cms_MS
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2687 | 2687 | BEDFORD CARE CENTER OF HATTIES | 255158 | #10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2016-06-02 | 253 | D | 0 | 1 | JF4711 | Based on observation, staff interview, record review, a facility statement, the facility failed to maintain corner molding and a doorway floor strip in the main dining room for 2 (two) of 3 (three) observations. Findings Include: Review of a statement on letterhead, not dated, revealed the facility's Policy on Floor and/or Wall Repair: Maintenance at (facility) will repair and/or replace any and all floor strips as needed. Maintenance will also repair and/or replace any and all wall molding as needed. These repairs are made daily through rounds or by the maintenance log books that are maintained on a daily basis. Observation on 6/1/2016 at 12:30 PM in the dining room revealed cracked corner molding on the wall near the entrance to the kitchen. Observation on 6/2/2016 at 8:50 AM revealed seven (7) gray strips of electrical tape approximately three (3) inches in width secured to the floor strip at the south end of the dining room entrance. Observation on 6/2/16 at 8:55 AM revealed partially secured, cracked corner molding on the corner of the wall near the kitchen entrance. Interview on 6/2/16 at 9:15 AM, with Maintenance Person #1, revealed he had glued the black floor strip down and the tape had been placed to keep it down to dry. Maintenance Person #1 stated that cleaning machines, water, and the difference in the two (2) types of flooring had likely caused the strip to come loose. Record review of the maintenance log/work order book revealed no reports of the loose floor strip or the damaged corner wall molding. | 2019-11-01 |
| 2688 | 2688 | BEDFORD CARE CENTER OF HATTIES | 255158 | #10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2016-06-02 | 280 | D | 0 | 1 | JF4711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review and facility policy review the facility failed to update a plan of care concerning code status for one (1) of 24 residents reviewed for care plans. (Resident #7) Findings Include: Review of facility policy entitled Care Plans-Comprehensive, dated (MONTH) 2013, revealed: An individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The facility's Care planning/Interdisciplinary Team in coordination with the resident, his family or representative (sponsor) develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. Care plans are revised as changes in the resident's condition dictate. Record review of Resident #7's original hand written physician's orders [REDACTED]. This instructs the caregivers not to initiate life saving measures if Resident #7 stops breathing or if her heart stops beating. Review of the printed cumulative orders for Resident #7 dated [DATE] - [DATE], revealed Code status-Full Code. This instructs caregivers to initiate life saving measures if Resident #7 stops breathing or if the heart stops beating. Review of Resident #7's Plan of Care dated [DATE], revealed a Full Code Status with interventions to initiate Cardio-pulmonary Resuscitation (CPR) in the event of a [MEDICAL CONDITION]. During an interview on [DATE] at 4:00 PM, the Director of Nursing (DON) confirmed the discrepancy between the physician's orders [REDACTED]. The Don stated Resident #7 was admitted on [DATE] and at that time, he was a full code. The DON stated the actual DNR order from the physician was not faxed to the facility until [DATE]; that's why the (MONTH) orders list Resident #7's status as a full code. During an interview on [DATE] at 4:30 PM, License Practical Nurse (LPN)… | 2019-11-01 |
| 2689 | 2689 | BEDFORD CARE CENTER OF HATTIES | 255158 | #10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2016-06-02 | 371 | F | 0 | 1 | JF4711 | Based on observation, staff interview, record review and facility policy review, facility staff failed to wash their hands before returning to the serving tray line for one (1) of three (3) kitchen observations. Findings included: A facility policy titled, Handwashing/Hand Hygiene, updated (MONTH) 2013, revealed: Employees must wash their hands for at least twenty (20) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: s. After handling soiled equipment or utensils. A review of facility training on Survey Readiness, dated (MONTH) 14th, (YEAR), revealed one (1) of the topics covered: Handwashing should follow after clearing away or scraping dishes or utensils. An observation on 06/01/16 at 5:00 PM revealed the Dietary Manager (DM) picked up a utensil that had fell on the floor and then placed it in the dish sink. The DM was not wearing gloves. The DM then walked back to the serving line and picked up a large metal container of bread/rolls and handed the container to another dietary staff employee who served the rolls with the dinner meal. The DM then walked to the employee sink to wash her hands. During an interview on 06/01/16 at 5:05 PM, the DM confirmed the observation of not washing her hands after she picked up a utensil off the the floor. The DM stated: She was waiting on the bread. | 2019-11-01 |
| 2690 | 2690 | BEDFORD CARE CENTER OF HATTIES | 255158 | #10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2016-06-02 | 514 | D | 0 | 1 | JF4711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility policy review and record review the facility failed to maintain accurate medical records concerning code status for one (1) of 24 records reviewed. (Resident #7). Findings include: Review of facility policy titled Physicians Orders revealed Physician orders [REDACTED]. Verbal telephone orders may only be received by licensed personnel (e.g., RN, LPN, Pharmacist, Physicians, ETC). Orders must be reduced to writing by the person receiving the order, and recorded in the resident's medical record. physician's orders [REDACTED]. Record review of Resident #7's original hand written physician order [REDACTED]. Review of the cumulative orders for Resident #7 dated 06/01/16 - 06/30/16 reads: Code status-Full Code. During an interview on 06/01/16 at 4:00 PM. the Director of Nursing (DON) confirmed the discrepancy between the physicians orders dated 05/23/16 and 06/01/16 - 06/30/16 and the cumulative physicians orders dated (MONTH) (YEAR) were different. The Don stated Resident #7 was admitted on [DATE] and at that time, he was a full code. The DON stated the actual DNR order from the physician was not faxed to the facility until 5/23/16 and that's why the (MONTH) orders listed Resident #7's code status as a Full Code. During an interview on 06/01/16 at 4:30 PM, License Practical Nurse (LPN) #1 confirmed the discrepancy between the physician's orders [REDACTED]. LPN #1 revealed she is the person that enters the orders into the computer and makes changes but the actual double-checking is carried out through chart checks by the Unit Supervisors. LPN #1 stated whoever received the order should have changed it in the computer. LPN #1 stated she never received a copy of the new order (DNR). During an interview on 06/02/16 at 9:16 AM, LPN #2 confirmed the discrepancy between the physician's orders [REDACTED]. She revealed she was the Nurse responsible for checking the charts for discrepancies. LPN #2 stated she … | 2019-11-01 |
| 3674 | 3674 | BEDFORD CARE CENTER OF HATTIES | 255158 | #10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2015-03-12 | 253 | E | 0 | 1 | VRQ211 | Based on observation, staff interview, and facility policy review, the facility failed to ensure a sanitary environment as evidenced by easily removable pink residue and black/brown residue on shower chairs in shower rooms in two (2) of three (3) resident care units. Findings include: Review of the facility's policy entitled, Cleaning and Disinfection of Resident-Care Items and Equipment, undated, revealed all reusable medical equipment should be cleaned and disinfected between residents. On 03/12/15 at 2:10 PM an observation of the facility's shower rooms revealed pinkish-colored residue that was easily removed on seven (7) shower chairs and black/brown residue on the underside of two (2) shower chairs located in shower rooms on two (2) of three (3) resident care units. Interview with Housekeeping/Maintenance Staff #1 on 03/12/15 at 2:35 PM revealed shower chairs were pressure washed twice a month but there was no set schedule as to when this was to be done and Certified Nursing Assistants should clean the shower chairs with disinfectant spray after each use. Housekeeping/Maintenance Staff #1 and #2 confirmed above observation. | 2018-10-01 |
| 3675 | 3675 | BEDFORD CARE CENTER OF HATTIES | 255158 | #10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2015-03-12 | 279 | D | 0 | 1 | VRQ211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and facility policy review the facility failed to develop a comprehensive care plan related to incontinence and the assistance required for transfer of one (1) of 21 records reviewed; Resident #24. Findings include: Review of the facility's policy entitled Care Plans-Comprehensive, dated (MONTH) 2013, revealed each resident should have a comprehensive care plan developed within seven (7) days of the completion of the resident's comprehensive assessment. The comprehensive care plan should include identified problems as well as identified risk factors associated with those problems to assist in the prevention of a functional decline. On 03/12/15 at 1:50 PM, review of Resident #24's comprehensive care plan revealed incontinence and the assistance required by the resident for transfers were not included. Interview on 03/12/15 at 11:00 AM with Registered Nurse (RN) #1 stated Resident #24 required a stand-in lift with assistance of two people for all transfers. On 03/12/15 at 12:10 PM an interview with Licensed Practical Nurse (LPN) #2 confirmed the required lift assistance was not listed on the comprehensive care plans. On 03/12/15 at 12:30 PM during an interview, the Director of Nurses (DON) stated it was not this facility's practice to include transfer information on the comprehensive care plan as it was posted on each resident's door frame. Interview on 03/12/15 at 11:45 AM with LPN #4 and Minimum Data Set (MDS) nurse stated any resident that experienced incontinent episodes should have incontinence care included in the comprehensive care plan. LPN #4 confirmed Resident #24 did not have a care plan related to incontinence. Review of the facility's face sheet revealed the facility admitted Resident #24 on 11/29/14 following a fall that resulted in a Right [MEDICAL CONDITION]. Resident #24's [DIAGNOSES REDACTED]. Review of Resident #24's MDS with an Assessment Reference Date of 02/23/15 revealed a Brief Int… | 2018-10-01 |
| 3676 | 3676 | BEDFORD CARE CENTER OF HATTIES | 255158 | #10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2015-03-12 | 282 | D | 0 | 1 | VRQ211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility policy review, the facility failed to follow the care plan for residents dependent on personal hygiene and grooming for two (2) of 20 residents reviewed; Residents #10 and #23. Findings included: Review of facility policy entitled Care Plans-Comprehensive, with effective date of (MONTH) 2013, revealed an individualized Comprehensive Care Plan should be developed to meet the resident's needs and designed to identify problem areas, identify the professional services responsible for each element of care, and aid in preventing or reducing declines in the resident's functional status or functional level. Resident #10 Review of Resident #10's current Plan of Care, with original date of 08/22/12, revealed Resident #10 was dependent on staff for Activities of Daily Living (ADL) care. Interventions included total assistance by one (1) staff member for personal hygiene. Observations on 03/10/15 at 10:10 AM, 12:15 PM, and 3:20 PM revealed Resident #10 had dry, crust on lower lip and yellow-white substance on lower front teeth. In an interview on 03/11/15 at 9:55 AM, Certified Nursing Assistant (CNA) #3 said mouth care was part of hygiene and grooming. CNA #3 said care was on the ADL sheet and said, We just know to do it. Interview on 03/11/15 at 11:05 AM with Registered Nurse (RN) #2 revealed, The CNAs (Certified Nursing Assistants) get an ADL (Activities of Daily Living) sheet every shift. It has information about transfer, care, et cetera; it is a simpler version of our care plan and is initiated from the care plan. Review of the facility's face sheet revealed the facility admitted Resident #10 on 09/22/11. Resident #10's [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/11/14 revealed Resident #10 had severe cognitive impairment. Resident #23 Review of Resident #23's current Plan of Care revealed an identified problem of ADL (Acti… | 2018-10-01 |
| 3677 | 3677 | BEDFORD CARE CENTER OF HATTIES | 255158 | #10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2015-03-12 | 312 | D | 0 | 1 | VRQ211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility policy review, the facility failed to include oral care, nail care and trimming of facial hair while providing personal hygiene for residents dependent on personal hygiene and grooming for two (2) of 20 residents reviewed; Residents #10 and #23. Findings included: Review of facility policy entitled Mouth Care, with review date of (MONTH) 2012, revealed the purposes of mouth care were to keep the resident's lips and oral tissues moist, to cleanse and refresh the resident's mouth and to prevent infections of the mouth. Review of facility policy entitled Care of Fingernails/Toenails, revised (MONTH) 2013, revealed the purposes of the procedure were to clean the nail bed, keep nails trimmed and to prevent infection. The policy revealed trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. Review of the facility policy entitled Shaving the Resident, revised (MONTH) 2013, did not address the trimming of nasal hair or eyebrows. Review of documentation by the facility dated 03/12/15 revealed the facility did not have a policy about removal of individual resident nasal hair. Resident #10 Observation on 03/10/15 at 10:10 AM revealed Resident #10 lying in bed, eyes closed and receiving continuous enteral feeding per PEG (Percutaneous Endoscopic Gastrostomy) tube. Resident #10's mouth was slightly open and had dry crusted skin on bottom lip and yellow-white substance on front lower teeth. Observation of Resident #10 on 03/10/15 at 12:15 PM revealed both lips were dry and bottom lip had dry, crusted skin with yellow-white substance on front lower teeth. Observation on 03/10/15 at 3:20 PM revealed Resident #10's condition of his mouth had not changed. Interview on 03/10/15 at 3:20 PM revealed Certified Nursing Assistant (CNA) #2 confirmed Resident #10's lips were dry and crusted and said Resident #10 was needing mouth care. It doesn't look like he… | 2018-10-01 |
| 3678 | 3678 | BEDFORD CARE CENTER OF HATTIES | 255158 | #10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2015-03-12 | 431 | D | 0 | 1 | VRQ211 | Based on observation, staff interview, and facility policy review, the facility failed to correctly label and store medication as evidenced by 53 loose and unpackaged medications found in 2 (two) of 6 (six) medication carts. Findings Include: Record review of facility policy entitled Storage of Medications, effective date 01/2013, revealed drugs and biological shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy was authorized to transfer medications between containers. The policy also stated nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean safe and sanitary manner. Observation of five Medication carts on 03/11/15 between 8:30 AM and 9:30 AM revealed 26 assorted, loose and unpackaged pills in the Back Hall medication cart and 27 in the Front Hall medication cart. During an interview on 03/11/15 at 8:40 AM, Registered Nurse (RN) #1 confirmed the count of 26 medications that were unpackaged in the Back Hall cart. She stated someone must have been popping them (pills) partially out of the blister packs. She said she worked two days on this cart and two days on another. She had cleaned a cart on the North Hall out a couple days ago, but it was his/her understanding that someone else should have cleaned the Back Hall cart. During an interview on 03/11/15 at 9:30 AM, License Practical Nurse (LPN) #1 confirmed the count of 27 loose and unpackaged medications in the Front Hall cart. He/she stated the blister packs in which the medications were dispensed and stored must become old, which caused the medications to spill. During an interview on 03/12/15 at 10:30 AM, the Director of Nursing (DON) stated the carts were to be periodically checked for loose medications by the nurses. He/she said they started cleaning and checking carts last Saturday but did not get to those two. He/she stated that an in-service on checking carts for unlabeled medications was started on the morning 03/12/14. Review of t… | 2018-10-01 |
| 4593 | 4593 | BEDFORD CARE CENTER OF HATTIES | 255158 | #10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2014-04-03 | 514 | D | 0 | 1 | PGZC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record reviews and facility policy review, the facility failed to maintain accurate medical records by documenting an inaccurate finger stick blood glucose result of 475 milligrams per deciliter (mg/dl) for one (1) of 24 records reviewed (Resident #8). Findings include: Reviewof the facility's policy entitled Guidelines for Charting and Documentation, revised on May 2013, revealed to be concise, accurate and complete when charting and documenting in the medical records. Review of the document entitled Bedford Care Center Job Description, for Job Title Licensed Practical Nurse (LPN), indicated the LPN Administers medications and treatments as ordered and records in the medical record, ensuring accurate medical records at all times. Resident #8 Record review of Nurses Notes revealed a documented Finger Stick Blood Glucose (FSBG) reading of 475 mg/dl on 3/7/14 at 9:30 PM and a repeat reading of 123 mg/dl at 11:00 PM signed by Licensed Practical Nurse (LPN) #1. The Nurses Notes for the date of 3/7/14 had no documentation Resident #8's physician had been notified of the elevated blood sugar of 475 mg/dl. Phone interview with LPN #1, while on speaker with the facility's Administrator and the Director of Nursing (DON) on 4/3/14 at 11:16 AM, she reported If I wrote that down it was wrong because his (Resident #8's) BS was never that high. She also reported she knew that was an error because she would have called the doctor. Interview with Resident #8's attending physician on 4/2/14 at 4:10 PM, he reported this reading was highly abnormal Blood Sugars (BS) for this resident and doubted the reading was accurate. Review of Resident #8's plan of care for Diabetes Mellitus with the onset date of 3/28/14 for interventions to notify MD for Blood Sugar (BS) >/= 400 or S/S of [MEDICAL CONDITION]. A review of the April 2014 Cumulative physician's orders [REDACTED].>/= 400 or S/S of [MEDICAL CONDITION]. The facility admitted Re… | 2017-06-01 |
| 5505 | 5505 | BEDFORD CARE CENTER OF HATTIES | 255158 | #10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2013-02-08 | 226 | D | 0 | 1 | 8BQ611 | Based on record review, policy review and staff interview, the facility failed to implement proper pre-employment screening of two (2) of five (5) employee files reviewed (Employees #2156 and #5757). Findings include: Employee #2156 Review of Employee #2156's personnel file on 02/08/2013 at 9:50 a.m., revealed that the form Reference Check Documentation had not been completed as evidenced that previous employers or individuals had not been contacted. Interview with Human Resources designee on 02/08/13 at 10:10 a.m. confirmed the above information and she stated, I have not completed background check, (Employee #2156) was working at (another long term care facility in the area) and was well known; he didn't want us to call his current employer. Employee #5757 Review of Employee #5757's personnel file on 02/08/2013 at 10:10 a.m. revealed an incomplete Acknowledgement of Employment Information form as noted by absence of Employee #5757's initials as directed on the instruction of the form. The instructions included the following statement: Initial beside each to acknowledge reading, reviewing, completing, and /or receiving the following: . Further review of the aforementioned form of Employee #5757's file revealed incompletion of the section This Section For Facility Personnel Administering This Form as it was not completed nor signed by Administrator of Designee. Review of Employee #5757's personnel file also revealed that the facility's Reference Check Documentation form had not been completed as previous employers or individuals had not been contacted. Interview with Human Resource designee 02/08/13 at 10:10 a.m. , also stated, I agree that an X is not an acknowledgement of receiving training and I should have called back. She (Employee #5757) was also still employed there and usually they don't want you to call there if they are still employed there. Interview with the Facility Administrator on 02/08/2013 at 10:15 a.m. confirmed above statements and he stated, We do constant training on abuse and neglect. We hav… | 2016-07-01 |
| 5506 | 5506 | BEDFORD CARE CENTER OF HATTIES | 255158 | #10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2013-02-08 | 253 | E | 0 | 1 | 8BQ611 | Based on observation, staff interview and facility policy review, the facility failed to maintain a sanitary environment for one (1) of three (3) days of survey as evidenced by improper storage of biohazardous medical waste, soiled linen containers had cracked and broken lids, and the exterior door to the Dietary department failed to properly close/latch. Findings include: Observation, during a tour of the facility on 2/6/13 at 10:15 a.m. with Housekeeping/Maintenance Staffs #1 and #2, revealed that the biohazardous waste storage area, outside of the facility, had three (3) black trash bags sitting on top of the covered red biohazardous waste containers. There were no markings on the outside of the black trash bags to indicate that they contained biohazardous waste, nor were the black trash bags stored in covered containers. Another observation, during the aforementioned tour, revealed that there were three (3) soiled linen containers in the A station soiled utility room with cracked and broken lids. A third observation, during the aforementioned tour, revealed that the outside door to the kitchen did not close or latch, which resulted in an open area directly from the outside into the kitchen. The aforementioned observations were confirmed by Housekeeping/Maintenance Staffs #1 and #2 during the tour. Review of the facility's policy on Medical Waste Storage, undated, confirmed Policy Interpretation and Implementation, 1. Containers of untreated medical waste that are not otherwise labeled will be labeled with a biohazard or infectious medical waste water resistant label affixed to the outside of the container whenever such a container is identified. Review of the facility's policy on Handling Soiled Linen, undated, did not address maintaining the soiled linen containers in good repair. Review of the facility's policy on Maintenance Service, undated, confirmed Procedure 1. The maintenance department is responsible for maintaining the buildings, grounds and equipment in a safe and operable manner at all times. | 2016-07-01 |
| 5507 | 5507 | BEDFORD CARE CENTER OF HATTIES | 255158 | #10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2013-02-08 | 279 | D | 0 | 1 | 8BQ611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and policy review, the facility failed to review and revise a comprehensive plan of care for two (2) of 24 records reviewed (Resident #10 and Resident #13). Findings include: Resident #10 Observation on 02/06/13 at 8:50 a.m. revealed Resident #10 was lying in his bed visiting with his son. Resident #10 was neat and clean in appearance. Record review revealed Resident #10 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed Resident #10 had a Brief Interview for Mental Status (BIMS)score of 06, indicating the residents' cognitive status was severely impaired. Review of Resident #10's Plan of Care, dated 01/01/13, read *259-SS:Res at times is not oriented to date. Strengths:Res is able to voice his own needs and concerns adequately. There are no documented goals identified nor are there any target dates for achievement of said goals. Interview with the Director of Nursing (DON) on 02/07/13 at 12:55 p.m. confirmed the aforementioned findings. Review of the facility's policy on Care Plans-Comprehensive, effective January 2013, documented 5. Care Plans are revised as the resident's condition changes and orders dictate. Care plans are reviewed per federal guidelines. Resident # 13 Observation of Resident # 13 on 2/6/13 at 10:50 a.m., revealed that he was lying in bed with his eyes closed. Resident # 13 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/20/12, revealed that he scored three (3) of 15 on the Brief Interview for Mental Status (BIMS) which indicated that he had severe cognitive impairment. Further review of Resident # 13's clinical record revealed the following entries on the Plan of Care: 1. An At risk for falls Plan of Care dated 7/16/12 which included an Intervention dated 11/27/12 to Place on 1 (one)… | 2016-07-01 |
| 5508 | 5508 | BEDFORD CARE CENTER OF HATTIES | 255158 | #10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2013-02-08 | 514 | D | 0 | 1 | 8BQ611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and policy review, the facility failed to maintain accurate medical records as evidenced by failure to discontinue a medication for one (1) of twenty-four (24) residents reviewed (Resident #22). Findings include: Resident #22 Observation of Resident #22 on 02/07/2013 at 4:05 p.m. revealed that Resident #22 lying in her bed covered with her personal blanket and watching television. Resident #22 was alert, oriented, pleasant and talkative. She was neat and well groomed. Record review revealed that Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #22's cognitive status on the Annual Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 01/07/2013, revealed that Resident #22's Brief Interview for Mental Status (BIMS) score was 15, indicating that Resident #22 was cognitively intact. Further record review of the physician's orders [REDACTED]. Further record review of the Medication Administration Record (MAR) for 02/01/13-02/08/13 revealed that Resident #22 continued to receive Senna two (2) tablets every morning. Interview with Director of Nursing (DON) on 02/08/2013 at 1:30 p.m. confirmed the above statement. DON stated, That didn't get picked up on the computer orders? No, I see it didn't and the MAR indicated [REDACTED]. You are absolutely right, the nurse that took off that order brought the order over but failed to discontinue the routine medication. Review of the facility's policy on Medical Records, with revision date of January 2013, documented Appropriate medical/clinical records shall be maintained for each resident. Review of the facility's policy on Electronic Medical Records, reviewed May 2012, documented Policy Interpretation and Implementation .#7(b) Our electronic medical records system: Has individual password and user ID codes and permission is established to ensure only authorized persons enter appropriate data. | 2016-07-01 |
| 6520 | 6520 | BEDFORD CARE CENTER OF HATTIES | 255158 | #10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2012-11-28 | 157 | D | 1 | 0 | PKWR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** CI MS # Based on record review, staff interview, family interview and policy review, the facility failed to notify Resident #1's Responsible Party (RP) of a change in treatment, of being started on [MEDICATION NAME] 0.5 mg (milligrams). This was for one (1) of four (4) residents reviewed (Resident #1). Findings Include: Resident #1 Record review for Resident #1 revealed the resident was admitted on [DATE] with diagnosis' which included Systolic Heart Failure, Acute [MEDICAL CONDITIONS] Fibulation, [MEDICAL CONDITION] Ulcer Disease, Mitral Valve Regurgitation and [MEDICAL CONDITION]. Resident #1 was also a status [REDACTED]. A review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/25/12, revealed the Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was very cognitive. The same MDS failed to be coded for any mood or behavior problems. A review of a Telephone Order, revealed that Resident #1's attending physician had given a new order dated 7/24/12 at 20:00 (8:00 p.m.) which read, [MEDICATION NAME] 0.5 mg (milligrams) PO (by mouth) Q (every) HS (hour of sleep). A review of the July 2012, Medication Administration Record [REDACTED]. There was no documented evidence that the facility notified the Responsible Party (RP) of the need for or the administration of the new medication. Further review of the MAR indicated [REDACTED]. There was no documentation that Resident #1 received any other psychoactive medications. Interview with the Director of Nursing (DON) on 11/28/12 at 12:00 noon, revealed Resident #1 had been readmitted back to the facility on [DATE]. The DON stated the family had been very demanding about dictating Resident #1's care. The family did not want the resident to have any pain medication except Tylenol. They did not want any psychoactive medications to be given even though Resident #1 had behaviors. The DON confirmed there was no documentation… | 2015-11-01 |
| 6916 | 6916 | BEDFORD CARE CENTER OF HATTIES | 255158 | #10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2012-06-01 | 224 | D | 1 | 0 | DHGU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to report an alleged occurrence of verbal abuse for one of eleven residents reviewed. Resident #10. Record review for Resident # 10 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the facility document entitled " Resident Grievance/Complaint Form " revealed Resident # 10 ' s family member had reported that on 10/21/11 a nurse did not respond to the resident ' s needs and on 10/22/11, the same nurse had told Resident # 10 to " shut up " . A review of the facility ' s investigation revealed the complaint had been substantiated and the nurse was terminated. On 6/1/12 at 11:00 am an interview with the facility ' s Administrator confirmed the incident of verbal abuse was not called in to the state agency. | 2015-08-01 |
| 7332 | 7332 | BEDFORD CARE CENTER OF HATTIES | 255158 | #10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2012-07-18 | 279 | D | 0 | 1 | 8U7R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and facility policy review, the facility failed to review and revise care plans per physician's orders for two (2) of 24 residents reviewed (Resident #2 and Resident #20). Findings include: Resident # 2 Observation on 7/16/2012 at 11:15 a.m. revealed that Resident #2 was sitting in bed eating lunch. Record review on 7/17/2012 revealed Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 07, indicating the resident's cognitive status was severely impaired. Review of the Physician's Orders, dated 6/20/2012, revealed Resident #2 had a diet order of Mechanical Soft, No Added Salt (NAS) Diet with Chopped Meats. Review of the Care Plan for Resident #2, with an original date of 11/4/2011 and estimated date of 11/4/2011, revealed that Resident #2's diet was changed on 4/29/2012 to Regular Soft Diet, no milk or Ensure. The facility failed to change the diet order on the care plan. Review of the facility's "Care Plans--Comprehensive Policy" revised September 2010 and reviewed January 2012 revealed, "Care plans are revised as the resident's condition changes and orders dictate. Care plans are reviewed per federal guidelines." An interview was conducted on 7/17/2012 at 9:15 a.m. with Dietary Staff #1. During the interview, it was revealed revealed that Resident #2 was served biscuit with sausage gravy, juice, coffee, and milk. Dietary Staff #1 stated, "(Resident #2) likes frosted flakes." During an interview on 7/18/2012 at 9:35 a.m. with the facility DON, it was confirmed that Resident #2's diet was not consistent with the physician ' s diet order. The DON stated, "(Resident #2) probably hasn't had an MDS update and that's the only thing I can think of. (Resident #2) went to the hospital and came back on 6/20/2012 and they haven't updated the care plan." Residen… | 2015-05-01 |
| 7333 | 7333 | BEDFORD CARE CENTER OF HATTIES | 255158 | #10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2012-07-18 | 367 | D | 0 | 1 | 8U7R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, staff interview, and facility policy review, the facility failed to ensure that residents received a therapeutic diet as ordered by the physician for two (2) of 14 residents reviewed (Residents #4 and #8). Findings include: Resident #4 Resident #4 was observed sitting at a table in the dining room on 7/16/12 at 11:30 a.m., and again on 7/17/12 at 11:55 a.m. During the aforementioned observations, Resident #4 was not served prune juice with her meals. Review of medical record for Resident #4 revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), with Assessment Reference Date of 6/4/2012, revealed that Resident #4 required assistance with Activities of Daily Living (ADLs). Review of the Physician orders [REDACTED]." Interview with Dietary Department Staff #1 on 7/17/12 at 11:55 a.m. verified that Resident #4 should have been served prune juice with every meal. Resident #8 Observation on 7/16/2012 at 11:15 a.m. revealed Resident #8 was sitting in her room eating lunch, which consisted of a stuffed bell pepper, green beans, rice and tomato gravy, peach cobbler, breadstick, nectar tea and nectar water. Record review on 7/16/2012 revealed Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE] revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 14, indicating Resident #8's cognitive status was cognitively intact. Review of the Physician Orders, dated 7/4/2012, revealed Resident #8 was ordered a Gluten Free Diet. Review of the dietary tray card on 7/16/2012 revealed Diet as follows: Gluten free diet, NAS with nectar thick liquids; Texture: whole meats; Allergy: potatoes; other: nectar thick liquids, nectar water, nectar tea; Dislikes: pasta, potatoes, raw vegetable, and turnips. An interview on 7/16/2012 at 11:45 a.m. with Dietar… | 2015-05-01 |
| 7334 | 7334 | BEDFORD CARE CENTER OF HATTIES | 255158 | #10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2012-07-18 | 514 | D | 0 | 1 | 8U7R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and facility policy review, the facility failed to ensure medical records were accurate and complete for two (2) of 17 residents records reviewed (Residents #18 and #19). Findings include: Resident #18 An observation of Resident #18 on [DATE] at 9:20 a.m. revealed that he was neatly dressed and seated in a chair while facility staff administered eye drops. Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS), with an Assessment Reference Date of [DATE], revealed that he scored 14 of 15 on the Brief Interview for Mental Status (BIMS), which indicated the resident was cognitively intact. Review of the Cumulative "Physician order [REDACTED].#18 revealed an order, dated [DATE], for "CPR (Cardiopulmonary Resuscitation) only per family request. " Review of the Advanced Directives for CPR revealed that the family signed for "Full Code. " Review of the Care Plan for Resident #18 revealed that there was no Care Plan for the code status. An interview with the Director of Nursing (DON), on [DATE] at 10:45 a.m., confirmed that the family signed for Full Code, but the Physician order [REDACTED].#18. During the aforementioned interview, the DON stated, "Only CPR would be performed in-house (in the facility). " When asked if the resident was transferred to a hospital with a copy of the current Physician Orders, would the hospital have performed a Full Code, he stated "no";the DON also confirmed that "Full Code" and "CPR only" are not the same. Review of the facility's policy "Advanced Directives", which was not dated, revealed "Policy Interpretation and Implementation, 4. Advance directives are defined as preferences regarding treatment options and include, but are not limited to: h. Other Treatment Restrictions - Indicates that the resident, legal guardian, healthcare proxy, or representative (sponsor) does not wish for the resident t… | 2015-05-01 |
| 7335 | 7335 | BEDFORD CARE CENTER OF HATTIES | 255158 | #10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2012-07-18 | 441 | D | 0 | 1 | 8U7R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, Staff interview and facility policy review the facility failed to ensure proper infection control techniques on two (2) of four (4) days of survey as evidenced by the following: Resident #6 (improper placement of feeding tubing); Resident #7 (improper disposal of dressing supplies); and Resident #18 (gloves were not worn while administering eye drops). Findings include: Resident # 6 Record review revealed Resident #6 was admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of the Minimum Data Set (MDS), with an assessment reference date of 6/11/12, revealed Resident #6's Brief Interview for Mental Status (BIMS) score was 04, indicating Resident #6's cognitive status was severely impaired. Observation on 7/17/12 at 11:10 a.m. revealed Licensed Practical Nurse (LPN) #3 disconnected Resident #6's feeding tube. LPN #3 then placed the tubing on the top bed sheet, which was covering Resident #6. There was no barrier or clean pad placed on the bed sheet upon which to lay the tubing. Resident #7 An observation of Resident #7 on 7/16/12 at 3:25 p.m. revealed that the resident was lying in the bed while staff performed care. Review of Resident #7's clinical record revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the clinical record and the Minimum Data Set, with an Assessment Reference Date of 5/21/12, revealed that the resident's cognitive status was severely impaired. Further review of the medical record for Resident #7 revealed a physician's orders [REDACTED]. Licensed Practical Nurse (LPN) #2 performed PEG site care on Resident #7 and disposed of the soiled supplies used during the PEG site care in a clear garbage bag; the clear garbage bag was then placed in the regular trash. An interview with LPN #2, conducted on 7/16/12 at 3:30 p.m., confirmed that she placed the soiled supplies for Resident #7 in the regular trash instead o… | 2015-05-01 |
| 7336 | 7336 | BEDFORD CARE CENTER OF HATTIES | 255158 | #10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2012-07-18 | 460 | D | 0 | 1 | 8U7R11 | Based on observation and staff interview, the facility failed to provide full visual privacy for 6 (six) of 60 semi-private rooms, including rooms on the South Hall (#17 and #19) and the North Hall (#1 and #3, #17 and #19). Findings include: During a tour of the facility on 7/17/12 at 9:30 a.m., an observation was made of Resident rooms on South Hall (#17 and #19), and North Hall (#1, #3, #17 and #19), which revealed that these rooms did not have privacy curtains at the foot of the beds. An interview with the Director of Nursing (DON), conducted on 7/17/12 at 9:50 a.m., confirmed that the North Hall rooms #1, #3, #17 and #19 did not have privacy curtains at the foot of the beds. An interview with Housekeeping/Maintenance Staff #1 on 7/17/12 at 10:25 a.m. confirmed that South Hall rooms #17 and #19 did not have privacy curtains at the foot of the beds. | 2015-05-01 |
| 7337 | 7337 | BEDFORD CARE CENTER OF HATTIES | 255158 | #10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2012-07-18 | 253 | E | 0 | 1 | 8U7R11 | Based on observation, staff interview, and policy review, the facility failed to maintain housekeeping and maintenance services in common areas of the facility for two (2) of four (4) days of the survey. Findings include: An initial tour of the facility was conducted on 7/15/12 from 6:05 p.m. to 7:25 p.m.; a second tour was conducted on 7/17/12 from 9:15 a.m. to 10:25 a.m., and revealed the following: North Hall: Clean linen cart - There were brown stains noted on the cover. This was confirmed with the Director of Nursing (DON) on tour. Whirlpool Room - There were pink stains noted on the grout in the shower area. This was confirmed with Housekeeping Staff Member #1 on tour. Housekeeping Staff Member #1 stated, "The soap is pink colored and it may be soap. " Housekeeping was in the process of cleaning this area during the tour. South Hall: Room 16 - There was a discolored stain on the floor by Bed B. This was confirmed on the environment tour with Housekeeping Staff Member #1. Clean linen cart - There were white stains noted on the cover. This was confirmed with the DON on tour. Rehab " C " Hall: Rehab flooring (carpet) - There were discolored areas noted on carpet throughout the rehab area. This was confirmed with Maintenance Staff Member #2 on tour. He stated, "This is in process of repair now. " Room 3 - There was a piece of wood missing from the entrance door to the room. This was confirmed with Maintenance Staff Member #2 on tour. Outside of Building on the Rehab North wall - There was a loose wire hanging down the wall to the ground. This was confirmed with Maintenance Staff member #2 on tour. The Maintenance Staff Member stated, "It is a TV cable. " This was corrected on tour. Dining Room: Dish holding area - There were grey stains noted on the wall. This was confirmed with the Administrator who stated, "This is in the process of being repaired." On 7/18/12 at 10:30 a.m. during an interview with Maintenance Staff Member #2, it was stated, "Everything noted on tour has been corrected, or a maintenance reque… | 2015-05-01 |
| 7338 | 7338 | BEDFORD CARE CENTER OF HATTIES | 255158 | #10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2012-07-18 | 323 | C | 0 | 1 | 8U7R11 | Based on observation, staff interview, and policy review, the facility failed to ensure that the residents' environment is free from accident hazards as is possible for two (2) of four (4) days of the survey. Findings include: An initial tour of the facility was conducted on 7/15/12, from 6:05 p.m. to 7:25 p.m.; a second tour was conducted on 7/17/12, from 9:15 a.m. to 10:25 a.m. These findings were revealed during the tours: North Hall: Oxygen Storage Room - There were three (3) unsecured cylinders in storage. This was confirmed with Maintenance Staff member #2 on tour. This was corrected on tour. South Hall: Oxygen Storage Room - There was one (1) unsecured cylinder in storage. This was confirmed with Housekeeping Staff member #1 on tour. This was corrected on tour. | 2015-05-01 |
| 8477 | 8477 | BEDFORD CARE CENTER OF HATTIES | 255158 | #10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2011-01-19 | 323 | G | TKDC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** CI MS #8904 Based on observation, interview, record and document review, the facility failed to follow the facility lift policy and the Resident's plan of care for one (1) of six (6) Residents in the sample (Resident #4) to prevent injury from falls. A Nurse Aide in Training transferred the Resident without assistance, failing to follow facility policy and the plan of care. This failure allowed Resident #4 to sustain an avoidable fall to the floor, sustaining multiple rib fractures, left chest contusion, left elbow abrasion and right knee contusion. Findings Include: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medications included Vitamin Supplements, Cymbicort Inhalants, Fosamax, Zestril and Iron Supplements. A comprehensive assessment dated [DATE] reflected that the Resident had no memory problems and could make cognitive decisions. Resident #4 was identified to be able to wheel self in a wheelchair but required assistance with transfers. A care plan dated 6/2/10 identified a problem: "At risk for falls" with a goal stating: "free from falls." Interventions stated to "transfer with assistance of two (2) CNA's with a stand-up lift." . Review of a Fall Risk Assessments completed on 11/20/10 and 12/16/10 reflected a score of "10", which represented a "High Risk" for falls. Review of the facility "Lift/Transfer Policy" reflected the facility is to provide a safe work environment, only Nursing Staff, therapist and Nursing Assistants are authorized to lift and transfer and that two nurse aides are to use the lift. A Nurse's Note at 5:45 a.m. on 12/10/10 reflected a Nurse was called to Resident #4's room by a Nursing Aide. The Resident was noted on the floor beside the stand-up lift, complaining of left side rib pain and stated "I fell off the lift." The Nurse Aide reported stepping back into the doorway to call for help, after putting the resident on the lift without assistance. The Physician ordered a transfer t… | 2014-04-01 | ||
| 8478 | 8478 | BEDFORD CARE CENTER OF HATTIES | 255158 | #10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2011-09-16 | 241 | D | X51K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and facility policy review, the facility failed to ensure residents were dressed and cared for in a private and dignified manner for four (4) of 14 residents reviewed. This is for Residents #4, #8, #14 and Unsampled Resident H. Findings include: Resident #8 Record review revealed Resident #8 had an admission date of [DATE]with [DIAGNOSES REDACTED]. Review of the MDS with an ARD of 8/13/11revealed Resident #8 had a BIMS score of 13 indicating Resident #8 was cognitively intact. Observation on 9/13/11 at 5:30 p.m., revealed Resident #8 sitting on the side of the bed uncovered. The occupational therapy (OT) staff was providing therapy. The door was open and the cover pulled back. Resident #8's incontinent brief was fully visible. Resident #8 did not have on any pants. The privacy curtain was not pulled. In an interview on 9/13/11 at 5:45 p.m. the occupational therapy staff confirmed the door was left open during the therapy session. The OT staff reported "I didn't think about closing the door." Resident #14: Record review revealed Resident #14 had an admission date of [DATE]with [DIAGNOSES REDACTED]. Review of the MDS with an ARD of 7/25/11revealed Resident #14 had a BIMS score of 09 indicating Resident #14's cognitive status was moderately impaired Observation on 9/14/11 at 12:20 p.m., during catheter care, revealed Certified Nursing Assistant (C.N.A.) #1 leave the bedside three (3) times leaving Resident #14 uncovered and fully exposed. In an interview on 9/14/11 at 12:35 p.m. C.N.A. #1 confirmed she left Resident #14 fully exposed while she left the bedside to wash her hands. C.N.A. #1 reported "I'm sorry." Unsampled Resident H: Record review revealed Unsampled Resident H had an admission date of [DATE]with [DIAGNOSES REDACTED]. Review of the MDS with an ARD of 6/25/11 revealed Unsampled Resident H had a BIMS score of 03 indicating Unsampled Resident H's cognitive status was severely impaired Observation … | 2014-04-01 | ||
| 8479 | 8479 | BEDFORD CARE CENTER OF HATTIES | 255158 | #10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2011-09-16 | 253 | D | X51K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, client birthday list review and facility policy review, the facility failed to maintain patient care equipment in a safe operating condition for nine (9) of twenty-six (26) residents who use wheelchairs (w/c's) for their primary mode of locomotion. This is for Residents #8 and #15 and Unsampled Residents A, B, C, D, E, F, and G. The facility failed to ensure a clean homelike environment for two (2) of three (3) halls. Findings include: Review of the "Client Birthdays List" provided by the facility revealed 26 residents used wheelchairs for their primary mode of locomotion. Nine (9) of these twenty-six (26) residents had wheelchair (w/c) arms that were ripped and torn. Resident #8: Record review revealed Resident #8 had an admission date of [DATE]with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/13/11revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 13 indicating Resident #8 was cognitively intact. Observation on 9/15/11 at 10:08 a.m. revealed Resident #8 sitting in his w/c at the end of North hall reading his Bible. The left of the w/c has cracked and torn areas on the arm. Resident #15: Record review revealed Resident #15 had an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the MDS with an ARD 8/29/11 revealed Resident #15 had a BIMS score of 11 indicating Resident #15's cognitive status was moderately impaired. Observation on 9/15/11 at 10:10 a.m. revealed Resident #15 sitting at the end of North hall in a navy blue w/c with black arms. The left arm of the w/c was cracked and torn. Unsampled Resident A: Record review revealed Unsampled Resident A had an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the MDS with an ARD of 8/22/11, revealed Unsampled Resident A had a BIMS score of 14 indicating Unsampled Resident A was cognitively intact Observation on 9/13/11 at 10:25 a.m. revealed Unsam… | 2014-04-01 | ||
| 8480 | 8480 | BEDFORD CARE CENTER OF HATTIES | 255158 | #10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2011-09-16 | 309 | D | X51K11 | Based on observation, record review, staff interview and facility policy review, the facility failed to ensure glucose control monitoring was in place for one (1) of three (3) nursing units. Findings include: Review of the North and South halls "(Name of Device) Blood Glucose Monitoring System Daily Quality Control Record" for August and September 2011 revealed the control log was in place but incomplete. There was not a control log provided by the facility for the Rehabilitation (Rehab) unit . In an interview on 9/15/11 at 3:30 p.m., the Director of Nursing (DON) reported "I couldn't find a log for the Rehab unit. I'll keep looking." In an interview on 9/16/11 at 10:45 a.m., the DON reported she was still unable to find a log for the Rehab unit. She reported "I initiated a log immediately." Review of the facility policy "Obtaining a Fingerstick Glucose Level" dated April 2001 revealed "Preparation: 4. Ensure that the equipment and devices are working properly by performing any calibrations or checks as instructed by the manufacturer or this facility." Review of the "Quality Checks" under section B of the monitor instruction book revealed "Use (Name of Device) Control Solutions to check if: *the meter and test strips are working correctly as a system * you are testing correctly." | 2014-04-01 | ||
| 8481 | 8481 | BEDFORD CARE CENTER OF HATTIES | 255158 | #10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2011-09-16 | 441 | E | X51K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and policy review the facility failed to ensure infection control measures to prevent the potential spread of infections for six (6) of twelve (12) residents reviewed and two (2) of four days of survey, for Residents #2, 4, 8, 19, 21, 22 and 24. Findings: An observation on 9/13/11 at 9:35 a.m. revealed the South Hall with isolation signs on rooms. The staffs were noted entering room [ROOM NUMBER] without gloves and the entrance was clearly marked with a contact isolation sign. An interview and observation was conducted on 9/13/11 at 9:35 with Certified Nurse Aid (CNA) #4. She was observed entering isolation room [ROOM NUMBER] and returning with a gray ice pitcher with lid and straw, scooping ice into the container, and then leaving the ice scoop in the chest. She re-entered isolation room [ROOM NUMBER], retrieved another ice pitcher, and scooped ice from chest without gloves or changing ice before entering another room across the hall, which had no isolation sign. CNA #4 entering the room, and retrieved the pitcher. The scoop was left in the ice chest the entire time. She was asked what should be done when serving residents in contact isolation stated, " Let me get an RN (Registered Nurse) for you. " When told her knowledge is what was required, she reported, " To wash hands before entering and after exiting and to wear gloves. " She was observed entering the room without gloves and filling resident pitchers without gloves. An observation on 9/13/11 at 9:40 a.m. revealed CNA #5 exiting contact isolation room [ROOM NUMBER] and proceed to the clean towel and linen cart to retrieve items. When asked what training she had received on contact isolation rooms she reported, " Gloves when giving care and to use red barrels in room for items. " An interview on 9/16/11 at 9:50 a.m. with the Director of Nursing (DON) when told of the concerns with infection control and the contact isolation observatio… | 2014-04-01 | ||
| 8482 | 8482 | BEDFORD CARE CENTER OF HATTIES | 255158 | #10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2011-09-16 | 502 | D | X51K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and facility policy review, the facility failed to ensure laboratory (lab) test were obtained as ordered by the physician for two (2) of 21 residents reviewed. This is for Resident #4 and Resident #8. Findings include: Resident #8: Record review revealed Resident #8 had an admission date of [DATE]with [DIAGNOSES REDACTED]. Review of the MDS with an ARD of 8/13/11revealed Resident #8 had a BIMS score of 13 indicating Resident #8 was cognitively intact. Review of a fax sheet from Resident #8's physician dated 8/20/11 revealed an order "BUN (Blood Urea Nitrogen), Cre (Creatinine) & 'lytes (electrolytes) in a.m.". Review of the physician orders for August 2011 revealed a handwritten order dated 8/22/11 "Bun, [MEDICATION NAME], Lytes in am." Review of the lab results revealed the aforementioned lab was not obtained until 8/23/11. In an interview on 9/15/11 at 3:15 p.m., the Director of Nursing (DON) confirmed the labs had not been obtained as ordered by the physician. The DON reported "it should have been drawn the next morning." Review of the facility policy "Lab and Diagnostic Test Results-Clinical Protocol" with a revision date of October 2010 revealed "2. The staff will process test requisitions and arrange for tests." Review of the facility policy "Physicians' Medication Orders" with a revised date of April 2007, 2008 revealed "4. Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include the date and time of the order." Resident # 4 was readmitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. On the admission Minimum Data Set (M.D.S.) with an Assessment Reference Date (A.R.D.) of 8-8-11, he/she was coded 5 of 15 on the Brief Interview for Mental Status (B.I.MS.), which indicates that he/she has severe cognitive impairment. Resident #4 was observed on 9-13-11 lying in bed with a visitor present. Record review of Resident … | 2014-04-01 | ||
| 8483 | 8483 | BEDFORD CARE CENTER OF HATTIES | 255158 | #10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2011-09-16 | 325 | D | X51K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and policy review, the facility failed to maintain acceptable parameters of nutritional status for 3 of 14 residents reviewed for weight, nutrition and swallowing concerns. These were Residents # 4, #7 and #18. Findings include: Resident # 4 was readmitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. On the admission Minimum Data Set (M.D.S.) with an Assessment Reference Date (A.R.D.) of 8-8-11, he/she was coded 5 of 15 on the Brief Interview for Mental Status (B.I.MS.), which indicates that he/she has severe cognitive impairment. Resident #4 was observed on 9-13-11 lying in bed with a visitor present. Resident #4 was readmitted with a Foley Catheter on 8-2-11. The Foley Catheter was discontinued on 9-13-11. On 9-9-11, Resident #4 was found to have two unstageable wounds on the penis. Readmission weight on 8-1-11 was 181. The next recorded weight was 174 on 9-6-11. Review of the Dietary notes for this resident revealed that there was no assessment completed by the Registered Dietician (R.D.) in the chart. An interview on 9-15-11 at 10:50 a.m. with the R.D. confirmed that the R.D. had not assessed the resident since readmission. The facility's policy for "RD Consultation" revised 12-09 stated "The RD is always available by telephone when not in the facility. She is able to complete evaluation and assessment by fax as needed." The Policy did not address specific problems that should be reported to the R.D., nor was there a timeframe to report problems to the R.D. The Registered Nurse Consultant confirmed in an interview on 9-16-11 at 1:50 p.m. that the Policy does not address guidelines as to which Residents to refer the R.D., or the timeframe that should be observed. Resident #7 was readmitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. On the quarterly M.D.S. with an A.R.D. of 6-27-11, Resident #7 had a B.I.M.S. score of 1of 15, which indicates that he/she has sever… | 2014-04-01 | ||
| 8646 | 8646 | BEDFORD CARE CENTER OF HATTIES | 255158 | #10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2010-11-17 | 241 | D | UWUD11 | Based on observation and interview, the facility failed to ensure privacy and dignity for one Unsampled Resident reviewed (Unsampled Resident #C). Unsampled Resident #C was not covered to protect her privacy during a care observation. Findings Include: Observation of Unsampled Resident #C on 11/16/10 at 2:55 p.m. revealed that Certified Nursing Assistant (CNA) #3 was applying a Foley Catheter strap to the resident's leg to secure the tubing in place. The Unsampled Resident #C was exposed from the waist down and and had her gown pulled up to her waist area. There was no privacy curtain in the room and a sitter was present during care. CNA #5 knocked on the door and the sitter opened the door partway and CNA #5 asked if CNA #3 needed help. CNA #3 replied that she did not. A few moments later CNA #5 knocked on the door again and when the sitter opened the door CNA #5 handed a sheet through the door and stated "cover her up". CNA #3 took the sheet and covered the resident's lower extremity and pulled her gown down below her perineal area. Interview with CNA #5 on 11/16/10 at 4:00 p.m. revealed that CNA #3 should have covered Unsampled Resident #C while doing care and that she had been exposed more than she should have been. CNA #5 stated that there were no privacy curtains in any of the private rooms. Interview with the Director of Nursing (DON) on 11/16/10 at 4:15 p.m. revealed that residents should be provided privacy during care and covered as much as possible while performing care and agreed that it would be a dignity issue if the resident was exposed unnecessarily. | 2014-03-01 | ||
| 8647 | 8647 | BEDFORD CARE CENTER OF HATTIES | 255158 | #10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2010-11-17 | 272 | D | UWUD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that a Minimum Data Set(MDS) was accurately documented for one (1) of six (6) residents reviewed (Resident #1). Resident #1 had a diabetic ulcer to his left foot that was not coded on the MDS for the period in which the ulcer was treated. Findings Include: Observation and interview of Resident #1 on 11/15/10 at 4:10 p.m. revealed that he was alert and oriented and his mother was present. There was a bandage to the side of his left foot dated 11/15/10. Resident #1's mother stated that it was a diabetic ulcer that had been there a long time and they were treating it almost daily and it was getting better now, that it had been treated at the wound clinic at one time before coming to the facility and afterward too. Observation of Resident #1's left foot during treatment on 11/16/10 at 8:45 a.m. revealed a thinly scabbed area approximately 1.0 x 1.2 centimeters (cm) with no redness odor or drainage. There were no open areas. The top of his left foot was scaly with scattered reddened areas with no breakdown noted. Review of Resident #1's medical record revealed that he was admitted [DATE] with [DIAGNOSES REDACTED]. Review of a Treatment Record (TAR) dated 07/01/10-7/31/10 revealed that Resident #1 had a left foot stage 2 diabetic ulcer with a treatment of [REDACTED]. This treatment was documented on the TAR from 7/1/10-7/19/10 and then the treatment was changed. The new treatment was for a Diabetic Ulcer (no stage) to cleanse with wound cleanser, pat dry and apply [MEDICATION NAME] Blue and cover with a transparent dressing and bordered foam dressing and change every other day. This treatment was documented 7/21/10-8/16/10 when the treatment was changed again and the TAR documented a Stage II Diabetic Ulcer on the left lateral foot with treatment of [REDACTED]. Review of Resident #1's MDS with an Assessment Reference Date (ARD) 8/2/10 revealed no documentation under se… | 2014-03-01 | ||
| 8648 | 8648 | BEDFORD CARE CENTER OF HATTIES | 255158 | #10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2010-11-17 | 281 | D | UWUD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review, the facility failed to ensure that physician's orders were followed for one (1) of six (6) residents reviewed (Resident #2). Resident #2 had physician's orders for Foley Catheter care every shift and it was not performed every shift as ordered. Findings Include: Observation and interview with Resident #2 on 11/15/10 at 4:18 p.m. revealed that she had a Foley Catheter with clear urine in the tubing. The catheter bag was covered. She was lying in bed and was alert and oriented to person, place and time. Resident #2 stated that she had not been able to control her bladder after back surgery and that's when she'd gotten her catheter. She stated that she had been in and out of the hospital couple of times since last month, mostly due to fluid and had a bowel infection. Observation and interview with Resident #2 on 11/16/10 at 9:10 a.m. revealed that she was sitting in a wheelchair watching television. She was alert and oriented. She stated that her Foley Catheter had been changed yesterday and was always changed on the 15th of each month. She stated that she took a shower every two or three days or whenever she wanted one. Resident #1 stated that a stand up lift was used for transfers and to be sat on the potty chair. She stated that she did not have a bowel movement daily and was usually continent but occasionally had an accident and that's why she liked to wear diapers. Resident #2 stated that when she got her showers they washed around her catheter with soap and water but that they did not clean her three (3) times a day around her catheter. She stated that sometimes they used those wipes and cleaned her off around that area but again not every shift. Resident #2 stated that she had been in the hospital last month with a bowel infection and had been back since with fluid and congestion with difficulty breathing and fever. States she drinks water a lot because it flushes out every… | 2014-03-01 | ||
| 8649 | 8649 | BEDFORD CARE CENTER OF HATTIES | 255158 | #10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2010-11-17 | 315 | E | UWUD11 | Based on observation, interview, record review and policy review, the facility failed to ensure that residents who had Foley Catheters received care as ordered and required to help prevent urinary tract infections for two (2) of four (4) residents observed for catheter care (Resident #2 and Unsampled Resident #A). Resident #2 and Unsampled Resident #A received catheter care that was provided in a manner not consistent with the policy and infection control guidelines. Findings Include: Cross refer to F-441 for the facility's failure to follow infection control guidelines of changing gloves and handwashing when providing Foley Catheter care for Resident #2 and Unsampled Resident #A. | 2014-03-01 | ||
| 8650 | 8650 | BEDFORD CARE CENTER OF HATTIES | 255158 | #10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2010-11-17 | 441 | E | UWUD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review, the facility failed to ensure that infection control technique was maintained to help prevent infections for residents with foley catheters for two (2) of four (4) observations for catheter care and one (1) observation of perineal care (Resident #2 and Unsampled Resident #A). Resident #2 and Unsampled Resident #A were provided catheter care and gloves were not changed and hands were not washed at appropriate times during the observed care. Findings Include: Observation of perineal/catheter care for Resident #2 on 11/16/10 at 2:00 p.m. revealed that CNA #1 provided the care while CNA #2 assisted with positioning of the resident. CNA #1 washed her hands and donned gloves, placed a towel under Resident #2 and explained the procedure. CNA #1 sprayed a perineal wash onto Resident #2's perineal area and used disposable wipes to wipe from the front to the back of the labia on both sides and then disposed of the wipe after one (1) stroke down each side. She did this twice. CNA #1 then wiped down the middle of the urinary meatus, front to back and disposed of the wipe. Then holding the catheter, CNA wiped down the catheter going away from the body. She then patted the areas dry. Without degloving CNA reached into Resident #2's bedside table and retrieved a tube of barrier cream and placed the cream on her gloved hand and rubbed the cream on the resident's thighs and then replaced the tube of cream into the bedside drawer. Resident #2 was then placed on her left side and CNA #1 used perineal spray and wipes to cleanse the buttocks, pat dry and again reached inside the bedside drawer, got the barrier cream onto her glove and applied to Resident #2's buttocks then replaced the barrier cream into the drawer. Without degloving and washing her hands, CNA #1 assisted to pull Resident #2 up in the bed and adjust the bed covers up around the resident. Resident #2 stated that she wanted to turn t… | 2014-03-01 | ||
| 8651 | 8651 | BEDFORD CARE CENTER OF HATTIES | 255158 | #10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2010-11-17 | 514 | E | UWUD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review, the facility failed to ensure that medical records had accurate and consistent documentation for seven (7) of ten (10) residents. Three (3) sampled and three (3) Unsampled residents had pre-documentation of Foley Catheter care before the care was actually provided. (Residents #2, #5, #6, Unsampled #B, #C and #D.) One (1) resident had inconsistent documentation of vital signs before transport to the hospital (Resident #3). Findings Include: Interview with RN #1 on 11/16/10 at 9:15 a.m. revealed that catheter care was done every shift by the Certified Nursing Assistants (CNAs) and should be documented. When asked about Resident #2's catheter care she stated that the CNA would provide the care and then let the nurse know so that it could be documented on the Medication Administration Record (MAR). She reviewed the Kardex for Resident #2 and saw that catheter care every shift was marked on the Kardex Care Plan. Interview with LPN #1 on 11/16/10 at 9:20 a.m. revealed that the CNAs did catheter care and let her know when it was done so that she could mark it on the MAR that it had been completed. LPN #1 stated that she often checked behind them to make sure that it has been done. LPN #1 stated that the CNA had not came and told her that Resident #2's catheter care had been done. When asked to see how it was documented on the MAR, LPN #1 flipped to Resident #2's MAR and the Foley Catheter care had already been documented for 11/16/10, 7-3 shift. LPN #1 stated that she had marked it because the CNAs are really good about doing their catheter care and she knew that it would be done and she had just marked it when she had given Resident #2 her medications-just her mistake. LPN #1 stated that she had not done the catheter care herself. The other resident's who had orders for Foley Catheter care every shift that LPN #1 was responsible for did not have pre-documentation of catheter care. Sh… | 2014-03-01 | ||
| 2376 | 2376 | METHODIST SPECIALTY CARE CENTER | 25A414 | 1 LAYFAIR DRIVE SUITE 500 | FLOWOOD | MS | 39232 | 2019-01-10 | 623 | D | 0 | 1 | SVDC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review, the facility failed to provided a written notice of transfer to the Resident Representative to include reason for transfer, facility transferred to, the name of the Ombudsman with address and phone number, or the appeal rights of the resident for two (2) of two (2) residents reviewed for transfer to the hospital. This affected Resident #21 and #18. Findings include: Facility Policy Review, titled Transfer or Discharge Notice, revealed the facility would not provide a written notice of transfer for an immediate transfer or discharge required by a resident's urgent medical needs. The policy failed to address the discharge/transfer notice to be provided to the resident and/or resident representative upon transfer to the hospital as soon as practicable. Resident #21: A review of the resident's medical record revealed [REDACTED]. An interview on 01/09/19 at approximately 4:42 PM, with Registered Nurse (RN) #1, confirmed Resident #21's hospitalization . An interview on 01/19/19 at 5:00 PM, with the Assistant Administrator, indicated the facility had completed a written notice of transfer to the hospital to the resident's family. A copy of the transfer notice was requested. A review of the copy of the transfer notice provided by the facility Administrator revealed the document did not include a reason for the transfer, the name of the facility that the resident was being transferred to, the name of the Ombudsman with address and phone number, nor the appeal rights of the resident. An interview on 01/10/19 at 9:13 AM, with the Medical Record Director, revealed she is responsible for sending the transfer letters. The Medical Record Director stated the facility's Bed Hold Letter is the document sent to the resident or resident Responsible Party (RP) when a resident is transferred from the facility. She also reviewed the Bed Hold Letter for the resident and confirmed the letter did not have … | 2020-09-01 |
| 2377 | 2377 | METHODIST SPECIALTY CARE CENTER | 25A414 | 1 LAYFAIR DRIVE SUITE 500 | FLOWOOD | MS | 39232 | 2017-09-15 | 282 | D | 0 | 1 | IHDF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon staff interview, record review and facility policy review, the facility failed to follow the care plan for incontinence and catheter care for two (2) of 15 care plans reviewed: Resident #2, and Resident #3. Findings Include: Review of the facility's policy titled Care Plans dated 07/14/14, revealed that a comprehensive individualized care plan will be developed for each resident by the interdisciplinary team. The policy did not include information about following the care plan. Resident #3: Review of the care plan for Resident #3, with the last review date of 08/01/17, revealed that when providing bowel incontinent care, a washing of the Perineal area is to be done in a motion of front to back. During an observation of incontinent care, on 09/13/17 at 9:30 AM, provided for Resident #3, Certified Nursing Assistant (CNA) #1 wiped from back to front four (4) times during care while cleaning Resident #3's buttocks area. During an interview on 09/14/17 at 1:30 PM, Registered Nurse (RN) #2/ Minimum Data Set (MDS) Coordinator/ Care Plan Coordinator, confirmed that Resident #3's care plan for incontinent care included cleaning from front to back and that it was the expectation of the care plan approach for incontinent care to be followed. During an interview on 09/14/17 at 4:10 PM and again on 09/15/17 at 9:10 AM, the Director of Nursing (DON), confirmed that the approach to wipe from back to front, when providing incontinent care, is the incorrect method to use. The DON stated that the care plan developed for each resident is to be followed. A review of the face sheet revealed Resident #3 was admitted to facility on 05/20/16, with [DIAGNOSES REDACTED]. A review Resident #3's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/25/17, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Resident #2 A review of Resident #2's care plan, dated 8/30/16, revealed to … | 2020-09-01 |
| 2378 | 2378 | METHODIST SPECIALTY CARE CENTER | 25A414 | 1 LAYFAIR DRIVE SUITE 500 | FLOWOOD | MS | 39232 | 2017-09-15 | 315 | D | 0 | 1 | IHDF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review, the facility failed to provide incontinent/catheter care in a manner to prevent possible spread of infection and/or trauma for three (3) of seven (7) incontinent/catheter care observations: Resident #2, Resident #3 and Resident #9. Findings Include: Review of the facility's policy titled Perineal Care, revised (MONTH) 23, (YEAR), revealed to gently wash the Perineal area from front to back. Front to back cleaning helps to minimize fecal contamination with urinary meatus and vaginal area in women. Resident #3: During an observation of incontinent care for Resident #3, on 09/13/17 at 9:30 AM, Certified Nursing Assistant (CNA) #1 wiped from back to front four (4) times during care while cleaning Resident #3's buttocks area. During an interview on 9/13/17 at 1:55 PM, CNA #1 confirmed that she did not clean the resident's buttocks area according to how she was trained. CNA #1 stated that she had been in-service and had competency skills check-off conducted by a facility nurse. CNA #1 stated, I got mixed up. During an interview on 09/13/17 at 2:00 PM, CNA #2/ CNA Supervisor, confirmed that wiping from front to back during Perineal care was the correct procedure. CNA #2 also stated that all the CNAs have had several in-services and skills check offs for Perineal care. During a review of the facility check off document titled Peri-Care Audit, dated 06/29/17, it was revealed that Certified Nursing Assistant (CNA) #1 had received a skills checkoff observation for incontinent care on 06/29/2017. During a review of the facility in-service documentation titled Perineal Care, dated 05/31/17, it was revealed that CNA #1 had a facility in-service on Perineal care using the front to back cleaning procedure on 08/23/17. During an interview on 09/14/17 at 4:10 PM, the Director of Nursing (DON) confirmed that wiping from back to front during Perineal care was not correct. The DON s… | 2020-09-01 |
| 2777 | 2777 | METHODIST SPECIALTY CARE CENTER | 25A414 | 1 LAYFAIR DRIVE SUITE 500 | FLOWOOD | MS | 39232 | 2016-07-07 | 279 | D | 0 | 1 | XRCS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy review, the facility failed to develop a comprehensive care plan for a resident with a wound to the left heel for one (1) of 17 residents reviewed for care plans; Resident #1. Findings include: Review of the facility's policy titled, Care Plans, dated 07/14, revealed a comprehensive care plan would be developed for each resident. The care plan is to be updated or revised after each quarterly review and when a significant change in assessment occurs. Nursing is assigned to update the care plan when changes in treatment or needs arise. A review of the facility's policy titled, Resident Assessment, dated 12/10, revealed residents should be assessed by a Registered Nurse (RN) on admission and on an ongoing basis. The plan of care should be reviewed and revised according to policy. Resident #1 A review of the annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 05/03/16, revealed Section M (Skin Conditions) was checked for a stage three (3) pressure wound. The Care Area Assessment Summary (Section V), revealed Pressure Ulcer had triggered, and the current care plan would be continued. A review of the cumulative physician orders [REDACTED].#1. Review of the care plan for Resident #1, revealed there was not a care plan developed to address the wound to the left heel. The Surveyor did note that there was a care plan for a wound to the right heel. Interview on 07/05/16 at 2:06 PM, with Registered Nurse (RN) #1 during the initial tour of the facility, revealed Resident #1 had a pressure ulcer to the left heel. Interview on 07/07/16 at 4:55 PM, with RN #1, confirmed Resident #1 had a pressure ulcer to the left heel. RN #1 revealed she was responsible for the Minimum Data Set assessment and care plan for Resident #1. Upon review of Resident #1's care plan, RN #1 revealed care plan was inaccurate. RN #1 stated, That's my mistake. RN #1 revealed Resident #1 previous… | 2019-11-01 |
| 2778 | 2778 | METHODIST SPECIALTY CARE CENTER | 25A414 | 1 LAYFAIR DRIVE SUITE 500 | FLOWOOD | MS | 39232 | 2016-07-07 | 322 | E | 0 | 1 | XRCS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, and facility policy review, the facility failed to ensure placement was checked on a feeding tube and the tubing flushed prior to the administration of medication for Resident #16. The facility further failed to ensure enteral medications were administered via gravity flow for Resident #5, a resident with a feeding tube. This was observed of two (2) of three (3) licensed nursing staff administering enteral medication for two (2) of three (3) feeding tube observations. Findings include: Review of the facility's policy titled, Medication Administration: Enteral Tubes, dated 12/2012, revealed enteral tube placement is to be verified by inserting a small amount of air into the tubing and by aspiration of stomach contents before administering medication into the tube. The enteral tubes are to be flushed before administration of medications with at least 15 milliliters (ml) of water. When administering medications per enteral tube, nurses are to allow medications to flow down the feeding tube via gravity. Resident #16 - An observation of medication pass for Resident #16, by Registered Nurse (RN) #1, was conducted on 7/6/16 at 8:31 AM. RN #1 prepared the liquid medication, [MEDICATION NAME] at the medication cart. RN #1 entered Resident #16's room, placed the medication on Resident #16's overbed table. RN #1 picked up a clear plastic graduated container from Resident #16's sink vanity and placed water in it. She placed the water on Resident #16's overbed table. RN #1 disconnected Resident #16's Jejunostomy (J tube) tubing from the feeding pump tubing. She attached the barrel of the cath tip syringe to the J tube's port and poured the liquid [MEDICATION NAME] into the J tube. RN #1 did not verify tube placement or flush the tubing with water, before the medication administration. In an interview on 7/6/16 at 2:16 PM, RN #1 acknowledged she did not verify placement or flush Resident #16's J tube before administe… | 2019-11-01 |
| 2779 | 2779 | METHODIST SPECIALTY CARE CENTER | 25A414 | 1 LAYFAIR DRIVE SUITE 500 | FLOWOOD | MS | 39232 | 2016-07-07 | 441 | E | 0 | 1 | XRCS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility policy review, the facility failed to prevent potential cross-contamination by ensuring nursing staff donned and changed gloves during medication set-up and administration for Resident #16 and Resident #17. The facility further failed to ensure nursing staff did not insert a bare finger inside pill pouches to open them for Resident #5. This was observed on three (3) of six (6) residents during medication pass observation. Findings include: The facility's policy titled Infection Control, dated 4/2015), Section VI - Standard Precautions, revealed gloves are to be changed between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces. The facility's policy titled Subcutaneous Insulin, dated 09/2010, revealed gloves are to be put on before giving an injection. Resident #16 During an observation of medication pass for Resident #16 on 7/6/16 at 8:31 AM, Registered Nurse (RN) #1 prepared liquid medication to be administered. RN #1 entered Resident #16's room and placed the plastic medication cup on the resident's overbed table. RN #1 entered Resident #16's bathroom and washed her hands. She then put on a pair of disposable gloves. RN #1 picked up a clear plastic graduated container containing a cath tip syringe. She turned the faucet handle on to place water into the container with her gloves on. After placing water in the container, RN #1 turned off the faucet with the same gloves on. RN #1 then placed her gloved hands on Resident #16's overbed table and rolled it to the bedside. She then touched the feeding pump and placed it on pause. RN #1 then used the same gloves to disconnect Resident #16's jejunostomy (J tube) from the feeding pump tubing. RN #1 connected the cath tip syringe to the port of the J tube and administered the … | 2019-11-01 |
| 3459 | 3459 | METHODIST SPECIALTY CARE CENTER | 25A414 | 1 LAYFAIR DRIVE SUITE 500 | FLOWOOD | MS | 39232 | 2015-09-10 | 278 | D | 0 | 1 | JO4211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review the facility failed to accurately assess Resident #5 for bowel continence on the Minimum Data Set (MDS) for one (1) of 15 records reviewed for MDS. Findings included: Observation on 09/08/15 at 2:45 PM revealed Resident #5 was incontinent of bowel requiring staff assistance. Review of Resident #5's MDS assessments dated 06/08/15 and 08/19/15 revealed the facility assessed Resident #5 as continent of bowel under Section H. In an interview on 09/09/15 at 5:10 PM, Registered Nurse (RN) #1, MDS Nurse, confirmed Resident #5 was incontinent. She stated Resident #5 was inaccurately assessed as continent on the MDS assessments. Review of the facility's face sheet revealed the facility admitted Resident #5 was on 03/11/15 with the [DIAGNOSES REDACTED]. | 2019-02-01 |
| 3460 | 3460 | METHODIST SPECIALTY CARE CENTER | 25A414 | 1 LAYFAIR DRIVE SUITE 500 | FLOWOOD | MS | 39232 | 2015-09-10 | 281 | D | 0 | 1 | JO4211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy review, the facility failed to omit administration of the [MEDICATION NAME] skin test (TST) to a resident who was contraindicated by history of a positive TST and treatment of [REDACTED]. follow a physicians order for documentation of medication allergies [REDACTED].#10 and Resident #1 Findings included: Review of facility policy entitled, TB Testing of Specialty Care Center Residents, revised 09/10/2015, revealed all residents were required to have a two-step [MEDICATION NAME] skin test (TST) unless individually excluded by medical contraindications or exceptions to this requirement. Exceptions to the requirement included the resident was receiving or had documentation of having received one year of TB ([MEDICAL CONDITION]) [MEDICATION NAME] therapy or documentation by the State [MEDICAL CONDITION] Program of treatment for [REDACTED]. Resident #10 Review of Resident #10's Immunization Record and Medication Administration Record [REDACTED]. Interview on 09/10/15 at 1:40 PM with the Director of Nursing (DON) and Registered Nurse (RN) #1 confirmed Resident #10 received a TST on 05/15/15. RN #1 said she had no knowledge of the reaction of the TST because Resident #10 was hospitalized on the date the TST was to be read. The DON said Resident #10 received [MEDICATION NAME] TB medication therapy upon admission to the facility on [DATE] and the facility contacted the state health department for information and recommendations. Interview on 09/10/15 at 2:15 PM with RN #1 confirmed, If you are a past positive, you shouldn't get the TB skin test. Review of the facility's face sheet revealed the facility admitted Resident #10 on 06/12/14. Resident #10's [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 08/03/15 revealed Resident #10 was comatose. Resident #1 Review of the facility policy entitled Orders, revised 04/04, and revealed 1. General Pr… | 2019-02-01 |
| 3461 | 3461 | METHODIST SPECIALTY CARE CENTER | 25A414 | 1 LAYFAIR DRIVE SUITE 500 | FLOWOOD | MS | 39232 | 2015-09-10 | 282 | D | 0 | 1 | JO4211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and facility policy review, the facility failed to provide perineal care per the resident's Care Plan for one (1) of eight (8) care observations, for Resident #2. Findings include: Review of facility policy entitled Plan of Care revised 11/17/2008 revealed each resident had an individualized written plan of care reflective of the resident's condition and needs. Review of the Care Plan for Resident #2 revealed a problem, dated 11/11/08, for incontinence with an approach for Give perineal care when resident is incontinent. The approach did not include the steps needed to perform the care correctly. Observation of perineal care for Resident #2, on 09/09/15 at 5:10 PM, revealed Certified Nursing Assistant (CNA) #1 did not perform the care to decrease the chance of infection. The CNA did not cleanse the penis and wiped the peri-anal area from back to front instead of front to back. Interview, on 09/10/15 at 9:50 AM, with Registered Nurse (RN) #1 confirmed the Care Plan for Resident #2 did not include the steps needed to correctly perform perineal care. RN #1 also stated staff had received an in-service on perineal care. Review of the Face Sheet revealed the facility admitted Resident #2 on 11/04/08 with diagnoses, which included [MEDICAL CONDITION]. Review of the annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/18/15, revealed Resident #2 had severely impaired decision-making abilities. | 2019-02-01 |
| 3462 | 3462 | METHODIST SPECIALTY CARE CENTER | 25A414 | 1 LAYFAIR DRIVE SUITE 500 | FLOWOOD | MS | 39232 | 2015-09-10 | 315 | D | 0 | 1 | JO4211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and facility policy review, the facility failed to perform perineal care to decrease the potential for Urinary Tract Infections for one (1) of eight (8) care observations for Resident #2. Findings include: Review of the facility policy entitled Perineal Care, revised 09/13, revealed, III Procedure, 4. Gently wash perineal area from front to back and IV General Instructions 2. Perineal care includes general cleansing and hygiene for urethra, vaginal area in women, penis in men and perianal area. Observation of perineal care for Resident #2, on 09/09/15 at 5:10 PM, revealed Certified Nursing Assistant (CNA) #1 did not cleanse the penis, and wiped from back to front instead of front to back on the peri-anal area. Interview, on 09/09/15 at 5:15 PM, with CNA #1 confirmed the penis was not cleansed and the peri-anal area was wiped back to front instead of front to back. CNA #1 stated he/she had received training on perineal care during the summer of (YEAR). CNA #1 also stated he/she usually wiped front to back when providing perineal care, and did not know why the care was not performed in the correct manner. Interview, on 09/09/15 at 5:45 PM, with the Director of Nursing (DON) confirmed the facility provided CNA #1 with an in-service on perineal care on 06/11/15. Review of the Face Sheet revealed the facility admitted Resident #2 on 11/04/08 with diagnoses, which included [MEDICAL CONDITION]. Review of the annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/18/15, revealed Resident #2 had severely impaired decision-making abilities. | 2019-02-01 |
| 3463 | 3463 | METHODIST SPECIALTY CARE CENTER | 25A414 | 1 LAYFAIR DRIVE SUITE 500 | FLOWOOD | MS | 39232 | 2015-09-10 | 441 | D | 0 | 1 | JO4211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility policy review, the facility failed to provide a clean work surface and practice clean technique to provide wound care for one (1) of eight (8) care observations. Resident #7 Findings included: Review of facility policy entitled Changing Post-operative Dressings, revised 07/09/12, revealed, 2. Clean technique is used for dressing changes. Observation on 09/09/15 at 2:00 PM revealed Registered Nurse (RN) #3 prepared to perform a dressing change for a surgical graft site for Resident #7. RN #3 placed the treatment supplies on Resident #7's unclean over bed table with no barrier placed. Resident #7's over bed table held an opened tube of protective barrier ointment and eyeglasses case. The treatment supplies included two (2) pairs of small scissors, four (4) opened tongue blades, a plastic bag contained clean gauze, a plastic cup contained [MEDICATION NAME] ointment and a plastic cup contained peroxide. RN #3 dropped the package of border gauze on the floor, picked it up and placed in on the over bed table. RN #3 did not change gloves after the soiled dressing was removed. RN #3 obtained clean gauze from the plastic bag, dipped the clean gauze in the peroxide and applied the peroxide soaked gauze to the surgical site without changing gloves. RN #3 changed gloves and obtained a tongue blade from the over bed table to apply the [MEDICATION NAME] ointment to the graft site. Interview on 09/09/15 at 2:35 PM reealed RN #3 did not identify the deficient practice and said a barrier was not needed because nothing was opened. RN #3 confirmed the observation. Interview on 09/09/15 at 3:35 PM with Director of Nursing (DON) said training for dressing change included the use of a barrier and clean technique. Review of the facility's face sheet revealed the facility admitted Resident #7 on 02/26/13. Resident #7's [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with Assessment Reference Date… | 2019-02-01 |
| 3464 | 3464 | METHODIST SPECIALTY CARE CENTER | 25A414 | 1 LAYFAIR DRIVE SUITE 500 | FLOWOOD | MS | 39232 | 2015-09-10 | 502 | D | 0 | 1 | JO4211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and facility policy review, the facility failed to obtain a magnesium laboratory test as ordered for one (1) of 11 records reviewed, for Resident #2. Findings include: Review of the facility policy entitled Laboratory Services, revised 11/08, revealed, Procedure 2. Laboratory orders are drawn and collected according to physicians order. Review of Resident #2's clinical record revealed on the cumulative Physician Orders, for 09/15, an order dated 10/31/13 for Magnesium level (laboratory test) Q 6 (every six) months. Review of the Treatment record for 05/15 revealed a Magnesium level was scheduled on 05/04/15, but there were no staff initials recorded to indicate the test had been completed. Review of the laboratory results for Resident #2 revealed there were no Magnesium level laboratory results in the clinical record. Interview, on 09/09/15 at 5:45 PM, with Registered Nurse (RN) #1 revealed staff monitored for completion of laboratory tests using the Treatment Records. Interview, on 09/10/15 at 10:05 AM, with the Director of Nursing (DON) confirmed the Magnesium laboratory test had not been completed as scheduled for Resident #2. Review of the Face Sheet revealed the facility admitted Resident #2 on 11/04/08 with diagnoses, which included [MEDICAL CONDITION]. Review of the annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/18/15, revealed Resident #2 had severely impaired decision-making abilities. | 2019-02-01 |
| 3777 | 3777 | METHODIST SPECIALTY CARE CENTER | 25A414 | 1 LAYFAIR DRIVE SUITE 500 | FLOWOOD | MS | 39232 | 2015-09-22 | 157 | D | 1 | 0 | WN0111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** CI MS # Based on observation, interview, record review and policy review the facility failed to notify one (1) of five (5) residents reviewed, Resident #1, of an incident of a significant medication error when Resident #1 received another resident's medications. Findings included: Review of the facility's Resident Rights policy, provided by the Director of Nursing (DON) on 9/22/15, revealed: The resident has the right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition. Review of a 9/7/15 Accident/Incident Investigation Summary revealed Licensed Practical Nurse (LPN) #1 administered Resident #1 medications that were ordered for Resident #2 in error during the 9:00 AM medication pass. Significant medications received by Resident #1 included controlled medications [MEDICATION NAME] 30 milligrams (mg), [MEDICATION NAME] Extended Release 30 mg, and [MEDICATION NAME] 75 mg. There was no documented evidence that Resident #1 was notified of the medication error when it occurred. Observation and interview with Resident #1 on 9/21/15 at 1:30 PM revealed he was alert and oriented to person, place and time. Resident #1 stated he was aware he'd been given the wrong medication on 3-11 shift when his Responsible Party (RP) and Registered Nurse (RN) #2 told him. Resident #1 stated he had not been notified that morning when the error had occurred. Interview with LPN #1 on 9/21/15 at 10:00 AM revealed she had given Resident #1 medications that were ordered for Resident #2 at the 9:00 AM medication pass on 9/7/15. LPN #1 stated she did not tell Resident #1 that he received medications in error because she and the charge nurse wanted to get a true picture of the resident. Interview with RN #1 on 9/22/15 at 11:05 AM, with the Director of Nurses (DON) present, revealed she had not notified Resident #1 of the medications he received in error on 9/7/15 because s… | 2018-09-01 |
| 3778 | 3778 | METHODIST SPECIALTY CARE CENTER | 25A414 | 1 LAYFAIR DRIVE SUITE 500 | FLOWOOD | MS | 39232 | 2015-09-22 | 279 | D | 1 | 0 | WN0111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** CI MS # Based on observation, interview, record review and policy review the facility failed to develop and/or revise the care plan for one (1) of five (5) residents reviewed, Resident #1, as evidenced by not revising the care plan for a urinary tract infection and not initiating a care plan for monitoring due to receiving medications that weren't prescribed. Findings included: Review of the facility's Care Plans policy dated 7/14/14, revealed: A comprehensive individualized plan of care will be developed for each resident. The care plan will be updated or revised after each quarterly review, and when a significant change in assessment occurs. Nursing and Respiratory Therapy should update care plan when changes in treatment or needs arise. Review of the resident's care plans revealed there was no documented evidence of a care plan for monitoring Resident #1 for adverse effects of medication he received in error. Review of an Accident/Incident Investigation Summary, dated 9/7/15, and a Quality Care Control Report (for medication error) dated 9/7/15 revealed Resident #1 received medications in error that were ordered for Resident #2 in error by LPN #1 during the 9:00 AM medication pass. Significant medications received by Resident #1 included controlled medications [MEDICATION NAME] 30 milligrams (mg), [MEDICATION NAME] Extended Release 30 mg, and [MEDICATION NAME] 75 mg. These medications were not routinely taken by Resident #1 and could cause side effects such as drowsiness, agitation, nausea, sedation, and confusion. Documentation on the Quality Care Control Report included vital signs monitored, check resident every hour, and Responsible Party (RP) notified. Review of an Emergency Department (ED) Chart dated 9/8/15 revealed Resident #1 presented to the ED at 11:04 AM with complaint of Altered Level of Consciousness and Confusion. Resident #1's [DIAGNOSES REDACTED].#1 was treated with Bactrim DS for seven (7) days. Review of Resident #1's ca… | 2018-09-01 |
| 3779 | 3779 | METHODIST SPECIALTY CARE CENTER | 25A414 | 1 LAYFAIR DRIVE SUITE 500 | FLOWOOD | MS | 39232 | 2015-09-22 | 333 | D | 1 | 0 | WN0111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** CI MS Based on observation, interview, record review and policy review the facility failed to ensure residents were free from significant medication errors for one (1) of five (5) residents reviewed, Resident #1, as evidenced by Resident #1 received another resident's medication in error which included controlled medications with the potential for adverse effects such as Central Nervous System (CNS)/ Respiratory Depression. Findings included: Review of the facility's policy Medication Administration General Guidelines, dated 12/12, revealed: Medications are administered as prescribed in accordance with manufacturer's specifications, good nursing principles and practices and only by persons legally authorized to do so. Documentation under the Medication Administration section #4: Medications are to be administered at the time they are prepared. 10. Residents are identified before medication is administered using at least two resident identifiers. Methods of identification may include: a. Check identification band. b. check photograph attached to medical record. c. Verify resident identification with other nursing care center personnel. 16. Medications supplied for one resident are never administered to another resident. Review of a facility Accident/Incident Investigation Summary, completed on 9/7/15, revealed Resident #1 was administered medications in error by LPN #1 that were ordered for Resident #2 during the 9:00 AM medication pass. Significant medications received by Resident #1 included [MEDICATION NAME] 30 milligrams (mg), [MEDICATION NAME] Extended Release 30 mg, and [MEDICATION NAME] 75 mg all of which were controlled substances. Review of a Quality Care Control Report revealed a Medication Related event occurred on 9/7/15 at 9:00 AM when the wrong patient got the wrong medication related to environmental factors of the resident receiving AM care at the time of medication preparation and administration and failure to follow establish… | 2018-09-01 |
| 3780 | 3780 | METHODIST SPECIALTY CARE CENTER | 25A414 | 1 LAYFAIR DRIVE SUITE 500 | FLOWOOD | MS | 39232 | 2015-09-22 | 514 | D | 1 | 0 | WN0111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** CI MS # Based on interview, record review, and policy review the facility failed to ensure accurate and complete medical records for one (1) of five (5) residents reviewed, Resident #1, as evidenced by failure to completely document monitoring of the resident after a significant medication error and failure to document changing the Supra-pubic catheter as ordered. Findings include: Review of the facility's policy from the Medication Policy & Procedure Manual with an effective date 03/10, revealed a section: Reporting, Quality Management & Improvement of Medication Errors: Procedure: A. When a medication error occurs: 1. The health professional recognizing the error will: a. Assess and intervene as appropriate with the patient. b. Notify the attending physician and other physicians as indicated according to the category of error. c. Follow any orders given by the physician and document the patient status on the medical record, including time of occurrence. d. Chart the following in the Nurse's Notes: date, time, drug, dose, route, who administered the drug, patient response, and any interventions initiated. e. Complete a Quality Care Control Report (QCC Report) completing all pertinent information and forward to the Nursing Manager or Patient Care Supervisor. Review of the facility's 9/7/15 Accident/Incident Investigation Summary revealed Licensed Practical Nurse (LPN) #1 administered in error Resident #1 medications that were ordered for Resident #2 during the 9:00 AM medication pass. Significant medications received by Resident #1 included [MEDICATION NAME] 30 milligrams (mg), [MEDICATION NAME] Extended Release 30 mg, and [MEDICATION NAME] 75 mg all of which were controlled substances. Review of Resident #2's Medication Administration Record (MAR) revealed Resident #1 also received the following medications that were not prescribed for him on 9/7/15 for 9:00 AM: Vitamin E, Vitamin D, Potassium Chloride, Multivitamin, and [MEDICATION NAME]. R… | 2018-09-01 |
| 4012 | 4012 | METHODIST SPECIALTY CARE CENTER | 25A414 | 1 LAYFAIR DRIVE SUITE 500 | FLOWOOD | MS | 39232 | 2015-05-04 | 221 | D | 1 | 0 | VTP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to ensure Resident #1 was free from physical restraints as evidenced by the facility placed Resident #1 in a safety enclosure bed to prevent wandering into other resident's rooms and climbing on furniture without attempts for less restrictive measures prior to the enclosure bed placement. This was for one (1) of two (2) residents reviewed for physical restraints. Findings include: A review of the facility's policy entitled, Restraints, with a revision date of 08/16/2005, revealed Procedures: 1. Assess the resident to determine the safest and least restrictive alternative to restraint. 3. Document the assessment and clinical justification for restraint use and the family/resident's understanding and consent to restraint use. 8. Select the correct size restraints. Choose one which will restrain the resident only as much as necessary AND NO MORE. 12. Restraints must be released every two (2) hours and the resident checked every thirty (30) minutes. 13. Obtain signature on release form if the resident and/or family refuse use of restraint. Document the family refused use of restraints for the resident. A review of the product manual for the safety enclosure bed entitled, (name of bed) Manufacturing Company Bed Enclosure Product Manual with no date, revealed, II Legal and Regulatory Issues, The Issue of Restraint Devices, revealed, The question of a bed enclosure being a restraint device is a frequent issue. Some classify it as a restraint device while others believe it is a seclusive unit. The problem of classification is that enclosure beds or bed enclosures (there is a difference) are relatively new in the clinical setting, as opposed to the typical mechanical restraint devices such as straps, belts, wrist, ankle cuffs and straightjackets. The (name of bed) Manufacturing Company Bed Enclosure Product Manual further stated, Restraint and seclusive devices can only… | 2018-05-01 |
| 4013 | 4013 | METHODIST SPECIALTY CARE CENTER | 25A414 | 1 LAYFAIR DRIVE SUITE 500 | FLOWOOD | MS | 39232 | 2015-05-04 | 279 | J | 1 | 0 | VTP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review and facility policy review, the facility failed to develop a comprehensive care plan related to contact isolation and to include supervision for wandering behavior for one (1) of seven (7) resident care plans reviewed (Resident #1). The facility's failure to develop a comprehensive care plan for Resident #1 related to contact isolation and supervision for wandering behaviors resulted in the likelihood of Resident #1 and other residents being placed in a situation in which could lead to serious harm. This resulted in an Immediate Jeopardy (IJ) identified on 05/01/2015 and determined to exist on 02/16/2015. The facility was notified on 05/01/2015 of the Immediate Jeopardy. An acceptable credible Allegation of Compliance (A(NAME)) was received on 05/03/2015. The State Agency survey team (SA) determined the Immediate Jeopardy (IJ) was removed prior to exit on 05/04/2015. The Scope and Severity for the IJ at 42 CFR-483.20(d) (F279) was lowered to a D while the facility develops and implements a plan of correction for the deficient practice. Findings include: A review of the facility policy Care Plans revision date 07/14/2014 revealed POLICY: A comprehensive individualized plan of care will be developed for each resident. The care plan will be updated or revised after each quarterly review, and when a significant change in assessment occurs. PR(NAME)EDURE: Nursing and Respiratory Therapy should update care plan when changes in treatment or needs arise. A review of the facility policy, ISOLATION GUIDELINES & TRANSMISSION-BASED PRECAUTIONS dated 7/14/14, revealed Initiate the precautions as soon as the patient has been assessed and a need established according to the CDC recommendations. and Nursing is responsible for enforcing all precautions as outlined on the laminated Precautions card found on the patient's door. This includes monitoring visitors and patients. If the patient is transported out of the room, … | 2018-05-01 |
| 4014 | 4014 | METHODIST SPECIALTY CARE CENTER | 25A414 | 1 LAYFAIR DRIVE SUITE 500 | FLOWOOD | MS | 39232 | 2015-05-04 | 282 | D | 1 | 0 | VTP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record review, and staff interview, the facility failed to implement interventions for Resident #1, who's plan of care directed the use of a restraint bed for one (1) of seven (7) resident care plans reviewed. Findings Include: A review of the facility policy Care Plans with a revision date 07/14/2014, revealed no policy or procedure for the implementation of a residents care plan. No other policy was provided which addressed the implementation of a residents' care plan. A review of the facility policy entitled Restraints revision date 08/16/2005 revealed PURPOSE: To provide guidelines and procedures for safe and appropriate use of restraints. The leadership, including the medical staff support time limited and clinically justified use of restraints and a culture emphasizing prevention, alternative strategies, and least restrictive measures prior to restraint use. and PR(NAME)EDURES: Restraints must be released every two(2) hours and the resident checked every thirty(30) minutes. A review of Resident #1's physician's order dated 02/16/15 revealed Safety Enclosure to bed for agitation, uncontrolled ambulation-resident safety. A review of physician's order dated 03/05/15 revealed Round and monitor resident Q (every) thirty (30) minutes ATC (around the clock). A review of Resident #1's care plan dated 02/24/15 revealed Problem/Need Potential for injury tented bed restraint with an approach to Check on resident at least every 30 minutes and follow facility protocol for release, exercise. Document interventions. A review of physician's orders for Resident #1, found the enclosed restraint bed was ordered on [DATE], discontinued on 03/04/15 . The bed was re-ordered on [DATE] and discontinued on 04/08/15. Interview with the Director of Nursing (DON) on 05/01/15 at 1:18 PM, the DON confirmed the bed was a restraint and stated, It should be on the MAR (Medication Administration Record) for checks-treatment actually. It … | 2018-05-01 |
| 4015 | 4015 | METHODIST SPECIALTY CARE CENTER | 25A414 | 1 LAYFAIR DRIVE SUITE 500 | FLOWOOD | MS | 39232 | 2015-05-04 | 319 | D | 1 | 0 | VTP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to ensure treatment and services met the need for Resident #1 with psychosocial and behavioral difficulties. This was for one (1) of seven (7) residents reviewed for behaviors. Findings included: A review of the Initial Social History for Resident #1 completed by the Licensed Social Worker (LSW) on 02/16/15, revealed Resident #1 had a history of [REDACTED]. LSW also documented that resident had involuntary commitment to a mental health facility. For the assessment of Present Emotional and Mental Status, portion of this social history, LSW documented, gets agitated if you touch her face or hair, and for the level of understanding by the resident for current illness, LSW documented, No understanding- mind has recovered, body hasn't. A review of nurses' notes revealed documentation of behaviors for Resident #1 beginning 02/25/15 when Resident #1 was observed being combative and aggressive with staff, dodging and pushing staff, taking clothes off all day long, and having feces on both hands. On 02/25/15 at 10:17 PM, Resident #1 was documented kicking and trying to bite staff when medications were being administered. Review of the nurses' notes also revealed on 02/28/15, Resident #1 was documented in nurses' notes as being combative and also running out of her room with clothes off. On 03/01/15, Resident #1 was noted becoming highly agitated, when bolus feedings were administered. On 3/4/15 at 10:44 PM by RN #3 noted Resident #1 stood in chair and got on top of the bedside table then was helped down off the table and sat back in chair. Resident #1 was then found sitting on top of TV cabinet (Armoire). Interview with Licensed Social Worker (LSW) on 05/01/14 on 12:10 PM, confirmed completing Resident #1's initial social history for Resident #1, and stated, (Resident #1) was not able to do anything, couldn't talk, so history was obtained from the sister. Sister reporte… | 2018-05-01 |
| 4016 | 4016 | METHODIST SPECIALTY CARE CENTER | 25A414 | 1 LAYFAIR DRIVE SUITE 500 | FLOWOOD | MS | 39232 | 2015-05-04 | 323 | J | 1 | 0 | VTP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide supervision to ensure the safety of Resident #1 and other resident related to Resident #1's wandering, climbing, and behaviors for one (1) of seven (7) residents reviewed. (Resident #1) The facility failed to provide supervision for the safety of Resident #1 and other residents residing in the facility as evidenced by Resident #1 going in and out of other residents rooms while on contact isolation, and with severely impaired cognitive status from an anoxic brain injury. Resident #1 was found on top of an armoire, canopy bed, and nightstand and was found in tracheostomy residents' rooms. Record review revealed 29 out of 31 residents on the third floor had a Tracheostomy on 2/16/15, the day the facility admitted Resident #1. An Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 5/1/15, and was determined to exist on 2/16/15 when Resident #1 was admitted to the facility on isolation and began having wandering behaviors on the tracheostomy unit without supervision. The facility was notified on 5/1/15 of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC). The facility submitted a credible Allegation of Compliance (A(NAME)) on 5/3/15, the State Agency (SA) survey team validated the facility's Allegation of Compliance (A(NAME)) and the Immediate Jeopardy (IJ), was determined to be removed prior to exit from the facility on 5/4/15. Therefore, F323 was lowered from J level deficiencies to D level or isolated deficiency while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review revealed Resident #1 was admitted to the facility on [DATE] and was discharged from the facility on 04/10/15. Resident #1 was not available for observation during the survey process. During an… | 2018-05-01 |
| 4017 | 4017 | METHODIST SPECIALTY CARE CENTER | 25A414 | 1 LAYFAIR DRIVE SUITE 500 | FLOWOOD | MS | 39232 | 2015-05-04 | 441 | J | 1 | 0 | VTP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain contact isolation to prevent the potential for spread of infection from a resident with [MEDICATION NAME] Resistant Entercocci (VRE) in her urine and Methicillin Resistant Staphylococcus Aureus (MRSA) in her sputum for one (1) of seven (7) residents reviewed for contact precautions. (Resident #1) The facility failed to maintain contact isolation precaution for Resident #1. This placed residents at risk for infections when the facility failed to ensure contact isolation for Resident #1 and allowed Resident #1 to go in and out of other residents rooms while on contact isolation. Resident #1 was also in the common areas such as the day room where other residents had access. An Immediate Jeopardy (IJ) was identified on 5/1/15, and was determined to exist from 2/16/15, when the facility admitted Resident #1 with behaviors and the facility failed to ensure contact isolation precautions. The facility was notified on 5/1/15 of the Immediate Jeopardy (IJ). The facility submitted a credible Allegation of Compliance (A(NAME)) on 5/3/15, the State Agency (SA) survey team validated the facility's Allegation of Compliance (A(NAME)) and the Immediate Jeopardy (IJ), was determined to be removed prior to exit from the facility on 5/4/15. Therefore, F441 was lowered from J level deficiency to a D level or isolated deficiency while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: The facility's policy entitled Isolation Guidelines and Transmission-Based Precautions; dated 4/17/2002, revealed Transmission-Based Precautions for MRSA, VRE and Clostridium difficile (C-diff) was examples of microorganisms that required Contact Precautions. For Contact Precautions, the patient should be placed in a private room or with another resident known or s… | 2018-05-01 |
| 4018 | 4018 | METHODIST SPECIALTY CARE CENTER | 25A414 | 1 LAYFAIR DRIVE SUITE 500 | FLOWOOD | MS | 39232 | 2015-05-04 | 490 | J | 1 | 0 | VTP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review the facility failed to provide effective administration to ensure Resident #1's and other residents' well-being for one (1) of seven (7) residents reviewed. The facility's failed to ensure Resident #1 received adequate supervision for wandering behaviors and measures to prevent the spread of infection. Resident #1 was admitted to the facility with an [MEDICAL CONDITIONS] on 02/16/15 and contact isolation [MEDICAL CONDITIONS] in sputum, and VRE ([MEDICATION NAME]-resistant [MEDICATION NAME]) in urine. The facility's failure resulted in the likelihood of infection or serious harm, injury, or death to other residents due to lack of supervision, lack of implementation of care plan and failure to implement measures to prevent the spread of infection. Immediate Jeopardy was identified on 05/01/15 and was determined to exist on 02/16/15, when Resident #1 began exhibiting behaviors of wandering with an order for [REDACTED]. The facility was notified on 05/01/15 of the Immediate Jeopardy (IJ). The facility submitted a credible Allegation of Compliance (A(NAME)) on 05/03/15, the State Agency (SA) survey team validated the facility's Allegation of Compliance (A(NAME)) and the Immediate Jeopardy (IJ), was determined to be removed prior to exit from the facility on 05/04/15. Therefore, F490 was lowered from J level deficiencies to D level or isolated deficiencies while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings included: A review of the signed job description for the Director of Long Term Care, signed by the Administrator on 09/30/2010, revealed Specific responsibilities include the promotion of residents rights, implementation of admission, transfer and discharge policies, establishing policies to monitor and report resident behavior and facili… | 2018-05-01 |
| 4019 | 4019 | METHODIST SPECIALTY CARE CENTER | 25A414 | 1 LAYFAIR DRIVE SUITE 500 | FLOWOOD | MS | 39232 | 2015-05-04 | 520 | J | 1 | 0 | VTP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to provide a Quality Assurance program to identify and meet the needs of Resident #1, who required increased supervision, and contact isolation for one (1) of seven (7) residents reviewed. The facility's failure to implement a Quality Assurance (QA) program, that identified the needs of the residents when an ambulatory Resident #1 with severely impaired cognition from an [MEDICAL CONDITIONS] and who was ordered on contact isolation was allowed to enter into residents with tracheostomies rooms. The QA program failed to address Resident #1's needs for increased supervision for wandering, climbing behavior, and contact isolation. Resident #1 was found by staff on top of an armoire, canopy bed and nightstand, and in other resident's rooms. The facility's failure to have an effective QA process resulted in the likelihood of ongoing potential for other residents to be at risk for lack of monitoring and supervision when required and the implementation of safe infection control practice to prevent the spread of diseases, which could result in harm or death. Immediate Jeopardy was identified on 05/01/15 and was determined to exist on 02/16/15, when Resident #1 was admitted to the facility and the resident was ambulatory without effective contact isolation and supervision. The facility was notified on 05/01/15 of the Immediate Jeopardy (IJ). The facility submitted a credible Allegation of Compliance (A(NAME)) on 05/03/15, the State Agency (SA) survey team validated the facility's Allegation of Compliance (A(NAME)) and the Immediate Jeopardy (IJ), was determined to be removed prior to exit from the facility on 05/04/15. Therefore, F520 was lowered from J level deficiencies to D level or isolated deficiencies while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with… | 2018-05-01 |
| 4276 | 4276 | METHODIST SPECIALTY CARE CENTER | 25A414 | 1 LAYFAIR DRIVE SUITE 500 | FLOWOOD | MS | 39232 | 2014-08-08 | 315 | D | 0 | 1 | M49611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility policy review, the facility failed to provide incontinent care to decrease the possibility of the spread of infection and promote skin integrity as evidenced by failure to rinse soap residue and obtain a clean cloth before wiping open areas for one (1) of four (4) care observations. (Resident # 5) Findings included: Review of the facility's policy entitled Perineal Care, dated 09/23/13, revealed the purpose for perineal care was to promote comfort, prevent infection and skin irritation and to emphasize good personal hygiene. The policy instructed to remove any obvious fecal material and /or urine with a clean, soft towel or tissue to help prevent cross-contamination. The policy revealed to apply mild soap to wash cloth after fecal material and/or urine had been removed and to rinse soap residue to assist in keeping the skin pH balanced. Review of the facility's policy entitled External Catheter Application, dated 04/11/09, did not address deficient practice. Observation on 08/06/14 at 11:20 AM revealed Certified Nursing Assistant (CNA) #1 had placed two (2) clean bath cloths, one (1) towel and one basin of water on barrier to provide external catheter care and incontinent care (perineal care) for Resident #5. CNA #1 removed the external condom catheter and did not wash hands or change gloves. CNA # 1squirted Men Care, Body and Face Wash in basin, placed bath cloth in soapy water and wiped Resident #5's penis. CNA #1 used same cloth, placed it back in soapy water and wiped Resident #5's penis again. CNA #1 did not rinse the penis and scrotal area. Men Care, Body and Face Wash had instructions on bottle to rinse thoroughly after use. CNA #1 turned Resident #5 to right side and revealed excoriated areas on both buttocks. CNA #1 wiped between Resident #5's buttocks with a clean cloth and removed fecal material. CNA #1 continued to use the same cloth, wiped several times between the butto… | 2017-11-01 |
| 4277 | 4277 | METHODIST SPECIALTY CARE CENTER | 25A414 | 1 LAYFAIR DRIVE SUITE 500 | FLOWOOD | MS | 39232 | 2014-08-08 | 441 | D | 0 | 1 | M49611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility policy review, the facility failed to perform bedside glucose monitoring in a manner to prevent the possibility of the spread of infection as evidenced by direct contact of the glucometer case with the over bed table for one (1) of 27 medication administration opportunities. (Unsampled Resident A) Findings included: Observation on 08/07/14 at 4:35 PM revealed License Practical Nurse (LPN) #1 placed a black fabric zippered case containing glucometer and supplies needed to perform finger stick glucose monitoring directly on Unsampled Resident A ' s over bed table. LPN #1 also placed a plastic container containing disinfectant wipes on the same table without barrier in place or without wiping table with the disinfectant wipes. After LPN #1 performed the blood glucose monitoring, LPN #1 did not wipe the fabric case or the container of disinfectant wipes. LPN #1 returned the black fabric case and the container of disinfectant wipes to the top of the medication cart. Interview on 08/07/14 at 4:45 PM with LPN #1 confirmed the above observation but could not identify proper procedure. LPN #1 said this practice could be a possibility for cross contamination. LPN #1 said the facility had passed around a hand out to read about glucometer (accucheck) procedure but could not recall the date. Interview on 08/08/14 at 8:20 AM with Director of Nursing (DON) said, The case should not be taken into the room and our policy reflects that. The DON said the LPNs are checked off on accucheck procedure and hand washing should be habit. Review of facility policy entitled Point of Care Glucose Monitoring, dated 04/04/12, did not address the deficient practice. Review of facility policy entitled Isolation Guidelines & Transmission-Based Precautions, dated 03/27/13, did not address the deficient practice. Review of an undated facility in-service entitled Review of Accucheck Procedure indicated LPN #1 had review… | 2017-11-01 |
| 5472 | 5472 | METHODIST SPECIALTY CARE CENTER | 25A414 | 1 LAYFAIR DRIVE SUITE 500 | FLOWOOD | MS | 39232 | 2013-09-05 | 164 | D | 0 | 1 | M68E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review and facility policy review, the facility failed to provide privacy and dignity during a personal care observation and to knock on the resident's doors prior to entry for one (1) of eleven (11) residents reviewed (Residents #9). Findings include: Resident #9 A review of the facility's policy Resident's Rights (no date) revealed the following: e). Privacy and Confidentiality: The resident has the right to personal privacy and confidentiality or his or her personal and clinical records. 1) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits and meetings of family and resident groups, but this does not require the facility to provide private rooms. Quality of Life: A facility must care for it's residents in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life. a) Dignity: The facility must provide care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. On 9/4/13 at 8:45 a.m. an observation revealed Resident #9 received Supra-Pubic (S/P) Catheter care by Licensed Practical Nurse (L.P.N.) #1. L.P.N. #1 placed the S/P Catheter care supplies on an over bed table, washed her hands and put on gloves. L.P.N. #1 removed Resident #9's bed cover from his waist down to his feet, exposing the lower abdominal area to the feet. L.P.N. #1 removed the old S/P dressing, changed gloves and began to clean around the S/P Catheter site stoma with the N/S on the 4X4 gauge pads. L.P.N. #1 changed gloves and began to pat the S/P Catheter stoma site dry. L.P.N. #1 did not have any more gloves on the over bed table and left the bedside to go to the bathroom to obtain more gloves leaving Resident #9 uncovered. L.P.N. #1 returned to the bedside, reported there were no gloves in the bathroom. L.… | 2016-09-01 |
| 5473 | 5473 | METHODIST SPECIALTY CARE CENTER | 25A414 | 1 LAYFAIR DRIVE SUITE 500 | FLOWOOD | MS | 39232 | 2013-09-05 | 252 | E | 0 | 1 | M68E11 | Based on observation, staff interview, and facility policy review, the facility failed to provide a clean and sanitary environment on one (1) of three (3) wings on the third (3rd) floor. Findings include: Review of facility's Patient Room Cleaning policy, dated 10/13/2010, failed to address strong, unpleasant odors in areas used by the residents. Observation on 9/3/2013, during the initial tour at 11:30 a.m., revealed a strong an unpleasant odor on the 3rd floor hall between Rooms #311 thru #320. Observation on 9/4/2013 at 11:40 a.m. revealed a strong, unpleasant odor on the 3rd floor hall between Rooms #311 thru #320. Observation on 9/5/2013 during the environmental tour at 12:20 p.m. revealed a strong, unpleasant odor on the 3rd floor hall between Rooms #311 thru #320. Staff interview on 9/5/2013 at 12:30 p.m. with Housekeeping/Maintenance Staff #2 confirmed the odor between Rooms #311 thru #320. Housekeeping/Maintenance Staff #2 stated, I know they have a problem with him (Unsampled Resident A) with refusing baths. Staff interview on 9/5/2013 at 3:30 p.m. with Housekeeping/Maintenance Staff #1 stated, We are working on that odor. I don't know what we plan to do, but we are working with nursing. | 2016-09-01 |
| 5474 | 5474 | METHODIST SPECIALTY CARE CENTER | 25A414 | 1 LAYFAIR DRIVE SUITE 500 | FLOWOOD | MS | 39232 | 2013-09-05 | 280 | D | 0 | 1 | M68E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and facility's policy review, the facility failed to review and revise care plans for one (1) of twelve (12) residents records reviewed (Resident #1). Findings include: Resident #1 Review of the facility's policy entitled Care Plans, dated 2/14/2004, revealed: A comprehensive plan of care will be developed for each resident. The care plan will be updated or revised after each quarterly and/or significant change assessment. Review of Resident #1's Care Plan with a problem onset date of 6/24/2013 revealed Resident #1 had actual skin breakdown to Left coccyx-Stage II. Goal was for Skin breakdown will be resolved by next review date. There was no review date indicated on the care plan. Review of Resident #1's Physician Orders, dated July 2013, revealed 7/9/2013 the order stated: D/C Duoderm to L coccyx area. Skin Healed. Interview on 9/5/2013 at 9:25 a.m. with RN#1 confirmed the lack of a revision to the care plan after the wound care was discontinued. RN #1 stated, It should have been resolved on the care plan. Observation on 9/4/2013 at 9:10 a.m. revealed Resident #1 was in bed with both side rails up. Resident #1 was able to make eye contact and mouth words such as, I love you and Bye Bye. Record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 01, which indicated severe cognitive impairment. | 2016-09-01 |
| 5475 | 5475 | METHODIST SPECIALTY CARE CENTER | 25A414 | 1 LAYFAIR DRIVE SUITE 500 | FLOWOOD | MS | 39232 | 2013-09-05 | 315 | D | 0 | 1 | M68E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review and facility policy review, the facility failed to provide Foley Catheter (F/C) and Bowel/Bladder Incontinent care in a manner to prevent the possibility of Urinary Tract Infections (UTIs) for two (2) of five (5) residents reviewed (Residents #5 and #8). Findings include: Resident #5 A review of the facility's policy Foley Catheter (Revised 8/9/09) revealed the following: II Policies and General Instructions: 8. Meticulous cleansing around the catheter and urethral meatus with soap and water should be done daily and as needed. Review of the policy does not address cleaning the F/C tubing, only to clean around the catheter. Does not specify going from the meatus out towards the F/C tubing and Drainage Bag tubing connection to ensure the tubing is clean to decrease the risk of UTIs. On 9/4/13 at 10:20 a.m. an observation revealed Resident #5 received F/C care by Licensed Practical Nurse (L.P.N.) #2. L.P.N. #2 placed supplies on an over bed table: 4X4 gauze, Normal Saline (N/S), gloves, and a red bag. L.P.N. #2 has washed her hands and put on gloves. L.P.N. #2 began to clean with the N/S on a 4X4 gauze, then changed to a bottle of Body Wash. L.P.N. #2 obtained a 4X4 took it to the bathroom to wet it, returned to the bedside and put some of the Body Wash onto the wet 4X4. L.P.N. #2 took the 4X4 gauze and wiped around Resident #5's meatus with the soap and water. L.P.N. #2 changed gloves, took another 4X4 to the bathroom to wet it, returned to the bedside, changed gloves, took the wet 4X4 and wiped around the meatus to rinse the soap off. L.P.N. #2 changed gloves, obtained a 4X4 and patted the area dry. L.P.N. #2 did not clean the F/C tubing from the meatus out towards the F/C tube and drainage tube connection. On 9/4/13 at 10:35 a.m. an interview with L.P.N. #2 revealed she did not clean Resident #5's F/C tubing from the meatus out towards the drainage tube connection. On 9/5/13 at 11:15 a.m. a… | 2016-09-01 |
| 5476 | 5476 | METHODIST SPECIALTY CARE CENTER | 25A414 | 1 LAYFAIR DRIVE SUITE 500 | FLOWOOD | MS | 39232 | 2013-09-05 | 322 | D | 0 | 1 | M68E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review and facility policy review, the facility failed to provide Percutaneous Gastrostomy Tube (PEG) site care in a manner to prevent the possible spread of infection/contamination for one (1) of five (5) residents reviewed (Resident #5). Findings include: Resident #5 A review of the facility's policy Gastrostomy Feeding Tube (Revised 10/15/04) revealed the following: Policy: 11. Clean Gastrostomy site daily with normal saline or water. Apply gauze dressing if drainage or bleeding from site present, otherwise dressing not needed. Review of the facility's policy Transmission-Based Precautions & Isolation Guidelines (no date) revealed the following: VI Standard Precautions: D. General guidelines for the usage of personal protective equipment (PPE) are as follows: 2. Gloves (clean, non-sterile gloves) are to be worn when a. Touching blood, body fluids, secretions, excretions, and contaminated items. b. Put on gloves just before touching mucous membranes, and non-intact skin. c. Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. d. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another patient. e. Wash hands immediately to avoid transfer of microorganisms to other patients or environments. On 9/4/13 at 10:00 a.m. an observation revealed Resident #5 received PEG Tube site care by Licensed Practical Nurse (L.P.N.) #2. L.P.N. #2 washed her hands and put on gloves. Supplies were placed on an over bed table: Normal Saline (N/S), gloves, tape, and 4X4 gauze pads. L.P.N. #2 removed the old PEG site dressing (dsy). Resident #5's PEG site stoma is slightly pink/reddish coloration without any drainage. L.P.N. #2 cleaned the PEG site with N/S on the 4X4 gauze pads, patted around the area with a dry 4X4 gauze pad, and then applied a clean dsy. … | 2016-09-01 |
| 5477 | 5477 | METHODIST SPECIALTY CARE CENTER | 25A414 | 1 LAYFAIR DRIVE SUITE 500 | FLOWOOD | MS | 39232 | 2013-09-05 | 441 | D | 0 | 1 | M68E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review and facility policy review, the facility failed to ensure measures to prevent the possibility for the spread of infection/contamination during the care provided for two (2) of six (6) Oxygen (O2) Therapy dependent residents, and proper disposal of used/soiled gloves for one (1) of one (1) Foley Catheter (F/C) care observations (Residents #5 and #8). Findings include: Resident #5 A review of Resident #5's Face Sheet revealed he was admitted to the facility on [DATE], and re-admitted on [DATE] with the included Diagnoses: [REDACTED]. A review of Resident #5's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/24/13, revealed Resident #5's Basic Interview for Mental Status (BIMS) was scored twelve (12), which indicated he has mild difficulty with decision making. Further review of the MDS revealed Resident #5's Special Treatments, Procedures, and Programs are checked for a Ventilator and Tracheostomy Care. On 9/4/13 at 10:05 a.m. an observation revealed Resident #5 received Tracheostomy care by a Registered Respiratory Therapist (RRT). The RRT washed her hands and put on gloves. The supplies were placed on an over bed table: Bottle of Hydrogen Peroxide (H2O2), red bag, Tracheostomy (Trach) Care Kit, Trach Ties, and a Trach Foam Dressing. The RRT opened the Trach Care Kit and put on the sterile gloves. The RRT opened the bottle of H2O2 with the sterile gloves and poured the H2O2 into the cleaning solution compartment in the Trach Care Kit. The RRT did not change her gloves after opening the bottle of H2O2. The RRT then removed Resident #5's Trach collar from around his neck, and cleans around Resident #5's neck with H2O2 on a 4X4 gauze. Obtained a clean 4X4 with H2O2 and cleans the Trach outer cannula area, removed the old Trach dsy., secured the Trach with other hand, obtained a clean 4X4 with H2O2 and cleansed under the outer cannula area. The RRT gets a cotton tip… | 2016-09-01 |
| 5478 | 5478 | METHODIST SPECIALTY CARE CENTER | 25A414 | 1 LAYFAIR DRIVE SUITE 500 | FLOWOOD | MS | 39232 | 2013-09-05 | 502 | D | 0 | 1 | M68E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and facility's policy review, the facility failed to obtain laboratory services per physician orders [REDACTED].#1). Findings include: Resident #1 Review of the facility's policy entitled Laboratory Services, with effective date 11/17/2008, and revision date 12/29/2008, revealed I. POLICY Laboratory services at MSCC (Methodist Specialty Care Center) are outsourced to the service providing laboratory coverage for Methodist Rehabilitation Center. II. PROCEDURE 1. Routine laboratory collections days are Monday and Thursday. Addition laboratory testing needs may be drawn by facility staff and call for pick up made to outsource lab for pick up. 2. Laboratory orders are drawn and collected according to physician order. Review of results of lab collected on 8/12/2013 at 9:35 a.m. CDT (Central Daylight Time) revealed an INR of 1.93. A handwritten note, signed and dated 8/13/2013 by the Registered Nurse (RN) stated, Increase [MEDICATION NAME] to 4.5 mg daily at 1700 (5:00 p.m.). Recollect on Monday 8/19/2013 A.M. Record review revealed the facility failed to recheck the INR on 8/19/2013. Interview on 9/3/2013 at 1:45 p.m. with Registered Nurse (RN) #1 confirmed the lack of lab results. RN #1 stated, It did not get done. We notified the Doctor and it will be done today. Record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 01, which indicated severe cognitive impairment. | 2016-09-01 |
| 6496 | 6496 | METHODIST SPECIALTY CARE CENTER | 25A414 | 1 LAYFAIR DRIVE SUITE 500 | FLOWOOD | MS | 39232 | 2012-05-21 | 166 | E | 0 | 1 | 051P11 | Based on resident council meeting, staff interview and policy review, the facility failed to ensure resident concerns/grievances were addressed and resolved to the resident's satisfaction. This affected 12 of 12 residents in the resident council meeting and had the potential to affect all residents who reside in the facility out of a census of 58. Findings Include: During the resident council meeting held on 05/18/12 at 1 PM, 12 residents who the facility identified as alert, oriented and interviewable voiced concerns that the facility staff do not always answer the call lights promptly. One (1) resident in attendance reported he had a bowel movement and call for assistance, it took staff more than two (2) hours to come clean him up. Another resident reported she had to call for assistance many times before she was changed and it sometimes took one (1) to two (2) hours to get assistance. Residents further stated that staff rarely made the two (2) hour rounds to turn and reposition them. They all agree this was a problem for them and that these things had been reported to the nursing staff on numerous occasions but nothing had been done to remedy the problems. On 05/19/12 at 2:25 PM, the Administrator was interviewed regarding the Quality Assurance Committee and was asked what is done to address resident grievances regarding care, call lights and treatment. The Administrator revealed it is done through implementation of auditing sheets. We address these issues through resident council. The Administrator was asked if complaints regarding nursing care are voice what is done. The Administrator replied, she and the Director of Nursing (DON) ask them (the residents) not to save (these complaints) this until resident council. They should come to me or the DON . The Administrator was asked what if the residents said to you: They (CNAs ) won't do anything for them (residents). The Administrator replied, we use that as a coaching method (with staff). The policy titled, Resident Rights documented, .Participate in his or her… | 2015-12-01 |
| 6497 | 6497 | METHODIST SPECIALTY CARE CENTER | 25A414 | 1 LAYFAIR DRIVE SUITE 500 | FLOWOOD | MS | 39232 | 2012-05-21 | 225 | E | 0 | 1 | 051P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and policy review, the facility failed to provide adequate supervision of staff to ensure resident concerns of mistreatment were followed up upon and thoroughly investigated to determine if abuse or neglect occurred as evidence by residents having ongoing concerns related to the lack of care provided in a timely manner (ie Incontinence care) and staff mistreatment by treating resident like children, not listening to them about care needs and concerns, talking down to them, and treating them like dogs. Twelve (12) of twelve (12) resident, out of a census of 58, who attended the resident council meeting on [DATE] at 1 PM, all agreed this has been an ongoing problem, they had reported their concerns to Charge Nurses and the facility Administration and they were told not to bring it up anymore. Furthermore, the facility failed to provide evidence that these allegations were followed up on, investigated and resident were protected pending the completion of an investigation . This practice specifically affected twelve (12) of twelve (12) residents in resident council, two (2) residents who wanted their interviews to be confidential, and Resident Identifiers (RI) #8 and RI #14. Findings Include: Resident Council Twelve (12) of twelve (12) resident who attended the resident council meeting on [DATE] at 1 PM, had ongoing concerns related to the lack of care provided in a timely manner (ie Incontinence care) and staff mistreatment by treating resident like children, not listening to them about care needs and concerns, talking down to them, and treating them like dogs and used the term Mental abuse and neglect during the meeting. Residents stated they had reported their concerns to Charge Nurses and the facility Administration and they were told not to bring it up anymore. 2 Confidential Interviews A Confidential Interview (CI) #1 was conducted with a resident on [DATE] at 4:40 PM. CI #1 stated it takes the… | 2015-12-01 |
| 8231 | 8231 | METHODIST SPECIALTY CARE CENTER | 25A414 | 1 LAYFAIR DRIVE SUITE 500 | FLOWOOD | MS | 39232 | 2011-06-16 | 241 | D | 0 | 1 | OGZZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and policy review, the facility failed to ensure that one (1) of five (5) residents observed during care was provided dignity and privacy during personal care (Resident #8). Findings include: Record review revealed that Resident #8 moved into the home on 1/27/11 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status of three (3), which indicated that Resident #8's cognitive status was severely impaired. Observation on 6/15/11 at 10:30 a.m. of incontinent care revealed Certified Nurse Aide #2 left Resident #8's body exposed with gown up to chest and bed linen down below knees while she disposed of water, linen and gloves used during the care. Interview with Certified Nurse Aide #2, at this time, confirmed Resident #8's body was left exposed during the care. Interview on 6/15/11 at 3:00 p.m. with the Director of Nursing (DON) regarding concerns with the resident being exposed during care revealed the DON shook her head. Review of the home's "Resident Rights" policy, revised 3/1/2005, noted: " ... a). Dignity. The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality ..." | 2014-09-01 |
| 8232 | 8232 | METHODIST SPECIALTY CARE CENTER | 25A414 | 1 LAYFAIR DRIVE SUITE 500 | FLOWOOD | MS | 39232 | 2011-06-16 | 371 | F | 0 | 1 | OGZZ11 | Based on observation, staff interview and policy review, the facility failed to prepare, serve and distribute food under safe and sanitary conditions for three (3) of four (4) days of survey as evidenced by failure to demonstrate calibration of thermometers, storing the scoop in a sugar storage bin, and reusing unopened items (milk, juice) on the residents' tray. Findings include: Observation on 6/13/11 at 1:20 p.m. with Dietary Staff #1 revealed the microwave oven door was coated with yellow colored splatters, and the inside of the microwave was coated with brownish, black colored splatters and food particles. Observation on 6/14/11 at 10:30 a.m. during the tray line temperature checks revealed Dietary #3 stated that thermometer were not calibrated every time because they come from (name of company) already done. Dietary Staff #3 stated that the calibration of the thermometers should be at zero (0) degrees. Observation on 6/14/11 at 10:30 a.m. of the Pot Pan Sink Temperature/Sanitation Log for the three (3) compartment sink revealed that sanitizer checks were recorded form 300 to 400 PPM (parts per millimeter) on 5/23/11, 5/24/11, 5/25/11, 5/30/11, 5/31/11, 6/4/11, 6/5/11, 6/6/11, and 6/13/11. Dietary Staff #2 was not aware of what should be done when the concentration was above 200 PPM. Observation of 6/15/11 at 8:05 a.m. in the dish room revealed Dietary Staff #4 was observed to take unopened containers of milk, juice, and fruit from used/dirty food trays and returned them to the dietary to be re-served to residents. Dietary Staff #3 was observed to place the unopened items on top of the food cart that was used to take foods to other residents. Interview on 6/15/11 at 8:05 a.m. with Dietary Staff #4 regarding reuse of items returned to the kitchen area, revealed Dietary #4 confirmed that she put the items there to be used later. Observation on 6/15/11 at 9:00 a.m. with Dietary Staff #5 revealed a scoop was stored in the dry sugar bin, the microwave oven door and interior was splattered with food items, and nin… | 2014-09-01 |
| 8233 | 8233 | METHODIST SPECIALTY CARE CENTER | 25A414 | 1 LAYFAIR DRIVE SUITE 500 | FLOWOOD | MS | 39232 | 2011-06-16 | 441 | E | 0 | 1 | OGZZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and policy review, the facility failed to ensure that an effective infection control program was maintained to prevent the potential for the spread of infection for one (1) of four (4) days of survey. Resident #8's external catheter was not closed during care, the medication cart was observed to contain an opened drink container with liquid that belonged to staff. Findings include: Record review revealed that Resident #8 moved into the home on 1/27/11 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status score of 3, which indicated that Resident #8's cognitive status was severely impaired. Review of the care plan for Resident #8, dated 6/2/11, noted: "Infection MRSA (Methicillin-resistant Staphylococcus Aureus) Pseudomonas in old [MEDICATION NAME] pump site ... Contact Isolation IV (intravenous) ABT (antibiotic therapy) [MEDICATION NAME] and [MEDICATION NAME] for infection. " Observation on 6/15/11 at 10:30 a.m. of incontinent care revealed Certified Nurse Aide (CNA) #2 removed the external catheter from Resident #8 then removed the catheter tubing from the external catheter. CNA #2 was not observed to cap the catheter tubing, leaving a closed system open to air. CNA #2 hung the uncapped catheter tubing across the urine drainage bag at bedside. After the care, CNA #2 inserted the catheter tubing into the replaced external catheter without cleaning the connection. Observation on 6/15/11 at 10:30 a.m. revealed the catheter tubing attached to an external catheter and bedside drainage bag was not secured to Resident #8. Observation on 6/15/11 at 10:50 a.m. revealed a banana and Styrofoam cup with straw was stored on top of medication cart. Interview on 6/15/11 at 10:50 a.m. with License Practical Nurse (LPN) #1 confirmed that the banana was from a resident ' s breakfast tray and the Styrofoam cup with the straw belonged to h… | 2014-09-01 |
| 8234 | 8234 | METHODIST SPECIALTY CARE CENTER | 25A414 | 1 LAYFAIR DRIVE SUITE 500 | FLOWOOD | MS | 39232 | 2011-06-16 | 253 | E | 0 | 1 | OGZZ11 | Based on observation and staff interview, the facility failed to maintain an environment that was safe, clean, and free from standing/pooling water inside the residents shower/toilet areas for two (2) of four (4) days of survey. Findings include: Observation on 6/14/11 at 7:00 p.m. revealed that resident ' s toilet areas in residents' Rooms #202 and #203 were covered with standing/pooling dirty water. Observation of both of the residents in Rooms #202 and #203 revealed that they both were dependent on staff for their Activities of Daily Living, and were totally dependent upon motorized wheelchairs due to being paralyzed. Interview on 6/14/11 at 7:00 p.m. with the resident in Room #202 revealed that the toilet/shower area was usually standing in water because the water would not drain. He stated that his morning shower at 10:15 a.m. on 6/14/11. Observation on 6/16/11 at 1:45 p.m. revealed that the entire floor area in toilet/shower area of resident Room #202 was standing in pooling, brownish colored water. Interview on 6/16/11 at 1:45 p.m. with the Housekeeping Supervisor revealed that she would go and get the Maintenance staff to come and see the standing water in Room #202. Interview on 6/16/11 at 1:50 p.m. with the Maintenance staff revealed that he felt that the floor was retaining the pooling water due to the floor design and the floor not having enough slop to drain properly. Maintenance staff stated that he would have the housekeeping staff to come after each use and mop up the standing water because it would not drain by itself. Review of the home's "Infection Control - Disinfection and Cleaning" policy, reviewed 5/4/09, noted: "Purpose To provide a policy and procedure for general cleaning and disinfection of all surfaces ..." | 2014-09-01 |
| 632 | 632 | BEDFORD CARE CENTER OF HATTIESBURG | 255158 | 10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2018-02-06 | 689 | D | 1 | 0 | BE2711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > CI MS # Based on observation, interview, record review, policy/procedure review and document review, the facility failed to ensure supervision to help prevent accidents for Resident #1, one (1) of five (5) residents at risk for elopement. On 12/31/17, Resident #1 left the facility without the knowledge of the facility staff. Resident #1 wore a wanderguard which did not activate after a nurse unlocked an exit/entry door using a remote phone system. Resident #1 held the exit/entry door open for the ambulance crew, then walked out the door unsupervised. Findings include: Review of the facility's Elopements policy statement, with an effective date of (MONTH) 2012, revealed: This facility will make every effort to protect the safety of all residents in the facility. Nursing personnel must report and investigate all reports of missing persons. Review of a facility handout procedure for A Systems Approach to Resident Safety, described elopement as an occurrence when a resident leaves the premises without authorization and/or necessary supervision to do so. While alarms can help to monitor a resident's activities, staff must be vigilant in order to respond to them in a timely manner. Alarms do not replace necessary supervision. Review of an incident report and facility investigation, dated 12/31/18, revealed Resident #1 left the facility unattended on 12/31/18 at approximately 12:08 AM, as a result of the locking mechanism on South #6 door failing to properly lock. Resident #1 was located within 30 minutes of departure and sent to the emergency room for evaluation of a knot on his head, and returned without new orders. Facility determined Resident #1 had no injury and placed him on enhanced supervision, disabled the remote phone system to unlock the exit door, and educated staff to use only the key pad entry system. The entry/exit sites were monitored for properly locking. Resident #1's statement was attempting to return home and that he missed his… | 2020-09-01 |
| 633 | 633 | BEDFORD CARE CENTER OF HATTIESBURG | 255158 | 10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2017-04-21 | 279 | D | 0 | 1 | CN6K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and facility policy review, the facility failed to develop a comprehensive care plan related to the potential for falls based on the resident's Minimum Data Set (MDS) Care Area Assessment (CAAs) for one (1) of 24 resident care plans reviewed, Resident #23. Findings include: Review of the facility's policy titled, Care Plans-Comprehensive, revised (MONTH) (YEAR), revealed an individualized comprehensive care plan would be developed to include measurable objectives and time tables to meet the resident's needs. The policy revealed the care plan would incorporate identified problem areas for the resident with the risk factors associated with them; then identify the professional services that were responsible for each element of care. The care plan would also aid in preventing or reducing declines in the resident's functional status. A review of Resident #23's Care Plan revealed the facility failed to develop interventions on the comprehensive care plan for Resident #23 for the potential for falls. The facility identified a problem area for a potential for falls, dated 12/27/16 with a goal to decrease the risk for falls thru next review with an estimate date of 06/28/17. A review of Resident #23's Minimum Data Set (MDS) Care Area Assessment (CAAs) Documentation Notes, dated 01/03/17, revealed the facility would proceed to the care plan to observe for, and decrease risk factors for falls due to the resident was weak, and had declined in transfers and gait. An interview on 04/20/17 at 11:30 AM, revealed Licensed Practical Nurse (LPN) #4 confirmed Resident #23 did not have any interventions listed on his care plan related to his potential for falls. LPN #4 said she completed the fall assessment for Resident #23 for the MDS dated [DATE]. LPN #4 said the care plan would not list any interventions because Resident #23 had not fallen. LPN #4 also said the care plan interventions would only list physician orders. A… | 2020-09-01 |
| 634 | 634 | BEDFORD CARE CENTER OF HATTIESBURG | 255158 | 10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2017-04-21 | 280 | D | 0 | 1 | CN6K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, staff interviews, resident interview, and the facility policy review, the facility failed to include on the care plan, monitoring for the potential or actual side effects/adverse reactions with the use of antibiotics for one (1) of 24 care plans reviewed, Resident #5. Findings include: Review of the facility's policy, Care Plans-Comprehensive revised (MONTH) (YEAR), revealed, 3. Each resident's Comprehensive Care Plan has been designed to: b. incorporate risk factors associated with identified problems; d. Reflect treatment goals and objectives in measurable outcomes. 5. Care plans are revised as changes in the resident's condition dictate or resident's choices change. Review of Resident #5's Current Plan of Care for actual UTI (urinary tract infection), effective date of 4/12/2017, revealed the facility failed to update the care plan to include the duration of antibiotics or include the potential for adverse reactions or side effects related to the resident receiving two antibiotics simultaneously. The care plan listed the interventions of notification of the medical doctor as needed, Bactrim DS (antibiotic) as ordered, and [MEDICATION NAME] (antibiotic) as ordered. Review of Resident #5's Cumulative physician's orders [REDACTED]. Review of Resident #5's Medication Administration Record [REDACTED]. After the resident returned from the hospital on [DATE], the facility resumed the Bactrim DS for UTI and began administering [MEDICATION NAME] for UTI. Review of the hospital discharge summary for Resident #5, revealed she had received treatment for [REDACTED]. Interview on 4/19/2017 at 3:20 PM with Licensed Practical Nurse (LPN) #4 who was also a care plan nurse stated there was no care plan developed for the use of antibiotics and monitoring and stated, I guess I just missed it. Review of the facility's face sheet revealed, the facility admitted the resident on 5/20/2016. Resident #5's [DIAGNOSES REDACTED]. Review of the… | 2020-09-01 |
| 635 | 635 | BEDFORD CARE CENTER OF HATTIESBURG | 255158 | 10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2017-04-21 | 312 | D | 0 | 1 | CN6K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview, and facility policy review, the facility failed to ensure dependent resident's nails were kept in a clean and trimmed condition for two (2) of 11 residents observed for nail care; Residents #11 and #13. Findings include: Review of the facility's policy titled, Care of Fingernails/Toenails, with a renewal date of (MONTH) (YEAR), revealed: The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections to include: 1. Review the resident's care plan to assess for any special needs of the resident. 2. Nail care includes daily cleaning and regular trimming. 3. Proper nail care can aid in the prevention of skin problems around the nail bed. 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. 5. Stop and report to the nurse supervisor if there is evidence of ingrown nails, infection, pain, or if nails are too hard or too thick to cut with ease. 6. Document the procedure. Report to the Supervisor any problems or refusal of treatment. Resident #11 On 4/19/17 at 9:55 AM, an observation revealed Resident #11 was sitting up in bed, smiling, and pleasantly confused. Further observation revealed Resident #11's toenails were long, with a yellowish coloration, and a dried dark substance under the nails. On 4/19/17 at 2:20 PM, at the conclusion of an incontinent care observation, Certified Nursing Assistant (CNA) #3 and #4 revealed for observation, Resident #11's toenails. The toenails observed were thick, elevated, and yellowish in color bilaterally. The 2nd and 3rd toenails bilaterally were long, and rolled downward over the ends of the toes. On 4/20/17 at 10:35 AM, an interview with CNA #3 revealed her recall of yesterday's observation of Resident #11's toenails. CNA #3 stated the resident's toenails at that time needed trimming and attention. CNA #3 said she did not report the need to the nurse, but … | 2020-09-01 |
| 636 | 636 | BEDFORD CARE CENTER OF HATTIESBURG | 255158 | 10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2017-04-21 | 329 | D | 0 | 1 | CN6K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, resident interviews, record interviews, and facility policy review, the facility failed to identify duplicate drug therapy and failed to monitor Residents #5 for the possible side effects/adverse effects of the duplicate antibiotic therapy for one (1) of 21 resident medication regimens reviewed. Findings include: Review of the facility's policy titled, Acute Condition Changes - Clinical Protocol, reviewed (MONTH) (YEAR), revealed: The Physician and nursing staff will identify any complications and/or problems that occurred during a recent hospital stay, which may indicate the risk of additional complications or instability. The Physician will help identify when a resident is receiving medications or medication combinations that are associated with adverse consequences that could cause significant changes in condition. The staff will monitor and document the resident's progress and responses to treatment, and the Physician will adjust treatment accordingly. Review of the facility's policy titled, Acute Charting List (Use As A Guideline), reviewed (MONTH) (YEAR), revealed: Infections: Guideline: Consider what type of infection and document according to the type of infection & antibiotic ordered. Resident #5 Review of Resident #5's Medication Administration Record [REDACTED]. Review of the MAR indicated [REDACTED]. Review of the cumulative Physician order [REDACTED]. Review of Nurse's Notes dated 4/12/2017 through 4/18/2017 revealed no documentation for antibiotic therapy assessment and monitoring. Interview on 4/19/2017 at 3:05 PM, with Licensed Practical Nurse (LPN) #4 revealed Resident #5 had gone to the hospital on [DATE], and returned on 4/12/2017. Bactrim DS (antibiotic) was started on 4/12/2017. Resident #5 went back to the hospital on [DATE], and returned to the facility on [DATE], with a [DIAGNOSES REDACTED]. LPN #4 stated there were no stop dates on either antibiotic. Interview on 4/19/2017 at 3… | 2020-09-01 |
| 637 | 637 | BEDFORD CARE CENTER OF HATTIESBURG | 255158 | 10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2017-04-21 | 514 | E | 0 | 1 | CN6K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document evidence of antibiotic monitoring per facility protocol for five (5) of 24 charts reviewed for Residents #2, #5, #8, #9, and #18. Findings include: Review of the facility's policy titled, Charting and Documentation, with an effective date of (MONTH) 2013, revealed: All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. 7. Documentation of procedures and treatments shall include care-specific details, and shall include at a minimum: c. The assessment data and/or any unusual findings obtained during the procedure/treatment; d. How the resident tolerated the procedure/treatment. Review of the facility's policy titled, Acute Charting List (Use As A Guideline), reviewed (MONTH) (YEAR), revealed: the facility was to document according to the type of infection & antibiotic ordered for each shift times three (3) days. After three (3) days and resident is stable, chart in weekly documentation the remainder of the treatment. Resident #2 A review of the Nurses Notes for Resident #2 dated 04/12/17 - 04/17/17, revealed no specific documentation regarding the assessment or monitoring for adverse/side effects of the antibiotic. The Nurse's Note, dated 04/12/17, documented new order for [MEDICATION NAME] x (times) five (5) days on return from the hospital. A review of Resident #2's Physician order [REDACTED]. Review of the (Name of Hospital) Discharge Instructions printed on 4/12/17, revealed the [DIAGNOSES REDACTED]. The Medication List included [MEDICATION NAME] (antibiotic) 300 milligram (mg.) capsule twice a day for five (5) days. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. A review of the facility's Record of Admission revealed the facility admitted Resident #2 on 01/19/15. Resident #2's [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an Assessment Re… | 2020-09-01 |
| 638 | 638 | BEDFORD CARE CENTER OF HATTIESBURG | 255158 | 10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2018-08-16 | 550 | D | 0 | 1 | 95J011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure Resident #25's dignity as evidenced by failure to provide coverage for the resident's indwelling urinary catheter drainage bag, for one (1) of four (4) residents reviewed with an indwelling urinary catheter bag. Findings include: A review of the facility's policy, titled, Quality of Life-Dignity, revised (MONTH) 2006, revealed: Staff shall promote dignity and assist residents as needed by helping residents to keep urinary catheter bags covered. On 8/13/18 at 5:40 PM, an observation revealed, Resident #25 had an indwelling urinary catheter connected to a gravity drainage bag, and there was no privacy bag covering the drainage bag. On 8/14/18 at 11:45 AM, an observation revealed, Resident #25 was sitting in his room in his wheelchair with an indwelling urinary catheter connected to a drainage bag, and there was no dignity bag covering his drainage bag. On 8/14/18 at 2:00 PM, an interview with Certified Nursing Assistant (CNA) #1 revealed Resident #25 does not have a dignity bag over his catheter bag. CNA #1 stated Resident #25 was not here this morning because he had an appointment. CNA #1 stated, it is a dignity issue (referring to the catheter drainage bag not covered by a privacy bag), and she will make sure she takes care of this issue. On 8/14/18 at 2:33 PM, an interview with the Director of Nurses (DON) revealed, it is a dignity issue not to have a privacy bag covering the catheter drainage bag. On 8/15/18 at 8:10 AM, interview with CNA #4 revealed, it is a dignity issue for the resident not to have a privacy bag covering the urinary catheter drainage bag. Record review of the Medication Administration Record [REDACTED]. Review of the Physician order [REDACTED]. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of (MONTH) 13, (YEAR), section H for bowel and bladder continence was coded for an indwelli… | 2020-09-01 |
| 639 | 639 | BEDFORD CARE CENTER OF HATTIESBURG | 255158 | 10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2018-08-16 | 656 | D | 0 | 1 | 95J011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy review, and staff interview, the facility failed to follow Resident #22's comprehensive care plan related to pressure ulcers, for (1) one of 30 resident care plans reviewed. Findings include: Review of the facility's policy, titled, Using the Care Plan, revised (MONTH) 2006, revealed, the care plan shall be used in developing the resident's daily care routines, and will be available to staff personnel who have responsibility for providing care or services to the resident. Review of Resident #22's Care Plan revealed the Problem for the Potential for Altered Skin Integrity, with an original date of 05/29/18, and on 06/05/18 a Deep Tissue Injury (DTI) to the right heel, and on 07/22/18, a stage three (3) to the right heel. Interventions, dated 05/29/18, included pressure relieving mattress to the bed, and cushion to the chair, observe for new onset of skin complications/breakdown, weekly body audits, and provide treatment to the stage three (3) pressure injury to the right heel as ordered until healed. On 06/07/18, an intervention to apply heel protectors to bilateral feet and float heels while in bed was added. Further review of the Care Plan revealed the Problem for Requiring Assist with ADLs (Activities of Daily Living) due to left sided [MEDICAL CONDITION]/involuntary tremors dated 05/29/18. The Interventions, dated 05/29/18, included extensive assist x 2 (times two) with bed mobility. Interventions, dated 08/09/18, included extensive assist x 1 (times one) with bathing, wheel chair mobility, and hygiene, and on 08/15/18, extensive assist x 2 (times two) with toileting. Review of Resident #22's Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/04/18, revealed there were no pressure ulcers present, and Resident #22 was at risk for developing pressure ulcers. Review of Resident #22's 60 Day Scheduled Assessment MDS, with an ARD of 07/24/18, revealed the presence… | 2020-09-01 |
| 640 | 640 | BEDFORD CARE CENTER OF HATTIESBURG | 255158 | 10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2018-08-16 | 686 | D | 0 | 1 | 95J011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review, the facility failed to prevent pressure ulcer development for (1) one of (6) six pressure ulcer observations, for Resident #22. Findings include: A review of the facility's policy titled, Pressure Ulcer/Skin Breakdown-Clinical Protocol, revised (MONTH) (YEAR), revealed the staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. On 8/14/18 at 12:05 PM, an observation revealed Registered Nurse (RN) #2, assisted by Certified Nursing Assistant (CNA) #5, provided wound care to Resident #22's right heel. Resident #22's right heel was noted to be pink with no drainage. Record review of the most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/7/18, revealed a pressure ulcer stage three (3) coded in section M of the MDS. Review of the Admission MDS, with an ARD of 6/4/18, revealed section M was coded to show no pressure ulcers present. Review of the (MONTH) (YEAR) Treatment Administration Record (TAR) revealed a treatment, with a start date of 07/22/18, for a stage three (3) pressure injury to the right heel, and to cleanse the pressure injury with Normal Saline (NS), pat dry, and apply [MEDICATION NAME] to the wound bed once every three (3) days. Apply skin prep to the peri-wound area, and cover with a border foam. Further review the TAR revealed the treatment changed, on 08/14/18, to cover the stage three (3) pressure injury to the right heel with a border foam dressing, and change every three (3) days and as needed (prn). Review of the (MONTH) (YEAR) Physician order [REDACTED]. Further review of the physician's orders [REDACTED]. On 8/15/18 at 11:15 AM, an interview, with the Director of Nurses (DON), revealed Resident #22 was admitted , and roughly about three (3) days later had a Deep Tissue Injury (DTI) that later opened. The DON stated everybody (referri… | 2020-09-01 |
| 641 | 641 | BEDFORD CARE CENTER OF HATTIESBURG | 255158 | 10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2018-08-16 | 880 | D | 0 | 1 | 95J011 | Based on observation, staff interview, record review and facility policy review, the facility failed to dispense ice in a sanitary manner on the South Wing to prevent the possible spread of infection for one (1) of three (3) wings observed. Findings include: Review of the facility's policy titled, Ice Machines and Ice Storage Chests, revealed ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice. Ice storage chests/containers, and ice can all become contaminated by unsanitary manipulation by employees, residents and visitors. To help prevent contamination of ice storage chests/containers or ice, staff shall follow these precautions: Keep the ice scoop/bin in a covered container when not in use. On 8/13/18 at 5:25 PM, an observation revealed Certified Nursing Assistant (CNA) #2 filled a resident's pitcher with ice from the ice chest. CNA #2 placed the ice scoop inside the ice chest and closed the top. CNA #3 came up seconds later, opened the ice chest, removed the scoop, filled a pitcher, and placed the scoop in the holder located on the side of the ice chest. An interview, on 8/13/18 at 5:30 PM, revealed CNA #2 stated she was an agency CN[NAME] CNA #2 stated, I left it (referring to scoop) in there, because she (CNA #3) was coming behind me. CNA #2 initially revealed there was not a problem with leaving the ice scoop inside the ice chest, but then stated, it could cause cross contamination. A review of the CNA Skills Checklist for CNA #2 provided to the facility from (Name of Agency), dated 11/10/17, revealed there was no training provided to CNA #2 for Infection Control. There was no documentation provided to indicate CNA #2 had received any training on Infection Control from the facility. An interview, on 8/13/18 at 5:35 PM, with CNA #3, revealed she was an agency CN[NAME] CNA #3 confirmed CNA #2 left the ice scoop inside the ice chest. CNA #3 stated the ice scoop was in the ice. CNA #3 further stated, I took it out and put it in the holder.… | 2020-09-01 |
| 642 | 642 | BEDFORD CARE CENTER OF HATTIESBURG | 255158 | 10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2019-09-26 | 577 | E | 0 | 1 | XFOF11 | Based on resident interviews, observations, and facility statement, the facility failed to ensure residents were aware of the location and availability of the most recent survey results, for four (4) of five (5) residents who attended the group meeting. Findings include: Review of the facility statement, signed by the Administrator, dated 9/26/19, revealed: One (1) of the Resident's rights is to have survey results, with plans of correction, for the past three (3) years, posted in a place accessible to residents. Per the Resident Rights, these results are in the facility at each nurse's station. During the group meeting on 9/24/2019 at 1:30 PM, four (4) of five (5) residents did not know where the survey results were located in the facility. During an interview, on 09/25/19 at 2:45 PM, Social Worker #1 did not know where last year's survey results were posted. Social Worker #1 stated she did not know how the residents were being educated as to where the survey results were posted. During an interview on 09/25/19 at 2:50 PM, Activity Director #1 stated that Social Services conducts Resident Council meetings. Activity Director #1 stated she had not educated the residents on where last year's survey results were posted. Observation on 09/25/19 at 9:30 AM, revealed survey results were posted on the table in the front lobby. There was a sign on the wall in the South Nursing Station, that survey results are posted in the front lobby. A sign was not posted on the North Hall or on the Rehabilitation unit, indicating where survey results were posted. | 2020-09-01 |
| 643 | 643 | BEDFORD CARE CENTER OF HATTIESBURG | 255158 | 10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2019-09-26 | 880 | D | 0 | 1 | XFOF11 | Based on observation, record review, facility policy review, and staff interview, the facility failed to prevent the possible spread of infection, during medication preparation for two (2) of five (5) nurses observed administering medications. Findings include: Review of the facility's Administering Medications, policy, dated 12/2017, revealed staff should follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) when these apply to the administration of medications. Review of the facility's Infection Control Guidelines for All Nursing Procedures, dated (MONTH) (YEAR), revealed the purpose of this document is to provide guidelines for general infection control while caring for residents. The document indicated standard and transmission-based precautions are used to prevent the spread of infection. The document noted that employees must wash their hands. The document noted in most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. The document noted the alcohol based hand rub is to be used before preparing or handling medications. During an observation on 9/24/2019 at 9:15 AM, Licensed Practical Nurse (LPN) #1 prepared to administer oral medications to a resident. LPN #1 placed her ungloved right (R) index finger into a bottle of Aspirin to retrieve a tablet. LPN #1 placed the tablet with her bare hand from the bottle into the medication cup. LPN #1 placed seven (7) additional pills into the same medication cup. LPN #1 administered all of the medications from the medication cup to a resident. During an interview on 9/24/2019 at 9:29 AM, LPN #1 confirmed that she had retrieved the Aspirin tablet with her bare hand and put it in the medication cup for a resident. LPN #1 stated, That was stupid, I knew I shouldn't have done that. LPN #1 stated that you should never touch a medication with your bare hands to give to a resident. LPN #1 stated that touching medications with your bare hands could cause the sprea… | 2020-09-01 |
| 644 | 644 | BEDFORD CARE CENTER OF HATTIESBURG | 255158 | 10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2018-12-04 | 609 | J | 1 | 0 | QD9Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > CI MS# Based on interview, record review, policy review, and facility investigation review, the facility failed to report the elopement and lack of supervision of Resident #4 to the State Agency (SA), when made aware, to ensure corrective actions were completed. This affected one (1) of three (3) residents reviewed for elopement risk. Resident #4, a demented resident with a past history of exit-seeking behaviors, assessed and care planned for an elopement risk, attempted to rise from the wheelchair and grab the front door exit approximately seven (7) times and actually eloped from the facility's front door, with assistance of a visitor, on 9/30/18. The Receptionist, responsible to monitor the door, to ensure residents did not exit the facility without supervision, was observed on video looking at her cell phone and was unaware of the resident's attempts and actual exit through the front door. The sidewalk in front of the building where Resident #4 was found by a visitor, was approximately 11 steps from the street and had a curb that was approximately three (3) inches high. Resident #4 had propelled down the sidewalk, in front of the North Hall door facing the front of the building, and was approximately 34 steps from the front door. The resident was outside the facility from three (3) to five (5) minutes without supervision. The facility's failure to report the elopement/lack of supervision to the State Agencies as required, to ensure corrective actions were taken, placed Resident #4 and other residents at risk for elopement, in a situation that was likely to cause serious harm, injury, impairment, or death. This situation was determined to be and Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 9/30/18, when Resident #4, a demented resident, assessed and care planned as an elopement risk, exited the building from the front door while the Receptionist, responsible to monitor the front door, sat at the front desk, … | 2020-09-01 |
| 645 | 645 | BEDFORD CARE CENTER OF HATTIESBURG | 255158 | 10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2018-12-04 | 656 | J | 1 | 0 | QD9Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > CI MS# Based on observation, interview, record review and policy review, the facility failed to implement the plan of care to ensure residents didn't exit the facility unsupervised and secure exits for one (1) of three (3) residents at risk for elopement, of seven (7) care plans reviewed; Resident #4. The facility also failed to develop a care plan for the actual elopement of Resident #4 on 9/30/18. Resident #4 a demented resident, care planned for the risk of elopement, with a past history of exit-seeking behaviors, eloped from the facility's front door on 9/30/18, assisted by a visitor, after attempting to exit by herself, and was found approximately 34 walked steps from the facility by another visitor. Resident #4 was assessed by the Registered Nurse with no injury. A staff person, the Receptionist responsible to monitor the door to ensure residents did not exit the facility without supervision, was observed on video looking at her cell phone and did not see the resident attempt and/or exit the building. The sidewalk in front of the building where Resident #4 was found, was approximately 11 steps to the street and had a curb that was approximately three (3) inches high. Resident #4 had propelled her wheelchair down the sidewalk, in front of the North Hall door facing the front of the building, when she was found by the daughter of another resident. Resident #4 had a history of [REDACTED]. The facility's failure to implement the care plan to have secured exit doors and supervision for residents with a known history of exit seeking behavior, placed this and other residents at risk for elopement in a situation that was likely to cause serious harm, injury, impairment, or death. This situation was determined to be and Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 9/30/18, when Resident #4 exited the building from the front door, assisted by a visitor, while the Receptionist sat at the front desk (a few feet away… | 2020-09-01 |
| 646 | 646 | BEDFORD CARE CENTER OF HATTIESBURG | 255158 | 10 MEDICAL BOULEVARD | HATTIESBURG | MS | 39401 | 2018-12-04 | 689 | J | 1 | 0 | QD9Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record review, interviews, facility investigation review, and policy review, the facility failed to provide adequate assessment and supervision for a confused, demented resident, with a past history of exit-seeking behaviors. Resident #4 eloped from the facility's front door on 9/30/18, assisted by a visitor, after attempting to exit by herself, and was found approximately 34 walked steps from the facility by another visitor. Resident #4 was returned by Licensed Practical Nurse (LPN) #1 with no injury. The Receptionist, responsible to monitor the door, was observed on video looking at her cell phone and did not see the resident attempt to stand seven (7) times to exit the front door, nor the exit itself, with the assistance of a visitor. There were no signs on the door to alert visitors of wandering residents. The sidewalk in front of the building where Resident #4 was found, was approximately 11 steps to the street and had a curb that was approximately three (3) inches high. Resident #4 had propelled the wheelchair down the sidewalk, in front of the North Hall door facing the front of the building, when she was found by the daughter of another resident. Resident #4 had a history of [REDACTED]. Per video review, Resident #4 was outside without supervision approximately less than five (5) minutes before a visitor saw her, left her unattended on the sidewalk, and got assistance. The facility's failure to implement systems for visitors to be aware of wandering residents and to supervise residents with a known history of exit seeking behavior, placed this and other residents at risk for elopement, in a situation that was likely to cause serious harm, injury, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 9/30/18, when Resident #4 exited the building, while the Receptionist, who's duty included monitoring the door, sat at the front de… | 2020-09-01 |
| 1392 | 1392 | BRANDON COURT | 255266 | 100 BURNHAM ROAD | BRANDON | MS | 39042 | 2019-01-04 | 561 | E | 0 | 1 | 5ICQ11 | Based on observation, interview, record review, and facility's Resident Care Manual review (used as policy/procedure), the facility failed to ensure resident food preferences were honored for six (6) of nine (9) residents interviewed regarding food choices. Resident #60 and five (5) of eight (8) group participants, which included an unnamed Resident and Residents #5,#8, #37, and #76. Findings Include: A review of the facility's Resident Care Manual, with a revision date of 11/17, revealed the facility would protect and promote the rights of the resident, all residents should have autonomy of choice, resident's individual preferences regarding such things as menus would be elicited and respected by the facility, and efforts would be made to accommodate those wishes. An observation and interview with Resident #60 on 01/02/19 at 12:15 PM, revealed she had an issue with the facility regarding meals. The resident reported she was repeatedly served food items she didn't like after telling staff that she didn't like them repeatedly. The resident's husband was in the room and stated this was true and he had spoken to dietary staff at least seven (7) times regarding the resident being served her dislikes. He stated grits and oatmeal were the biggest problem. The resident stated the staff brought grits or oatmeal almost every day even though she requested to have no grits or oatmeal served to her. The resident stated there were other food items she disliked that the facility would serve to her. The resident stated that many days she was not served what was on the menu. During the interview the resident was served a lunch tray by staff and received red beans and rice, turnip greens, cornbread, and a piece of cake. The tray ticket listed Baked Chicken, Rutabagas, Black eyed Peas, Cornbread, and cake. A review of the tray ticket revealed it did not have resident likes/dislikes listed on it. Resident #60 stated she didn't want red beans and rice, requested peanut butter and jelly sandwiches from staff and received them. In a R… | 2020-09-01 |
| 1393 | 1393 | BRANDON COURT | 255266 | 100 BURNHAM ROAD | BRANDON | MS | 39042 | 2019-01-04 | 565 | D | 0 | 1 | 5ICQ11 | Based on Resident Council interview, staff interview, record review, and facility policy review, the facility failed to promptly act on a recommendation of the Resident Council for two (2) of 12 months of Resident Council Minutes reviewed; November/December (YEAR). Findings Include: A review of the facility's policy titled Resident Council, with a revision date of 11/17, revealed the facility was to consider the views of the group and act promptly upon recommendations regarding issues of resident life in the facility. A review of Monthly Resident Council Minutes revealed there was a group recommendation to have cheese toast as an option for breakfast in the month of (MONTH) and (MONTH) (YEAR). The (MONTH) minutes were recorded by designated Activity Staff (AS) #1. The (MONTH) minutes were recorded by designated AS #2. Although the recommendation was made in November, the (MONTH) minutes did not indicate any old business and neither monthly minutes indicated any action taken on the recommendation to have cheese toast as an option for breakfast. In a Resident Council meeting on 01/03/19 at 1:46 PM, the residents in the meeting stated they had requested that they wanted cheese toast as a choice for breakfast, but the facility had not provided the cheese toast, and no one had told them anything or heard back from the request. The residents stated AS #1 and AS #2 were to tell Dietary about the request. An interview on 01/03/19 at 5:00 PM, with AS #1, revealed her acknowledgement of the residents' request for cheese toast to be added as an option for breakfast in the Resident Council meeting in November. AS #1 stated as far as she knew the request has not been acted upon, because some of the residents told her they still hadn't been offered cheese toast. AS #1 stated when residents made a request or brought up problems in group, she typed the issue and gave a typed copy to the departmental staff the issue pertained to. AS #1 stated she typed the request for cheese toast as an option for breakfast and gave it to the Die… | 2020-09-01 |
| 1394 | 1394 | BRANDON COURT | 255266 | 100 BURNHAM ROAD | BRANDON | MS | 39042 | 2019-01-04 | 645 | D | 0 | 1 | 5ICQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy review, the facility failed to ensure a Pre Admission Screening (PAS) was completed to reflect a [DIAGNOSES REDACTED].#6 Findings include: Review of the Facility Policy entitled Pre-Admission Screening PAS/PASRR (MS Only), latest Revision: 10/18, revealed, Anyone applying for admission into a nursing facility must be approved prior to the admission by the Division of Medicaid (DOM) and/or the appropriate Level II authority. The PAS with Level II must be submitted to DOM and approved prior to admission to a nursing facility regardless of payment source When Level I screening on the PAS indicates possible Mental Illness or Intellectual Disability/Developmental Disability and related conditions (RC) the DOM will notify Ascend to review the case. Ascend will determine and notify provider if: 1. Level II evaluation not required. 2. Eligibility for an abbreviated Level II evaluation. 3. Requires onsite Level II evaluation. The Level II evaluation must occur prior to admission and whenever the resident has a significant change in status.PAS The nurse case manager or other facility designee will be responsible for completing the PAS. Review of the PAS for Resident #6, dated 10/1/13, revealed that a Level II PASARR (Pre-Admission Screening and Resident Review) was not performed on admission as indicated by the Electronic Attestation section of the PAS, which indicated that, A level II evaluation is not indicated at this time. Review of the History and Physical dated 10/1/13, revealed Resident #6 with the [DIAGNOSES REDACTED]. In a interview with Registered Nurse #1 (RN), on 01/03/19, at 08:23 AM, she stated, She should have had a Level II because she came in with a psych diagnosis. RN #1 confirmed that Resident #6 did not have a Level II completed on admission to the facility and that it is important for a PAS to be completed accurately to see if they are appropriate for long term placement.… | 2020-09-01 |
| 1395 | 1395 | BRANDON COURT | 255266 | 100 BURNHAM ROAD | BRANDON | MS | 39042 | 2017-08-17 | 155 | J | 1 | 0 | 14X611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Complaint investigation # Based on staff interview, record review, and policy/procedure review, the facility failed to ensure Resident #1's rights and wishes were honored related to Advance Directives for one (1) of seven (7) Sampled and two (2) Unsampled residents. Immediate Jeopardy (IJ) was determined to exist when Cardio-Pulmonary Resuscitation (CPR) was not initiated for Resident #1, with an Advance Directive for a full code status. Certified Occupational Therapy Assistant (COTA) #1 found the resident unresponsive on [DATE], at approximately 7:39 AM, and informed Licensed Practical Nurse (LPN) #1. LPN #1 and LPN #2 went to Resident #1's room and COTA #1 returned to Resident #1's room with the medical record. LPN #1 and LPN #2 met her in the hall outside of the resident's room. After reviewing the code status of Resident #1 in the medical record, LPN #1 and LPN #2 walked back to the nurse's station without initiating CPR on Resident #1, per Advanced Directive. LPN #2 called the Resident's Medical Doctor (MD), Coroner, and Resident #1's Responsible Party (RP). Emergency Personnel were not notified. The coroner arrived to the facility at approximately 8:05 AM on [DATE]. The facility's failure to ensure residents received CPR, per their Advance Directive for full code status, led to the death of Resident #1 and placed other residents in a situation that was likely to cause serious harm, injury, impairment, or death. Based on the facility's implementation of corrective actions, as of [DATE]-[DATE], initiated prior to the SA entrance on [DATE], the SA determined the IJ to be Past Non-Compliance (PNC) and removed as of [DATE]. Findings include: The facility's Resident Rights policy, with a revision date of ,[DATE], revealed All residents in a long term care facility have rights guaranteed to them under Federal and State law. 18. To request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental resear… | 2020-09-01 |
| 1396 | 1396 | BRANDON COURT | 255266 | 100 BURNHAM ROAD | BRANDON | MS | 39042 | 2017-08-17 | 224 | J | 1 | 0 | 14X611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > MS Complaint Investigation # Based on policy/procedure review, record review and staff interview; the facility failed to ensure the residents were free of neglect for one (1) of seven (7) sampled and two (2) Unsampled residents, Resident #1, as evidenced by Resident #1 had an advance directive and physician order [REDACTED].#1 expired. Immediate Jeopardy (IJ) and substandard Quality of Care (SQC) was determined to exist when Cardio-Pulmonary Resuscitation (CPR) was not initiated for Resident #1 with an Advance Directive for a full code status. Certified Occupational Therapy Assistant (COTA) #1 found the resident unresponsive on [DATE] at approximately 7:39 AM, and informed LPN #1. LPN #1 and LPN #2 went to Resident #1's room while COTA #1 went to retrieve the medical record of Resident #1. As COTA #1 returned to Resident #1's room, LPN #1 and LPN #2 met her in the hall outside of the resident's room. After reviewing the code status of Resident #1 in the medical record, LPN #1 and LPN #2 walked back to the nurses station without initiating CPR. Emergency Personnel were not notified. The coroner arrived to the facility at approximately 8:05 AM, on [DATE]. The facility's failure to ensure residents received CPR, per their Advance Directive for full code status, lead to the death of Resident #1 and placed other residents in a situation that was likely to cause serious harm, injury, impairment, or death. Based on the facility's implementation of corrective actions as of [DATE]-[DATE], initiated prior to the SA facility entrance on [DATE], the SA determined the Immediate Jeopardy to be Past Non-Compliance and removed as of [DATE]. Findings include: Review of the facility's policy/procedure for Abuse/neglect Elder Justice Act with a revision date ,[DATE], revealed the definition of neglect being the failure of a caregiver or fiduciary to provide the goods or services that are necessary to maintain the health or safety of an elder. Record review of… | 2020-09-01 |
| 1397 | 1397 | BRANDON COURT | 255266 | 100 BURNHAM ROAD | BRANDON | MS | 39042 | 2017-08-17 | 282 | J | 1 | 0 | 14X611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > MS Complaint Investigation # Based on policy/procedure review, record review and staff interview; the facility failed to ensure an Advance Directive care plan was followed for a full code for Resident #1 when facility staff failed to provide Cardiopulmonary Resuscitation (CPR) for one (1) of seven (7) sampled and two (2) Unsampled residents as evidenced by Resident #1 was found unresponsive with no pulse on [DATE], and Licensed Practical Nurse (LPN) #1 and LPN #2 failed to perform CPR as per her Advance Directive Care Plan. Immediate Jeopardy (IJ) was determined to exist when CPR was not initiated for Resident #1 with an Advance Directive for a full code status. Certified Occupational Therapy Assistant (COTA) #1 found the resident unresponsive on [DATE], at approximately 7:39 AM, and informed Licensed Practical Nurse #1. LPN #1 and LPN #2 went to Resident #1's room as COTA #1 went to retrieve the medical record of Resident #1. As COTA #1 was returning to Resident #1's room, LPN #1 and LPN #2 met her in the hallway out side of the resident's room. After reviewing the code status of Resident #1 in the medical record, LPN #1 and LPN #2 walked back to the nurse's station without initiating CPR. LPN #2 called the Resident's Medical Doctor (MD), Coroner, and Resident #1's Responsible Party (RP). Emergency Personnel were not notified. The coroner arrived to the facility at approximately 8:05 AM on [DATE]. The facility's failure to ensure residents received CPR per their Advance Directive for full code status care plan led to the death of Resident #1 and placed other residents in a situation that was likely to cause serious harm, injury, impairment, or death. Based on the facility's implementation of corrective actions as of [DATE]-[DATE], initiated prior to the SA facility entrance on [DATE], the SA determined the IJ to be Past Non-Compliance and removed as of [DATE]. Findings Included: Review of the facility's policy for Care Plan Process with a … | 2020-09-01 |
| 1398 | 1398 | BRANDON COURT | 255266 | 100 BURNHAM ROAD | BRANDON | MS | 39042 | 2017-08-17 | 309 | J | 1 | 0 | 14X611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Complaint investigation MS # Based on policy/procedure review, record review and staff interview; the facility failed to ensure that staff provided necessary services to attain or maintain resident highest level of well being for one (1) of seven (7) sampled and two (2) Unsampled residents, Resident #1, as evidenced by Resident #1 was found unresponsive and without a pulse and Licensed Practical Nurse (LPN) #1 and LPN #2 failed to perform Cardiopulmonary Resuscitation (CPR) on Resident #1 as ordered, requested and care planned. Resident #1 was a full code, with a full code physician's orders [REDACTED]. There was no initiation of CPR on [DATE] at approximately 7:39 AM, when the facility staff found Resident #1 unresponsive and without a pulse and Resident #1 expired at the facility. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was determined to exist when CPR was not initiated for Resident #1 with an Advance Directive for a full code status. Certified Occupational Therapy Assistant (COTA) #1 found the resident unresponsive on [DATE], at approximately 7:39 AM, and informed nursing staff. LPN #1 and LPN #2 went to Resident #1's room as COTA #1 went to retrieve the medical record of Resident #1. After reviewing the code status of Resident #1 in the medical record, LPN #1 and LPN #2 walked back to the nurse's station without initiating CPR. LPN #2 called the Resident's Medical Doctor (MD), Coroner, and Resident #1's Responsible Party (RP). Emergency Personnel were not notified. The Coroner arrived and pronounced the resident at approximately 8:05 AM on [DATE]. The facility's failure to ensure residents received CPR per their Advance Directive for full code status led to the death of Resident #1 and placed other residents in a situation that was likely to cause serious harm, injury, impairment, or death. Based on the facility's implementation of corrective actions as of [DATE]-[DATE], initiated prior to the State Agency (SA) fac… | 2020-09-01 |
| 1399 | 1399 | BRANDON COURT | 255266 | 100 BURNHAM ROAD | BRANDON | MS | 39042 | 2017-09-08 | 282 | D | 0 | 1 | 2EBR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy review, the staff failed to follow the comprehensive care plan as evidenced by A). Wiping the resident from back to front during incontinent care, Resident #6; B). Not providing feeding assistance to resident during mealtime, Resident #8; and C). Crushing extended release cardiac medications and administering them to Unsampled Resident A; for three (3) of 15 resident care plans reviewed. Findings Include: Review of the Facility's policy entitled, Care Plan Process, with a revision date of 08/17, revealed the facility's staff shall follow the resident's care plan. The care plan is driven to identify the resident's issues, strengths, needs and unique characteristics. This approach can provide optimal approaches to quality of care, quality of life needs of the individual residents. Resident #6 Review of Resident #6's incontinent care plan, with an onset date of 02/02/15, and a goal date of 10/25/17, revealed an intervention to provide incontinent care after each incontinent episode. Observation of Resident #6's incontinent care, on 09/06/17 at 2:45 PM, performed by Certified Nurse Aide (CNA) #1, revealed her wiping the resident's buttocks and anal area downward from back towards the resident's groin. Staff interview, on 09/08/17 at 3:10 PM, with Registered Nurse (RN) MDS Assessment Nurse #1, revealed performing incontinent care includes, wiping the residents from front to back during care. She said the staff failed to follow the incontinence care plan as evidence by the staff wiping the resident's buttocks and anal area towards the genital area during incontinence care. Review of the facility's face sheet revealed the facility admitted the resident on 02/02/15. Resident 6's [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/14/17, revealed Resident #6 had a Brief Interview Mental Status (BIMS) score of 6, indicating the resident ha… | 2020-09-01 |
| 1400 | 1400 | BRANDON COURT | 255266 | 100 BURNHAM ROAD | BRANDON | MS | 39042 | 2017-09-08 | 312 | D | 0 | 1 | 2EBR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the staff failed to accommodate a resident who required assistance to eat, for one (1) of 11 residents observed during meals, Resident #8. Findings Include: Review of Resident #8's physician's orders [REDACTED].#8 was to have a mechanical soft, low concentrated sweet diet, with gravy on meats, and thin liquids (no straws), small bites, alternating solids and liquids, and eat at the Feeders Table. Observation on 09/07/17 at 8:30 AM, revealed Resident #8, sitting on the side of her bed, in her room with her breakfast tray on her over- bed table. She was alert, with mumbling speech, reaching for her food, with a left wrist brace intact. There was a carton of milk spilled on her tray. Staff interview, and observation of Resident #8, with Licensed Practical Nurse (LPN) #1/Charge Nurse, on 09/07/17 at 8:34 AM, revealed the resident continuing to sit on the side of her bed, reaching for her food. LPN #1 asked the resident if she needed assistance to eat. The resident nodded her head. LPN #1 replied that the resident is usually fed by her sitter, or fed at the Feeder Table in the dining room. Interview with CNA #6, on 09/07/17 at 9:07 AM, revealed she was assigned to Resident #8. She stated she did not normally work this unit and did not know this resident. She replied that she did not know the resident was to eat in the dining room and be fed by the staff. CNA #6 said she was not informed by CNA #7, during the shift change this morning, of the resident needing assistance to eat and to eat at the Feeder Table. Staff interview with CNA #7, on 09/07/17 at 8:55 AM, revealed Resident #8 is assigned to eat at the Feeder's Table in the dining room and is required to be fed, or the resident's sitter comes and feeds her. She stated the sitter was not with the resident today. She confirmed she did not report to CNA #6 of Resident #8 requiring assistance to eat, and said she had worked the 11: 00 PM to … | 2020-09-01 |
| 1401 | 1401 | BRANDON COURT | 255266 | 100 BURNHAM ROAD | BRANDON | MS | 39042 | 2017-09-08 | 315 | D | 0 | 1 | 2EBR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and facility policy review, the staff failed to wipe the resident from front to back during incontinent care for one (1) of seven (7) care observations, Resident #6. Findings Include: Review of the Facility's policy entitled, Perineal Care, with a revision date of 02/17, revealed clean the anal area from the base of the perineum to the peri-anal area. Review of the Resident #6's incontinent care, on 09/06/17 at 2:45 PM, performed by Certified Nurse Aide (CNA) #1, revealed CNA #1 wiped the resident's buttocks and anal area downward from back towards the resident's groin. Staff interview, on 09/08/17 at 2:55 PM, with CNA #1, confirmed she performed incontinent care on Resident #6, by using back to front strokes on the resident. CNA #1 confirmed a break in infection control, which could cause the resident to get a Urinary Tract Infection. Staff interview, on 09/08/17 at 4:25 PM, with the Director of Nursing (DON), confirmed the CNA failed to provide incontinent care correctly by not using front to back strokes on Resident #6. Review of the facility's face sheet revealed, the facility admitted the resident on 02/02/15. Resident 6's [DIAGNOSES REDACTED]. Review of the Minimum Data Set with an Assessment Reference Date of 06/14/17, revealed Resident #6 had a Brief Interview Mental Status (BIMS) score of 6, indicating the resident had severe cognitive impairment. | 2020-09-01 |
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CREATE TABLE [cms_MS] ( [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 );