plan for wound to right foot and verbalized understanding. Granddaughter called. MD made aware and will continue with current treatment. Review of a care plan initiated, for R#5, dated [DATE] notes the following problem: Resident has pressure ulcer to right heel r/t immobility. Interventions include: Avoid skin to skin contact Complete Braden Scale Risk Assessment quarterly and prn Consult/make referral for screen prn Wound nurse Notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bathing or daily care. Notify resident or RP of any new areas of breakdown Wound care as ordered by physician. (See current Wound Treatment and Progress Record) Documentation indicates care plan reviewed on [DATE]. Updates dated [DATE] include off-loading heels while in bed, pressure reduction surface, and cushion in chair. Observation on [DATE] at 3:40 p.m. R#5 observed to be out of bed in wheelchair. Dressing in place to foot dated [DATE]. No concerns noted. Observation on [DATE] at 10:12 p.m. revealed R#5 out of bed in day room. Wound dressing to right foot intact and dated [DATE]. No concerns noted. Review of Braden scale, for Resident R dated [DATE] documents a score of 14, indicating the resident is at moderate risk for skin breakdown. Review of skin assessment dated [DATE] documented skin excoriation to buttocks, dressing to right heel with dressing in place. Addendum to Progress note, for Resident R dated [DATE] at 10:54 PM by LPN MM revealed MD aware of heel wound and treatment orders changed to Santyl and foam dressing and prn. Progress note, for Resident R, dated [DATE] at 10:54 PM by LPN MM documented MD and daughter informed of new wound and new treatment orders to left heel. Review of care plan, for Resident R, revealed care plan initiated [DATE]. Review documented on [DATE] with documentation of unstageable pressure ulcer to left heel and resident at risk for additional pressure wounds. Updated interventions include off load heels, consult wound MD, report change in skin status to physician and responsible party, wound care as ordered, pressure reduced surface Observations on [DATE] at 10:00 a.m. revealed Resident R sitting in wheelchair during activities. Dressing to left heel dated [DATE]. Resident left heel observed to be floated. Review of a Braden Scale, for R#424, completed on [DATE]. Score is 17 indicating resident is at risk for breakdown. Weekly Skin Integrity Data Collection, for R#424, indicates skin assessment completed on [DATE]. Body diagram indicates DTI to left heel, blanching redness to right heel, and open area to sacrum. A physician's orders [REDACTED]. Nursing note dated [DATE] by ADON HH documents that the resident was updated on care plan and progress of wounds. Responsible Party notified as well. MD notified and will continue with treatment orders. A care plan for R#424 documents the following: Problem: [DATE]: Resident has pressure ulcer on left lower buttock, left buttock, right buttock, and left heel r/t immobility. Interventions include assist prn to reposition/shift weight to relieve pressure. Complete weekly skin check Consult/make referral for screen prn for PT, Wound Care Encourage use of side rails and/or trapeze to assist turning in bed Float heels when in bed as resident allows Minimize pressure over boney prominence. Notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bathing or daily care. Provide incontinence care after incontinence episodes. Provide pressure relieving or reduction device. Update ,[DATE] indicated mattress to be added. Report changes in skin status, non-healing new area to MD and responsible party [DATE]; Pressure reduction surface area [DATE]: cushion in chair. Observation on [DATE] at 10:10 a.m. revealed the dressing to R#424's buttocks dated as ordered as follows: [DATE] and a dressing to the heel dated [DATE]. The resident was on her side with a pressure relieving mattress underneath her. A pressure relieving cushion was noted in her wheelchair. The following interviews were conducted on [DATE] at 10:30 a.m., with RN K who works the 7:00 a.m. to 3:00 p.m. shift; at 9:50 a. m , with CNA XX , at 10:00 a.m. with RN FF., at 10:05 a.m., with CNA YY at 9:30 a.m., at 9:45 a.m. with LPN NN , at 10:10 a.m. with LPN PP, at 12:30 p.m. with RN GG, Interviews for the ,[DATE] shift were conducted on [DATE] at 3:15 p.m. with LPN AAA, at 3:45 p.m. with RN EE works all shifts, with LPN unit manager EE at 3:45 p.m., at 4:00 p.m. with unit manager LPN MM , at 4:15 p.m. with CNA CCC, at 4:20 p.m. with LPN DDD, at 4:45 LPN MMM, at 5:00 p.m. with RN VV. Interviews on [DATE] ,[DATE] shift interviews were conducted at 6:25 a.m. with CNA FFF, at 6:30 a.m. with RN KKK, at 6:38 a.m., with CNA JJJ, at 7:00 a.m. with CNA III, at 7:05 a.m. with CNA HHH, at 7:10 am with CNA III, at 7:10 a.m. RN GGG, , at 7:50 a.m. with LPN ZZ. Interviews with the licensed nurses and CNA's revealed that all licensed nursing had received in-service education training related to Physician and patient representative notification of pressure ulcers and implementation of treatment, performing and documenting patient skin assessments, Physician and patient representative notification of skin changes, Implementing and documenting orders/TARS, pressure ulcer care planning and abuse and Neglect which include ident cation and reporting. All Certified Nursing Assistants verified that they had received in-service training on the following pressure ulcer prevention, reporting skin condition to nursing supervisor and abuse and neglect policies which include identification and reporting Monitoring: Interview on [DATE] at 10:51 a.m., with the Executive Director she revealed that in the daily clinical grand rounds meeting, they will review everything going on each unit, including to ensure the initial skin assessment and Braden score was done for new residents, treatment in place for any wounds, and that this was care planned. She further revealed that if there was a change in a wound, they would ensure that the family and physician has been notified and everything was in place to treat the wound. She revealed that they would be reviewing the previous day's skin assessments to ensure they were done, and that the Unit Managers and DON would also be responsible for checking skin assessments, new treatment orders, notification, implementation, and that the care plan was updated at the end of each day. The Executive Director further revealed that she would be responsible for ensuring that everything that they said they would do was being implemented, and revise the plan as needed. She further revealed that audit results would be brought to her weekly so she could ensure everything was in place, and have an ad hoc PI meeting if necessary to correct any problem areas. She further revealed that the DON would be responsible for bringing audit results back to the PI Committee. Interview on [DATE] at 12:01 p.m., with the DON she revealed that the monitoring findings mentioned in the AOC came from audits and observations made from deficiencies cited during the last survey as well as from the Immediate Jeopardy (IJ) deficiencies. She revealed that the unit managers will bring audit information to her and they review them, and the findings are presented in the PI (Performance Improvement) meeting. The DON revealed during further interview that they have had a couple of PI meetings since the IJ was identified, and everyone in the committee had input in developing the AOC. She revealed that they put together an AOC book that contained everything they had done related to the AOC, such as Braden scores and skin assessments, and presented that at PI. She further revealed that there were a lot of things they would be monitoring, such as admission skin assessments, which would also be presented to PI. The DON revealed that they implemented a new process for the weekly skin audits to make it more accessible to the staff, and would be reporting back to PI about if this has been successful for monitoring. The DON further revealed that they had not yet identified any non-compliance for implementation of components of the AOC as it had only been a few days, but if they did find non-compliance, anyon(TRUNCATED) | 2017-11-01 |