rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
1,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2017-05-10,164,D,1,1,ZMNB11,"> Based on observation, review of the facility's educational information on privacy, and staff interview, the facility failed to provide privacy for 1 of 4 sampled residents (Resident #4) observed during personal cares in the resident's bathroom. Failure to provide privacy is an infringement of the resident's rights and may lead to a loss of dignity. Findings include: On the afternoon of 05/10/17, an administrative nurse (#1) stated the facility did not have a privacy policy and provided information from the Clinical Services Portal. This information titled, Privacy and Confidentiality dated 12/2012, stated, . The resident has the right to personal privacy . 1. Personal privacy includes . personal care . Observation on 05/09/17 at 10:20 a.m., showed two certified nursing assistants (CNAs) (#2 and #3) toileting Resident #4 in the resident's bathroom. The CNA's failed to close the bathroom door or pull the privacy curtain allowing Resident #4's roommate to observe the cares provided. During an interview on 05/10/17 at 10:10 a.m., an administrative nurse (#1) stated she would expect staff to pull the roommate's privacy curtain when performing personal cares for Resident #4 in her bathroom.",2020-09-01
2,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2017-05-10,309,D,1,1,ZMNB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, review of professional literature, and staff interview, the facility failed to provide the care and services necessary to attain the highest degree of safety possible for 1 of 1 sampled residents (Resident #7) requiring staff assistance with meals. Failure to provide proper positioning during/following meals, failure to cut the meats into appropriate bite sized pieces, and failure to follow the 3 cough rule as outlined by therapy, placed Resident #7 at a greater risk for aspiration. Findings include: Swigert's The Source for Dysphagia, 3rd ed., Pro-Ed, Inc., Texas, 2007, pages 9, 15, 16, 125, and educational handouts, identified, . Signs and symptoms of dysphagia . coughing/choking . left hemisphere stroke indicative of oral dismotility . [MEDICAL CONDITION] . swallowing problems . often begin with reduced tongue based retraction and repetitive tongue rolling, followed by delayed initiation of the pharyngeal swallow . head and [MEDICAL CONDITION] . [MEDICAL CONDITION] therapy can have a significant impact on pharyngeal swallowing, sometimes years after the [MEDICAL CONDITION] therapy . During the oral intake of . liquids, it is optimal for a patient to be seated at a 90 degree angle . (when) in a chair . Even a slightly reclined position while eating greatly increases the risk of premature loss of food over the back of the tongue . Review of Resident #7's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], identified long and short term memory problems, extensive assistance with meals, and extensive assistance of two for bed mobility and transfers. A Speech Therapy progress note, dated 12/26/15, stated, . She requires 1:1 feeding. Pt (patient) should be upright for all meals at least 90 degrees, straws are ok, 3 cough rule-discontinue texture if more than 3 coughs are noted and notify SLP (speech language pathologist), encourage self-feeding and monitor lungs/temps (temperatures) closely for any signs of aspiration. A current physician order, dated 04/27/17, identified, . 3 cough rule - if pt coughs with anyone item - discontinue (sic) for current meal tray & notify SLP. Patient to remain upright for a min (minimum) of 30 - 40 minutes after intake. HOB (head of bed) up at 90 degrees and alert for all P.O. (oral) intake. Resident #7's current care plan stated, . ADL (activities of daily living) . deficit as evidenced by the need for assistance related to disease process . physical limitations, visual impairment . all meals in dining room with assist of 1 for feeding . Regular diet, thin liquids, . cut up all meat, . Resident #7's current kardex also stated, . Must sit upright 30-45 minutes after meals . Observation showed the following: * On 05/09/17 at 8:10 a.m., Resident #7 sat in her reclining wheel chair in the dining room with the head of chair reclined at an approximately 35 to 45 degree angle. A CNA (#11) fed Resident #7 large pieces of sausage (approximately two inches in diameter), hash browns, toast, cream of wheat, and cranberry juice. * On 05/09/17 from 8:30 a.m. to 10:50 a.m., Resident #7 sat in her reclining wheel chair in a lounge. Her chair remained in the same position (reclined to 35 to 45 degrees). * On 05/09/17 at 10:50 a.m., after providing cares, a CNA (#3) raised the head of Resident #7's bed to an approximate 30 degree angle (which placed her at an approximate 35 degree angle with the pillow behind her head) and offered her a drink of water, which she swallowed. The CNA (#3) then lowered the head of the bed to an approximate 25 degree angle and exited the room. * On 05/09/17 at 12:05 p.m., Resident #7 sat in her reclining wheel chair in the dining room with the head of the chair reclined to an approximate 35 to 40 degree angle. A CNA (#11) fed Resident #7 pieces of roast beef, mashed potatoes and gravy, peas, bread, and apple juice. Resident #7 coughed (loose non-productive) four times during the meal. * On 05/09/17 at 12:20 p.m., Resident #7 fell asleep in her reclining wheel chair in her room. Her chair remained in the same position (reclined to 35 to 45 degrees). * On 05/10/17 at 8:45 a.m., Resident #7 laid in bed. The head of the bed remained reclined at an approximate 30 degree angle. The CNA (#12) left Resident #7 a glass of water on the table, within her reach, prior to exiting the room. Facility staff members failed to ensure Resident #7 sat at a 90 degree angle prior to offering food or fluids, failed to ensure she remained upright for at least 30 to 45 minutes after each meal, failed to cut her meats into appropriate bite sized pieces, and failed to follow the three cough rule as outlined by the SLP. During an interview on 05/10/17 at 11:35 a.m., an administrative staff member (#1) confirmed staff last assessed Resident #7's swallow ability in (YEAR). The medical record showed she was diagnosed with [REDACTED]. Facility staff failed to reassess her swallow following this last bout of aspiration pneumonia to determine if there were any additional changes to her swallowing ability.",2020-09-01
3,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2017-05-10,312,D,1,1,ZMNB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, review of faility policy, staff interview, and resident interview, the facility failed to provide activities of daily living (ADL) assistance for 2 of 9 sampled residents (Resident #3 and #7) observed during personal cares. Failure to provide assistance with oral care (Resident #3) and incontinence care (Resident #7) may result in decreased intakes, urinary tract infections, and a loss of dignity and comfort. Findings include:- Review of Resident #3's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Resident #3's current Minimum Data Set (MDS), dated [DATE], identified intact cognition and supervision and set up help from staff for personal hygiene. The current care plan stated, . Assist resident with applying fixadent sealer to bottom dentures daily . A nurse's note, dated 11/23/16, stated, . Patient returned from dental appt. (appointment) with upper and lower dentures. Pt (patient) was told to come back if she needs ay (sic) adjustment. Pt needs to use Fixodent with the lower denture per (provider name) . Observations on the mornings of 05/09/17 and 05/10/17 showed staff assisted Resident #3 with morning cares, but failed to assist the resident with applying denture adhesive or cue the resident to apply it herself. Observations during these times showed the resident's dentures loose when she spoke. During an interview on 05/10/17 at 10:22 a.m., Resident #3 stated, The bottom ones (dentures) are loose. I knew that was going to happen, the gums have eroded. Review of facility policy titled INCONTINENCE CARE occurred on 05/08/17. This policy, revised (MONTH) 2014, stated, . if feces present, remove with toilet paper or disposable wipe by wiping from front of perineum toward rectum. Cleanse peri-area and buttocks with cleansing agent or disposable wipe wiping from front of perineum toward rectum. Use separate area of cloth or new disposable wipe for each stroke. Gently separate labia and wash area using downward [MEDICAL CONDITION] from pubic area to rectal area. Use alternative sites on washcloth or new disposable wipe with each downward stroke. - Review of Resident #7's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The current quarterly MDS, dated [DATE], identified extensive assistance of one for toileting and personal hygiene and always incontinent of stool. Observation on 05/08/17 at 3:45 p.m., showed two certified nursing assistants (CNAs) (#4 and #5) provided incontinence cares for Resident #7 who had visible stool on her buttocks and perineal area. The CNA (#5) wiped the rectal area from back to front three times with visible stool on the second wipe, two times with the third wipe, and four times with the forth wipe, without folding any of the wipes to ensure a clean area of the wipe was used. The CNAs (#4 and #5) placed Resident #7 onto a bed pan and she had another bowel movement. The CNA (#5) removed the bedpan and cleansed the rectal area from back to front three times with visible stool on the wipe and without folding it. The CNAs (#4 and #5) applied a clean brief and failed to cleanse the front perineal area. During interview on the morning of 05/10/17, an administrative staff member (#1) confirmed staff should complete pericares from front to back.",2020-09-01
4,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2017-05-10,314,D,1,1,ZMNB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and staff interviews, the facility failed to provide appropriate interventions and treatment to promote healing for 1 of 2 sampled residents (Resident #7) with a current pressure ulcer. Failure to provide timely and appropriate interventions and ensure staff consistently implemented those interventions resulted in further deterioration of Resident #7's existing pressure ulcer. Findings include: Review of Resident #7's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], identified severely impaired cognition, at risk for pressure ulcers, and extensive assistance of two or more persons for bed mobility. Resident #7's current care plan stated, . Focus At risk for alteration in skin integrity related to: . impaired mobility. Encourage to reposition as needed; use assistive devices as needed. Observe skin condition . report abnormalities. Focus deep purple tissue injury on left heel . Administer treatment per physician orders [REDACTED]. Resident #7's current certified nursing assistant (CNA) kardex stated, . SKIN CARE encourage and/or assist to reposition frequently. HEEL PROTECTOR-left foot. SUSPEND HEELS . The nurse practitioner progress note, dated 03/24/17, stated . CHIEF COMPLAINT: complaints of pain in left heel . OBSERVATIONS: . approximately 4 cm (centimeter) round purplish area on left heel that is not blanchable. Diagnosis: [REDACTED]. boots (heel protector) on, when she is in bed she will have her heels floated so nothing is touching them. We'll continue to follow closely. If wound worsens will send her to wound clinic. The progress notes identified the following: * 03/22/17, Deep purple area 4 x (by) 3 cm. Surrounding purple area is red, . * 03/24/17, Wound rounds: Deep purple and not blanchable measuring 4 x 3 cm. The progress's notes showed the nursing staff failed to notify the physician when the wound size increased. * 04/07/17, . Left heel has deep purple tissue injury to left heel measuring 6 x 4 cm. Skin around is blanchable. * 04/14/17, . Patient has deep purple tissue injury to left heel measuring 6 x 3 cm. Surrounding skin is light purple in color and blanchable. * 05/05/17, . Deep purple discoloration still to left heel measuring 6 x 2.5 cm. Observations showed the following: * 05/08/17 at 12:45 p.m., Resident #7 sat in her reclining wheel chair in the dining room with gripper slippers on both feet. The left heel rested directly against the foot board. The staff failed to place the heel protector boot on the left foot. * 05/08/17 at 4:40 p.m., Resident #7 sat in her reclining wheel chair and the CNA (#4) placed the heel protector boot on the right foot. The left heel rested directly against the foot board. The CNA placed the heel protector boot on the wrong foot. * 05/09/17 at 7:45 a.m., 8:30 a.m., 9:45 a.m. and 10:50 a.m., Resident #7 sat in her reclining wheel chair in her room with the heel protector boot located on a chair in her room. The left heel rested directly against the foot board. The staff failed to place the heel protector boot on the left foot. During an interview on 05/10/17 at 11:35 a.m. and 3:30 p.m., an administrative staff member (#1) confirmed Resident #7's deep tissue injury is from failure to off load the heel. The nurse manager should complete a weekly assessment on Resident #7's heel.",2020-09-01
5,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2017-05-10,322,D,1,1,ZMNB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide the appropriate treatment and services for 1 of 1 supplemental resident (Resident #18) observed receiving medications through a gastrostomy tube. Failure to administer the appropriate amount of fluid with administration of medications into a gastric tube and clean the syringe after administration may result in harm to the resident. Findings include: Review of the facility policy titled Enteral Tubes: Medication Administration occurred on 05/10/17. The policy, dated (MONTH) 2012, stated, . Procedure . dissolve medication in medicine cup using 10 to 30 ml (milliliters) of water . (before medication) Flush tube with a minimum of 30 ml of water . flush between each medication with a minimum of 5-10 ml of water . flush tube at end of medication administration with a minimum of 30 ml water . rinse reusable syringe, allow to air dry . - Review of Resident #18's medical record occurred on 05/09/17. The current physician order stated, Flush (gastric) tube with at least 30 ml of water before and after an external feeding and/or medication administration Observation on 05/09/17 at 3:42 p.m. showed a licensed nurse (#6) entered Resident #18's room to administer the contents of the [MEDICATION NAME] (nerve pain) medication capsule. The nurse (#6) checked placement of the tube, checked the stomach residual with a syringe, and flushed the syringe with 5 ml of water. The nurse (#6) administered the [MEDICATION NAME] powder with 5 ml of water into the gastric tube, flushed with 20 ml of water, clamped the gastric tube, and placed the used syringe in a bag to air dry. The licensed nurse (#6) confirmed she flushed the gastric tube with 5 ml of water, then gave the medication with 5 ml of water, and did a final flush with 20 ml of water. The nurse (#6) failed to flush the tube with 30 ml of water before and after medication administration, dissolve the medication in 10 to 30 ml of water, and rinse the reusable syringe. Observation on 05/09/17 at 5:05 p.m. showed a licensed nurse (#6) entered Resident #18's room to administer a crushed pyridostigmine (muscle strength) medication. The nurse checked placement, checked the stomach residual, and gave the medication with water flushes. When completed the nurse failed to rinse the reusable syringe. During an interview on 05/10/17 at 2:15 p.m., a nurse manager (#1) confirmed nursing staff are to follow doctors orders and facility policy on water flushes and cleaning of syringes with each use.",2020-09-01
6,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2017-05-10,328,D,1,1,ZMNB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, review of professional reference, review of facility policy, and staff interview, the facility failed to provide the necessary care and services for 1 of 3 sampled residents (Resident #8) receiving oxygen therapy. Failure to follow the medical providers orders, and provide guidance to the facility staff on oxygen usage does not allow the facility or the health care provider to assess the effectiveness of the resident's oxygen therapy. Findings include: Berman and Snyder, S., Kozier & Erb's Fundamentals of Nursing Concepts, Process, and Practice, 10th ed., Pearson Education, Inc., New Jersey, page 1259 states, . Like any medication, oxygen is not completely harmless to the client. Clients can receive an inadequate amount or an excessive amount of oxygen and both can lead to a decline in the client's condition. Review of the facility policy titled Respiratory: Oxygen Administration occurred on 05/10/17. This policy, dated (MONTH) (YEAR), stated, . Procedure: 1. Verify Physician's order . Review of Resident #8's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Current physician's orders stated, OXYGEN AT 3L (liter) PER NASAL CANNULA AT BEDTIME AND AS NEEDED FOR SOB (short of breath)/WHEEZIN[NAME] Resident #8's care plan identified the following Focus: Resistive/noncompliant with oxygen therapy related to: [MEDICAL CONDITION], belief that treatment is not needed/working . The certified nurse aide (CNA) kardex identified OXYGEN 2L continuous, neb (nebulizer) prn (as needed), patient will remove O2 (oxygen) at times. Observations of Resident #8 showed the following: * 05/08/17 at 4:26 p.m. sitting in her room in her wheelchair wearing a nasal cannula connected to an oxygen tank set at 2 liters per minute (LPM). * 05/09/17 at 8:51 a.m., self propelling her wheelchair in the hallway wearing a nasal cannula connected to an oxygen tank set at 2 LPM. * 05/09/17 at 12:27 p.m. self propelling her wheelchair in the hallway wearing a nasal cannula connected to an oxygen tank set at 2 LPM. * 05/09/17 at 2:00 p.m. in her room lying on the bed wearing a nasal cannula connected to an oxygen tank set at 2 LPM. During an interview on the afternoon of 05/10/17, an administrative nurse (#1) confirmed information on the kardex failed to match the physician's order. The facility failed to ensure the consistency in the delivery of Resident #8's O2 per nasal cannula in regard to the liter flow rate and usage of O2.",2020-09-01
7,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2017-05-10,371,E,1,1,ZMNB11,"> Based on observation, review of the facility's policies, manufacturer recommendations, and staff interview, the facility failed to store and/or prepare food in a safe and sanitary manner in 2 of 3 food service areas (kitchen & North nurses station). Failure to ensure sanitizing solutions are at the correct concentration and failure to store food appropriately in a refrigerator may result in a food borne illness that can affect all residents who eat food prepared and served in these areas. Findings include: Review of the facility policy titled Manual[NAME]Washing occurred on 05/09/17. This policy, revised (MONTH) (YEAR), stated, . Some items which cannot be washed in the dishwasher are washed manually in the three compartment sink. Fill the third sink with hot water. Add Oasis 146 (multi-quaternary sanitizer) to give a concentration of 200-400 ppm (parts per million). Test the concentration with the QT-40 (quaternary) test strip designed for Oasis 146 . Check the concentration of the sanitizing solution periodically and add sanitizer or replace solution if necessary . Review of the manufacturer wall chart titled Oasis 146 Multi-Quat Sanitizer occurred on 05/09/17. The undated wall chart, stated, . Sanitation range . should be between 150-400 ppm . Review of the facility policy titled Pantry/Nutrition Room Cleaning occurred on 05/09/17. This policy, revised 03/01/03, stated, . Housekeeping staff will clean and disinfect the Medication Room on a daily schedule. Clean and defrost refrigerator as needed . - An observation of the kitchen on 05/09/17 at 2:00 p.m. showed a cook (#8) washed soiled dishes in a three compartment sink. The cook (#8) washed pots, ladles, and steam table buckets in the three compartment sink and set them out to dry. Using a QT-40 test strip, the dietary manager (#9) obtained a reading of 150 ppm in the third compartment sink containing Oasis 146 sanitizing solution. Observation also showed a quaternary wash bucket sitting on a counter. The dietary manager (#9) obtained a reading of 0 ppm in the wash bucket, and confirmed staff had used the mixture to clean tables in the dining room. During an interview on 05/09/17 at 2:30 p.m., the dietary manager (#9) confirmed the Oasis 146 sanitizing solution should range from 200-400 ppm in the three compartment sink and the quaternary wash buckets should be at least 150 ppm. - An observation of the North nurses station on 05/09/17 at 2:35 p.m. showed a refrigerator freezer containing three nutrition supplement cartons dated 11/01/16 and an ice cream cup frozen to the freezer. The dietary manager (#9) confirmed staff needed to clean the freezer. During an interview on 05/09/17 at 3:00 p.m., the dietary manager (#9) confirmed staff needed to clean the refrigerator, and reported staff did not have a cleaning schedule for the refrigerator.",2020-09-01
8,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2017-05-10,441,D,1,1,ZMNB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, review of the facility policies, review of professional literature, and staff interview, the facility failed to follow infection control practices for 2 of 9 sampled residents (Resident #4 and #7) observed during personal cares and/or foley catheter cares. Failure to follow infection control practices of hand hygiene following perineal cares (Resident #4 and #7) and foley catheter cares (Resident #7) has the potential to spread infection to other personnel, residents, and visitors. Findings include: Review of the facility policy titled, Hand Hygiene occurred on 05/10/17. This policy, dated 12/2009, stated, . When to wash hands or use an alcohol-based hand rub: * Before applying and after removing gloves . *After contact with body fluids and excretions . Review of facility policy titled, INCONTINENCE CARE occurred on 05/10/17. This policy, revised (MONTH) 2014, stated, . if feces present, remove with toilet paper or disposable wipe . Discard soiled materials and gloves. Perform hand hygiene . Dry peri-area and buttocks . Remove and discard gloves. Perform hand hygiene. Reposition for comfort . provide additional care needs . - During observation on 05/09/17 at 10:20 a.m., two certified nursing assistants (CNAs) (#2 and #3) provided perineal cares for Resident #4 after using the toilet. A CNA (#2) completed the cares, including the cleansing of a smear of bowel movement (BM). Following the incontinence care and assisting Resident #4 into the wheelchair, the CNA (#2) removed her gloves, failed to perform hand hygiene, and donned a new pair of gloves. The CNA then proceeded to complete other tasks of pushing Resident #4 out of the bathroom and applying leg rests to the wheelchair. During an interview on 05/10/17 at 10:10 am, an administrative nurse (#1) stated she would expect staff to perform hand hygiene after removing gloves, and before doing other tasks. Berman and Snyder, Kozier & Erb's Fundamentals of Nursing Concepts, Process, and Practice, Tenth Edition, Pearson Education, Inc., New Jersey, page 1192 and 1198, states, . MAINTAIN THE URINARY CATHETER . Maintain a sterile, closed drainage system. Empty the collection bag regularly with a separate, clean collecting container . prevent contact of the drainage spigot with the nonsterile collecting container. Nursing care of the client with an indwelling catheter and continuous drainage is largely directed toward preventing infection of the urinary tract . preventing contamination of the drainage system . Dugan, Successful Nursing Assistant Care, Second Edition, Hartman Publishing Inc., New Mexico, page 300-301, states, Emptying a catheter drainage bag . Open drain or clamp on the bag. Allow urine to flow out of the bag into the graduate. When urine has drained, closed clamp. Using alcohol wipe, clean the drain clamp. Replace the drain in its holder on the bag. - Review of Resident #7's medical record occurred all days of survey. [DIAGNOSES REDACTED]. The current quarterly Minimum Data Set (MDS), dated [DATE], identified an indwelling catheter (suprapubic), always incontinent of bowel, and extensive assistance of one to two required for all cares. During an observation on 05/09/17 at 1:45 p.m., two CNAs (#2 and #10) assisted Resident #7 with perineal cares. The CNA (#2) applied gloves and cleansed the front perineal area which showed visible stool on the wipe. The CNA (#2) picked up a piece of stool off the blanket on the bed with a wipe, placed it in the garbage can, and without removing her soiled gloves adjusted the clean brief, pulled up the resident's pants, adjusted her shirt, and repositioned the resident. The CNA (#2) removed her gloves and adjusted the level of the bed using the controls then washed her hands and left the room. The CNA (#2) failed to remove her gloves and perform hand hygiene after providing perineal cares and prior to completing other cares. During an observation on 05/09/17 at 2:00 p.m., a CNA (#10) entered Resident #7's room to empty the catheter drainage bag. She applied gloves, went into the bathroom, took two clean collection containers and placed approximately 75 milliliters (ml) of water from the bathroom faucet into one of the containers. The CNA placed the container with the water on the bedside table. She placed a paper towel on the floor and the empty container on the paper towel, opened the end of the drainage tube from the indwelling catheter collection bag, and drained the urine in to the container. The CNA (#10) took the end of the collection bag tube, turned it upwards, and poured water from the other container into the catheter bag, shook the bag and stated I'm rinsing out the catheter bag. The CNA (#10) drained the water back into the container, wiped off the port with an alcohol swab, and disposed of the contents in the toilet. The CNA removed her gloves and sanitized her hands. During an interview on 05/10/17 at 11:35 a.m., an administrative staff member (#1) confirmed the CNA (#10) did not follow facility practice when emptying the catheter drainage bag.",2020-09-01
9,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2019-05-16,574,C,1,1,FA2L11,"> Based on interview with the resident council, observation, review of the admission packet, and staff interview, the facility failed to provide residents, in writing, with a complete and/or accurate list of names, addresses (mailing and email), and/or telephone numbers of all the pertinent State regulatory, advocacy, and informational agencies. Failure to provide this written information to residents has the potential to limit residents' and their families' access to these agencies and has the potential to impact all residents. Findings include: During the resident council interview conducted on 05/14/19 at 2:38 p.m., the residents stated they were not clear about how to contact the pertinent State regulatory, advocacy, and/or informational agencies. Observation on (MONTH) 14-16, 2019, showed a wall mounted enclosed glass case and a binder located near the entrance hallway, that contained written information for the residents and public to view. The wall mounted enclosed glass case contained a list with names and telephone numbers, the binder contained a list with some names, mailing addresses, and telephone numbers, such as the State Ombudsman program, the State Survey Agency, etc. However, the lists contained some inaccurate information (i.e. names, addresses, etc.) and failed to include all the pertinent required agencies. In addition, the lists lacked a statement informing residents that they may file a complaint with the State Survey Agency concerning any suspected violation of nursing facility regulations, non-compliance with the advance directives requirements, and requests for information regarding returning to the community. On the morning of 05/16/19, review of the facility's admission packet of written information/material provided to the residents contained the same inaccurate information as in the above-stated binder. During an interview on the afternoon of 05/16/19, two administrative staff members (#1 and #4) verified the facility failed to provide residents, in writing, with a complete and/or accurate list of names, addresses, e-mails, and/or telephone numbers of all the pertinent State regulatory, advocacy, and informational agencies.",2020-09-01
10,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2019-05-16,580,D,1,1,FA2L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of facility policy, family interview, and staff interview, the facility failed to notify residents' representatives or physicians promptly of a change in condition for 2 of 20 sampled residents (Resident #31 and #49). Failure to update resident representatives promptly on injuries of unknown origin and new treatment orders (Resident #31 and #49) and failure to update the physician promptly on a deterioration in skin condition (Resident #31) may delay treatment and is a violation of residents' rights. Findings include: Review of the facility policy titled Change in a Resident's Condition or Status occurred on 05/16/19. This undated policy stated, . Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): . discovery of injuries of an unknown source . need to alter the resident's medical treatment significantly . Unless otherwise noted by the resident, a nurse will notify the resident's representative when: . The resident is involved in any accident or incident that results in an injury including injuries of an unknown source . there is a significant change in the resident's physical, mental, or psychosocial status . - Review of Resident #31 medical record occurred on all days of survey. Progress notes stated the following: * 04/18/19 at 11:00 p.m. to 11:26 p.m.: . resident left dorsal foot area has open area, due to [MEDICAL CONDITION], skin cleaned and dressing applied . measurement on left dorsal foot 2 x 1.5 cm (centimeter) . resident left foot has pitted [MEDICAL CONDITION] +2, wear ACE wrap in AM and off at HS (hour of sleep) . has some redness around the wound . will continue to monitor. * 04/24/19 at 5:43 p.m.: . called physician to notify of ulceration and request new treatment. Cleanse ulceration to L (left) dorsal foot with NS (normal saline) once daily. Apply [MEDICATION NAME] to slough and cover with a dry gauze dressing daily. * 04/26/19 at 11:21 a.m.: Residents sister (name of person) called and notified of resident skin alteration. The medical record lacked evidence of wound monitoring from 04/19/19 to 04/24/19. During an interview the morning of 05/16/19, an administrative nurse (#7) confirmed the physician and resident representative were not notified promptly of a change in Resident #31's medical condition. - During an interview on the afternoon of 05/13/19, a family member stated the facility does not update her of changes to Resident #49's plan of care/health status. The family member stated, She could have skin issues, I'd never know. They don't tell me anything. The family member also stated Resident #49 started speech therapy and staff failed to update her. Review of Resident #49's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. *02/10/19 at 10:46 p.m.: . 4th nail on right toe has come of (sic). No pain and no bleeding noted. Note left for NP (nurse practitioner) to visit. To covered (sic) with bandage . *02/11/19 at 11:19 a.m.: . New orders per (NP) to apply [MEDICATION NAME] ointment to left fourth toe and cover with bandaid - change BID (twice per day) and PRN (as needed). Notify provider/NP if no improvements/worsens on 2/15/19. *02/11/19 at 4:53 p.m. (NP note): . pt (patient) seen today for left toe nail that was removed likely due to trauma. Pt reports discomfort at nail injury site. Toe nails are over grown and nursing will trim. *03/27/19 at 1:21 p.m.: . New orders per (NP) for SLP (speech-language pathology) evaluate and treat for dysphagia and difficulties with self feeding. Resident #49's medical record lacked evidence of representative notification of the above injury and new order for speech therapy.",2020-09-01
11,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2019-05-16,607,D,0,1,FA2L12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility policy, and staff interview, the facility failed to implement abuse investigation policies regarding injuries of unknown origin for 1 of 13 sampled residents (Resident #9) reviewed during the on-site revisit. Failure to assess, monitor, and investigate injuries of unknown origin placed Resident #9 at risk for abuse/neglect. Findings include: Review of the facility policy titled Abuse Investigation and Reporting occurred on 06/18/19. This undated policy stated, . All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Review of Resident #9's medical record occurred on (MONTH) 17-18, 2019. [DIAGNOSES REDACTED]. At risk for alteration in skin integrity related to: impaired mobility, spending more time in bed, decrease in appetite, wheel self around and often scratch self on walls or on objects in room and bathroom . Interventions . Observe skin condition with ADL (activities of daily living) care daily; report abnormalities . Current physician's orders included geri sleeves (long sleeves ok) on in AM (morning) off at HS (bedtime). A weekly skin assessment, dated 06/15/19, identified no skin issues. Observation on 06/17/19 at 12:41 p.m. showed Resident #9 had bruising/swelling and a skin tear covered with a Band-Aid to her left hand, bruising to her right forearm and shin, and wearing a short-sleeved shirt without geri sleeves in place. The certified nursing assistant (CNA) (#1) stated she did not know how the injuries occurred. Observation on 06/17/19 5:10 p.m. showed Resident #9's left hand covered with a [MEDICATION NAME] dressing and no geri sleeves in place. Review of Resident #9's treatment administration record (TAR) on 06/17/19 at 5:36 p.m. showed staff signed off the geri sleeves for the morning of 06/17/19; however, observations throughout the day on 06/17/19 showed staff failed to apply Resident #9's geri sleeves. A nurse's note, dated 06/17/19 at 11:55 p.m., stated, . area was cleaned and miplex (sic) applied . The record contained no further assessment/description of the bruising/skin tear. During an interview on the afternoon of 06/18/19, a supervisory nurse (#2) agreed direct care staff should report injuries of unknown origin to the nurse.",2020-09-01
12,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2019-05-16,640,E,1,1,FA2L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.16), the facility failed to ensure timely electronic data submission of required Minimum Data Sets (MDS) assessments for 9 of 20 sampled residents (Resident #1, #12, #13, #16, #20, #35, #38, #40, and #54) and 2 of 3 closed resident records reviewed (Resident #64 and #65). Failure to follow the MDS data submission specifications does not meet the intended regulatory requirements. Findings include: Review of Resident #1, #12, #13, #16, #20, #35, #38, #40, and #54's medical records occurred on all days of survey. Review of Resident #64 and #65's medical records occurred on 05/16/19. The MDSs showed the following: ENTRY TRACKING: The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.16), page 2-36 stated, the entry tracking record, . Must be completed within 7 days after the admission/reentry. Must be submitted no later than the 14th calendar day after the entry (entry date (A1600) + 14 calendar days). Review of Resident #20's medical record identified an admission date of [DATE]. The entry tracking record was submitted to the Centers for Medicare and Medicaid Services (CMS) on 02/04/19, 10 days late. ADMISSION: The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.16), page 2-21 regarding completion dates stated, . The MDS completion date (Item Z0500B) must be no later than day 14 (the admitted counts as day one). This date may be earlier than or the same as the CAA(s) (Care Area Assessment Summary) completion date, but not later . The CAA(s) completion date (Item V0200B2) must be no later than day 14 (the admitted counts as day one). -Review of Resident #12's medical record identified an admission date of [DATE]. The admission MDS, dated [DATE], showed the facility dated items V0200B2 and Z0500B 12/18/18, 15 days late. -Review of Resident #13's medical record identified an admission date of [DATE]. The admission MDS, dated [DATE], showed the facility dated items V0200B2 and Z0500B 12/07/18, three days late. -Review of Resident #16's medical record identified an admission date of [DATE]. The admission MDS, dated [DATE], showed the facility dated item V0200B2 09/14/18, one day late. -Review of Resident #35's medical record identified an admission date of [DATE]. The admission and 5-day PPS MDS, dated [DATE], showed the facility dated V0200B2 and Z0500B 11/16/18, three days late. -Review of Resident #64's closed record identified an admission date of [DATE]. The admission and 5-day PPS MDS, dated [DATE], showed the facility dated V0200B2 and Z0500B 02/19/18, two days late. -Review of Resident #65's closed record identified an admission date of [DATE]. The admission and 5-day PPS MDS, dated [DATE], showed the facility dated V0200B2 and Z0500B 02/10/19, three days late. ANNUAL: The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.16), page 2-22 stated, . The MDS completion date (Item Z0500B) must be no later than 14 days after the ARD (Assessment Reference Date) (ARD + 14 calendar days). This date may be earlier than or the same as the CAA(s) completion date, but not later . Review of Resident #40's annual MDS with an ARD of 01/04/19, showed the facility dated V0200B2 and Z0500B 02/09/19, 22 days late. QUARTERLY: The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.16), page 2-33 stated, . The MDS completion date (Item Z0500B) must be no later than 14 days after the ARD (ARD + 14 calendar days). Review of Resident #54's quarterly MDS with an ARD of 01/25/19, showed the facility dated Z0500B 02/19/19, 11 days late. OBRA DISCHARGE: The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.16), page 2-37 stated, Discharge Assessment-Return Not Anticipated . Must be completed (Item Z0500B within 14 days after the discharge date (A2000 + 14 calendar days). Must be submitted within 14 days after the MDS completion date (Z0500B + 14 calendar days). Review of Resident #1's medical record identified a discharge date of [DATE]. The facility failed to complete a discharge assessment and submit it to CMS. MEDICARE PPS DISCHARGE: The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.16), page 2-46 stated, . Part A PPS Discharge Assessment (A0310H=1) . Must be submitted within 14 days after completion of the MDS completion date (Z0500B + 14 calendar days). Review of Resident #38's Medicare Part A PPS discharge assessment, dated 01/16/19, showed the facility dated Z0500B 01/19/19 and submitted the assessment to CMS 02/04/19, two days late.",2020-09-01
13,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2019-05-16,641,D,1,1,FA2L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.16), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Sets (MDSs) for 2 of 20 sampled residents (Resident #12 and #54). Failure to accurately complete Section A (Identification Information) and Section P (Restraints and Alarms) of the MDS does not allow each resident's assessment to reflect their current status/needs, and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION A: IDENTIFICATION INFORMATION The Long-Term Care Facility RAI Manual, revised (MONTH) (YEAR), page A-19 to A-20, stated, . Section A1500: Preadmission Screening and Resident Review (PASRR) . Coding Instructions: Code 0, no: and skip to A1550, Conditions Related to ID/DD Status, if any of the following apply: PASRR Level I screening did not result in a referral for Level II screening, or Level II screening determined that the resident does not have a serious mental illness . Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions. Coding instructions: Code A, Serious mental illness: if resident has been diagnosed with [REDACTED]. - Review of Resident #12's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The record showed a completed PASRR Level I and Level II screen for an indicated serious mental illness prior to Resident #12's admission to the facility on [DATE]. Review of the admission MDS, dated [DATE], showed section A1500 coded No which resulted in a skipped coding pattern and staff failed to code section A1510 [NAME] Serious mental illness. SECTION P: RESTRAINTS AND ALARMS The Long-Term Care Facility RAI Manual, revised (MONTH) (YEAR), page P-1 to P-8, stated, . Prior to using any physical restraint, the nursing home must assess the resident to properly identify the resident's needs and the medical symptom(s) that the restraint is being employed to address. If a physical restraint is needed to treat the resident's medical symptom, the nursing home is responsible for assessing the appropriateness of that restraint. Bed rails used with residents who are immobile. If the resident is immobile and cannot voluntarily get out of bed because of a physical limitation or because proper assistive devices were not present, the bed rails do not meet the definition of a physical restraint. Coding instructions: Identify all physical restraints that were used at any time (day or night) during the 7-day look-back period. After determining whether or not an item listed in (P0100) is a physical restraint and was used during the 7-day look-back period, code the frequency of use: Code 0, not used: if the item was not used during the 7-day look-back or it was used but did not meet the definition. Code 1, used less than daily: if the item met the definition and was used less than daily. Code 2, used daily: if the item met the definition and was used on a daily basis during the look-back period. - Review of Resident #54's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The most recent quarterly MDS, dated [DATE], identified Resident #54 as cognitively intact. The current care plan stated, . Use of side rails to bed , (top rails only), for assistance with changing position due to bilateral shoulder pain related to severe arthritis. Review of the quarterly MDS, dated [DATE], showed section P0100 [NAME] Bed rail coded a 2 to indicate a restraint used daily during the look-back period. During an interview, on 05/15/19 at 11:20 a.m., an administrative nurse (#18) stated Resident #54's bed rails are used as an assistive device for bed mobility and agreed she coded the MDS incorrectly.",2020-09-01
14,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2019-05-16,656,D,1,1,FA2L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and review of facility policy, the facility failed to develop and implement a comprehensive care plan for 1 of 3 sampled residents (Resident #16) receiving [MEDICAL TREATMENT]. Failure to comprehensively assess [MEDICAL TREATMENT] care and implement interventions related to access sites/monitoring of residents may result in complications, including bleeding, loss of access sites, or [MEDICAL CONDITION]. Findings include: Review of the facility policy titled [MEDICAL CONDITION], Care of a Resident with occurred on 05/16/19. This undated policy stated, Education and training of staff, may include the following as applicable: . The type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis . Signs and symptoms of worsening condition and/or complications of [MEDICAL CONDITIONS] . The care of grafts and fistulas . The resident's comprehensive care plan will reflect the resident's needs related to [MEDICAL CONDITION]/[MEDICAL TREATMENT] care . Resident #16's current care plan stated, . Focus . I have a potential for complication related to [MEDICAL TREATMENT] for [DIAGNOSES REDACTED]. Date Initiated: 02/21/2019 . Goal . I will not develop complications related to [MEDICAL TREATMENT] through next 30 days. Interventions . I will attend ([MEDICAL TREATMENT] center name) three days per week . Resident #16's [MEDICAL TREATMENT] care plan failed to identify access sites and interventions related to the assessment and care of sites and monitoring of Resident #16 for complications related to [MEDICAL TREATMENT].",2020-09-01
15,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2019-05-16,657,D,1,1,FA2L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > THIS IS A REPEAT DEFICIENCY FROM THE SURVEYS COMPLETED ON 06/28/18. Based on observation, record review, and staff interview, the facility failed to review/revise the comprehensive care plans to reflect the current status for 2 of 20 sampled residents (Resident #17 and #54). Failure to revise the care plan limited staff's ability to communicate care needs and ensure continuity of care for each resident. Findings include: - Review of Resident #54's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The skilled therapy notes showed physical therapy services discontinued on 12/31/18 and occupational therapy services discontinued on 01/11/19. The most recent quarterly Minimum Data Set ((MDS) dated [DATE], identified Resident #54 to be cognitively intact. The progress notes showed the following: * 02/07/19 at 3:02 p.m., . Continues to refuse to get up despite being offered multiple times, . * 04/18/19 at 10:30 p.m., . Order signed by MD (physician) for D/C (discontinue) of Ensure [MEDICATION NAME] this date. * 04/24/19 at 11:10 p.m., . Bed mobility: . prefers to stay in bed . Toileting: Is incontinent of b & b (bowel and bladder). Check et (and) change as needed . Resident #54's current care plan stated, . Interventions: Remind resident to wear gripper socks when up . Get up every morning at 11:00 AM for therapy . OT (Occupational Therapy) ADL (Activities of Daily Living) training/adaptive equipment to improve self-care, home management training, meal preparation, safety procedures and/or instructions in use of assistive devices and/or technology . Get up and be ready for therapy by 10:30 AM and go to therapy by 11:00 AM . Adjust toileting times to meet patient needs . Provide assistance with toileting . Supplements: 8 oz (ounces) Ensure [MEDICATION NAME] PM and HS (hour of sleep) . Assist with dentures as needed . Refer to dentist/hygienist for evaluation/recommendations re: denture realignment, new fitting . Fistula to right upper arm: assess for bruit/thrills . Observation on all days of survey showed Resident #54 did not wear dentures, the resident reported she preferred not to wear her dentures. During an interview on 05/15/19 at 5:20 p.m., an administrative nurse (#1) reported Resident #54 had a fistula insertion procedure in (MONTH) (YEAR) to be prepared for [MEDICAL TREATMENT]. Later Resident #54's physician determined she did not need [MEDICAL TREATMENT], however the fistula remained intact and no longer required monitoring. The administrative nurse (#1) confirmed staff failed to update Resident #54's care plan in all areas noted above. - Review of Resident #17's medical record occurred on all days of survey. Resident #17's progress notes showed the following: * 03/22/19 at 12:33 p.m., . Order received: (MONTH) remove [DEVICE] (Gastric tube) . Resident #17's current care plan stated, . Focus: presence of [DEVICE] . Interventions: Provide water flushes as ordered . Observation on all days of survey showed Resident #17 did not have a [DEVICE]. During an interview on 05/15/19 at 4:30 p.m., an administrative nurse (#1) confirmed staff failed to update Resident #17's care plan.",2020-09-01
16,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2019-05-16,658,E,1,1,FA2L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record review, review of facility policy, review of professional reference, family and staff interview, the facility failed to follow professional standards of nursing practice for 5 of 20 sampled residents (Resident #30, #35, #43, #49, and #61). Failure to carry out a physician's order (Resident #35), failure to follow facility policy when priming insulin pens (Resident #43 and #61), and failure to ensure residents received follow up care as ordered (Resident #30 and #49) may result in adverse health effects. Findings include: PHYSICIAN'S ORDERS Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 10th Edition, (YEAR), Pearson, Boston, Massachusetts, page 68, stated, . Carrying Out a Physician' Orders . If the order is neither ambiguous not apparently erroneous, the nurse is responsible for carrying it out. - Review of Resident #35's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. A cardiology progress note, dated 04/08/19, identified an order for [REDACTED].#35 on 9 of the past 37 days. During an interview on the morning of 05/16/19, an administrative nurse (#1) confirmed she expects nurses to follow physician orders and that the weights were missed. - Review of Resident #30's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The record identified a hospital stay from (MONTH) 3-7, 2019 for a [DIAGNOSES REDACTED]. Discharge instructions identified a follow up appointment at the urology clinic on 03/18/19. The medical record lacked evidence the resident went to this appointment. During an interview on the afternoon of 05/16/19, an administrative nurse (#1) confirmed Resident #30 did not go to the urology appointment. - During an interview on the afternoon of 05/13/19, a family member stated she was upset because Resident #49 missed a neurology appointment in (MONTH) which was previously scheduled. The resident was then unable to see the neurologist until June. Review of Resident #49's medical record occurred on all days of survey and identified a [DIAGNOSES REDACTED]. Pt. (patient) returned from appointment with (medical doctor). Continue with exercise and ROM (range of motion) at least twice a day. Pt. to follow-up with (neurologist) on 3/18/19 at 1030. The record also contained an appointment reminder letter from the medical provider which listed a neurology appointment on 03/18/19. Resident #49's record lacked evidence the resident went to this appointment. During an interview on the morning of 05/16/19, a supervisory nurse (#7) confirmed Resident #49 missed the neurology appointment and is scheduled to go in June. Failure to ensure residents receive scheduled follow up care may result in inadequate medical management and adverse health outcomes. INSULIN PENS Review of the facility policy titled, Insulin Administration Instructions occurred on 05/16/19. This undated policy stated, . - Take off and keep the outer needle cap, then remove the inner needle cap and discard it - Select a dose of 2 units by turning the dosage selector - Hold the pen with the needle pointing upwards and tap the insulin reservoir so that any air bubbles rise up towards the needle - Press the injection button all the way in and check if insulin comes out, repeat the process until you see a drop of insulin, a max of six times . - Review of Resident #43's medical record occurred on all day of survey and identified a physician's order for Humalog (a rapid acting insulin). Observation of medication pass occurred on 05/13/19 at 5:08 p.m. A nurse (#5) selected two units on Resident #43's Humalog Pen and pressed the injection button without holding the pen upwards. The nurse (#5) failed to hold the pen upwards to properly prepare the pen for insulin administration to Resident #43. - Review of Resident #61's medical record occurred on 05/14/19 and identified physician order's for Tresiba (a long acting insulin) and [MEDICATION NAME] (a rapid acting insulin). Observation of medication pass occurred on 05/14/19 at 1:17 p.m. A nurse (#6) failed to remove the needle cap selected two units on Resident #61's Tresiba pen and pressed the injection button without holding the pen upwards. The nurse (#6) prepared Resident #61's [MEDICATION NAME] Pen without removing the needle cap, selected two units and pressed the injection button without holding the pen upwards. The nurse (#6) failed to remove the needle cap and to hold the pen upwards to prepare the pen for injection to Resident #61.",2020-09-01
17,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2019-05-16,677,D,1,1,FA2L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide activities of daily living (ADL) assistance to 1 of 11 sampled residents (Resident #45) who required staff assistance for toileting. Failure to provide appropriate assistance to residents who cannot independently carry out ADLs may result in avoidable incontinence, poor grooming/hygiene, decreased self esteem, and an avoidable decline in ADL ability. Findings include: Review of the facility policy titled Activities of Daily Living (ADLs), Supporting occurred on 05/16/19. This undated policy stated, . Residents will (be) provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); b. Mobility (transfer and ambulation, including walking); c. Elimination (toileting) . Review of Resident #45's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Focus . ADL Self care deficit related to physical limitations . Interventions . hands on staff assist with bed mobility, transfers, w/c (wheelchair) locomotion on and off unit, dressing, toileting, personal hygiene, eating and bathing. Staff anticipate needs as ADL's do fluctuate . Transfer: extensive assistance of one with gait belt and pivot . Focus . At risk for falls due to impaired balance/poor coordination . Interventions . assist to bathroom after meals as needed . check on resident and offer toileting regularly . Don't leave patient unattended in bathroom . Observation on 05/14/19 at 9:20 a.m. showed a certified nursing assistant (CNA) (#8) transported Resident #45 in her wheelchair to her room. The CNA called for help from another CNA (#16). The CNA (#16) entered the room and asked the CNA (#8) if they were toileting the resident. The CNA (#8) stated, No, we are going to change her in bed. She's just so hard to transfer. The CNAs attempted to transfer Resident #45 to bed, but the resident became resistive. A nurse (#6) entered the room and instructed the CNAs to re-approach the resident. At 10:44 a.m., two CNAs (#8 and #13) transferred Resident #45 into bed (without offering toileting) and attempted to check and change her incontinence brief. The resident again refused. At 11:31 a.m., observation showed a nurse (#6) exited Resident #45's room. The nurse indicated she checked and changed Resident #45's brief. During an interview on 05/14/19 at 2:16 p.m. a CNA (#8) stated she checked and changed Resident #45's brief in bed and she was now asleep. Observation on 05/15/19 at 11:15 a.m. showed two CNAs (#8 and #9) transferred Resident #45 into bed (without offering toileting) and checked and changed her incontinence brief. When asked if Resident #45 uses the toilet, the CNA (#8) stated, Not much. She's so unsteady. During an interview on the morning of 05/16/19, a supervisory nurse (#1) agreed staff should follow resident's care plans regarding ADL assistance.",2020-09-01
18,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2019-05-16,684,D,1,1,FA2L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and review of professional reference, the facility failed to provide care and services to ensure safe positioning for meals for 1 of 4 sampled residents (Resident #30) observed eating in bed. Failure to ensure proper mealtime positioning placed Resident #30 at risk for aspiration. Findings include: Swigert's The Source for Dysphagia, 3rd ed., Pro-Ed, Inc., Texas, 2007, pages 9, 10, 125, and educational handouts, identified, . Signs and Symptoms of Dysphagia . coughing . during a meal . Some patients cough and choke when they aspirate . During the oral intake of . food and/or liquids, it is optimal for a patient to be seated at a 90 degree angle, whether in bed or in a chair. Even a slightly reclined position while eating greatly increases the risk of premature loss of food over the back of the tongue. Review of Resident #30's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Nurses' notes identified the following: *03/10/19 at 7:26 p.m.: . ProMod Liquid (a protein supplement) . Patient unable to swallow medication without coughing . *03/10/19 at 7:30 p.m.: . Juven Packet (a nutritional supplement) . Patient choking on liquids will update NP (nurse practitioner) . *03/10/19 at 10:42 p.m.: . Writer went into residents (sic) room where he was sitting up eating in bed. Writer gave him his 3 o'clock medication and patient began to cough. Patient face dark red in color. Patient was able to stop coughing after couple min. (minutes) . On call was called and writer was instructed to leave progress note . for NP. Observation on 05/14/19 at 12:48 p.m. showed Resident #30 eating lunch in bed. The head of the bed was at a 45 degree angle. Observation showed the resident coughed while eating. At 1:00 p.m., observation showed Resident #30 coughed and choked on his food, expelling pieces from his mouth while his eyes watered. The surveyor entered the room and asked if he needed to sit up. The resident replied, Yes. The surveyor found a certified nursing assistant who then raised the head of the bed to an almost 90 degree angle. Observation showed a sign next to the bed which stated, Safe Swallow Strategies . Food . Sit Upright . Drinks . Sit Upright . The resident's care plan failed to identify interventions to ensure safe swallowing/positioning during meals. Failure to position Resident #30 (who has dysphagia) in an upright position during meals resulted in the resident choking on his food, and may have resulted in aspiration.",2020-09-01
19,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2019-05-16,686,G,1,1,FA2L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 06/28/18. Based on observation, record review, review of facility policy, and family and staff interview, the facility failed to provide appropriate treatment and services to prevent the development and/or deterioration of pressure ulcers for 3 of 5 sampled residents (Resident #17, #30 and #31) with pressure ulcers. Failure to consistently implement interventions, ensure adequate monitoring/assessment, and complete wound care as ordered resulted in the deterioration of Resident #30's pressure ulcer, and delayed treatment/deterioration of pressure ulcers for Resident #17 and #31. Findings include: Review of the facility policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol occurred on 05/16/19. This undated policy stated, . In addition, the nurse shall describe and document/report the following, as applicable: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue . The physician may guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. Review of the facility policy titled Repositioning occurred on 05/16/19. This undated policy stated, . The purpose of this procedure is to provide guidelines . to promote comfort for all bed- or chair-bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents. Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief. Positioning the resident on an existing pressure ulcer should be avoided since it puts additional pressure on tissue that is already compromised and may impede healing. - Review of Resident #30's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The current Minimum Data Set (MDS), dated [DATE], identified no rejection of cares, extensive assistance from two or more people for bed mobility and two Stage IV pressure ulcers. Resident #30's current care plan stated, . Focus . I have potential for altered nutrition and weight changes r/t (related to) diuretic in use, presence of wounds . Interventions . Provide Regular diet with enhanced foods, double portions of protein and honey thick liquids as ordered . Provide supplements as ordered for wound healing. Focus . At risk for complications due to musculoskeletal problems r/t MS ([MEDICAL CONDITION]) . Interventions . Assist with bed mobilty . Focus . Resident has pressure ulcer(s) to right ischium related to: hx (history) of pressure sores, decreased mobility, MS, cardiac, and tendency to stay in one position per preference, resident chooses to set up longer in w/c (wheelchair) against the order to sit up only for 30 minutes for meals . Encourage and assist as needed to turn and reposition; use assistive devices as needed . Encourage resident to follow the limit time up in w/c and provide education about risk and benefit of following order or not following order. Pressure reducing surface on bed/wheelchair: Clinitron bed (sand bed) in use since (MONTH) 8th, 18 (2018) . Repositioning during ADLs (activities of daily living) . Resident has pressure ulcer(s) to left ischium related to: hx of pressure sores, decreased mobility, and tendency to stay in one position per preference, resident chooses to set up longer in w/c against the order to sit up only for 30 minutes for meals . Interventions . Adding yogurt to meal trays to try to improve intakes . Nurses' notes and wound assessments stated the following: *01/09/19 at 3:04 p.m.: . Pt. (patient) returned from appointment at (wound clinic). Left and Right Ischial ulcer: fill with Mesalt (a type of gauze dressing that uses a wicking action to cleanse draining wounds) and cover with [MEDICATION NAME] (a bordered foam dressing designed to minimize trauma to the wound and surrounding skin at removal) - change daily and PRN (as needed). Use barrier spray to peri (around) wound skin. Continue with activity orders - up for meals only (60 minutes only) and turn every 2 hours. *01/11/19 at 10:12 a.m.: . The unstageable pressure sore to the right ischium measures 2.0 x 2.0 x 0.3 cm (centimeters) (length x width x depth). The wound bed is 100% granulation tissue. No undermining/tunneling noted. The unstageable pressure sore to the left ischium measures 1.2 x 1.2 x 0.2 cm. The wound bed is 100% granulation tissue. No undermining/tunneling noted. Preventative measures in place include the use of the clinitron bed, keeping skin clean and dry, keep ischium wound sites off pressure, pressure reduction cushion in w/c (wheelchair), turning and repositioning regularly, assistance with meals, daily nutritional supplements, daily skin audit, and weekly skin assessment by nurse. *02/19/19: L ischium 1 cm x 0.8 cm x 0.8 cm, wound bed red and 100% granulation tissue, no undermining/tunneling noted, small amount serosanguinous drainage; R ischium 1.7 cm x 1.7 cm x 1.1 cm, wound bed red and 100% granulation tissue, tunneling at 7 o'clock, 2.2 cm, small amount serosanguinous drainage *03/07/19 (admission assessment post hospitalization ): L ischium 0.5 cm x 0.8 cm x 0.3 cm, no tunneling documented; R ischium 1 cm x 2 cm x 1.2 cm, no tunneling documented *03/13/19: L ischium 1.5 cm x 0.6 cm x 0.4 cm, no undermining/tunneling noted, small amount serosanguinous drainage; R ischium 1.2 cm x 2 cm x 1 cm, tunneling at 7 o'clock, 2.5 cm and 10 o'clock, 3.2 cm, small amount of sanguinous drainage *04/18/19: L ischium 0.5 cm x 1.5 cm x 0.8 cm, small amount of purulent drainage, periwound macerated; R ischium 1.2 cm x 1.2 cm x 0.8 cm, tunneling at 10 o'clock, 3 cm, moderate amount of serous drainage, periwound macerated *04/30/19: L ischium 1 cm x 1.5 cm x 1 cm, indicated wound was assessed at clinic on this day; R ischium 2 cm, 1.9 cm x 2 cm, indicated wound was assessed at clinic on this day *05/01/19 at 1:39 p.m.: . met for skin and wt (weight) review. Wound is stable, and treatment changed yesterday at wound clinic. Will offer Greek yogurt at meals. *05/15/19: L ischium 2.5 cm x 1.3 cc (sic) x 0.8 cm; R ischium 4 cm x 2.8 cm x 6.5 cm deep *The record identified staff failed to take measurements from 04/30/19 until 05/15/19 (15 days later). The wound clinic progress note stated the following: *04/30/19: . Patient was last seen by myself on 03/26/19. Last visit, Bilateral ischial ulcers were filled with mesalt ribbon, followed by [MEDICATION NAME] border foam dressings. Today, right ischial ulcer was not adequately packed, causing some peri wound skin maceration. Gauze and tape was also utilized by SNF (skilled nursing facility), not [MEDICATION NAME] borders as ordered. Assessment: . Decubitus ulcer of left ischium, stage 3 . Decubitus ulcer of right ischium, stage 3 . Plan: . Mesalt ribbon (fill wounds lightly but adequately) bilaterally, to cover with large [MEDICATION NAME] borders, use NO TAPE, [MEDICATION NAME] only. Change dressings daily and PRN. Wounds will not heal if not adequately packed - I wrote to SNF . Must use barrier spray to bilateral ischial wound with each dressing change to protect peri wound skin - I wrote to SNF . Continue with orders also given to turn patient every 2 hours when in bed, and for him to be up for meals only, for no longer than 60 minutes each time. Resident #30's treatment administration record (TAR) identified twice daily dressing changes (not daily as indicated by the wound clinic), and identified packing to the right ischial ulcer (not bilaterally as indicated by the wound clinic). During an interview on the afternoon of 05/14/19, a nurse (#19) stated Resident #30's skin has really improved since we stopped using tape, and she thought the wounds were healing. During an interview on the morning of 05/16/19, a nurse (#20) stated, Not yet, when asked if staff were packing Resident #30's left ischial ulcer. She further stated, I have a feeling we're going to need to start (packing the wound), and it's starting to get a little deeper. The nurse identified staff measure pressure ulcers weekly. Observation of the dressing changes on the morning of 05/16/19 showed the nurse failed to pack the left ischial wound. The nurse packed the right ischial wound and stated, It tunnels back. After completing the dressing change, the nurse stated to the CNA, We should leave him like that (on his left side) for awhile, get him off that right side. The nurse asked the resident, who agreed. Observations on 05/13/19 at 11:38 a.m., 12:28 p.m., 2:09 p.m., 2:50 p.m., 3:42 p.m., 4:47 p.m., 5:50 p.m., and 6:31 p.m. showed Resident #30 lying supine in bed with a pillow under his left hip (placing pressure on his right ischial ulcer for nearly seven hours). Observations on 05/14/19 at 7:51 a.m., 8:42 a.m., 9:08 a.m., 9:55 a.m., 10:39 a.m., 11:17 a.m., and 12:48 p.m. showed Resident #30 supine in bed (five hours). Certified nursing assistant (CNA) charting identified Resident #30 was up in his wheelchair for 45 minutes, charted at 10:41 a.m.; however, observations during this time showed the resident remained in bed. Observations on 05/15/19 at 8:47 a.m., 9:55 a.m., 10:37 a.m., 11:03 a.m., 11:41 a.m., 12:14 p.m., and 1:19 p.m. showed Resident #30 supine in bed (four and a half hours). Resident #30's medical record failed to identify repositioning records and/or refusals to be repositioned. Observations of the following meals showed staff failed to provide double servings of protein and/or yogurt as indicated in his care plan: *Noon meal on 05/13/19 (no double protein or yogurt) *Breakfast meal on 05/14/19 (no double protein or yogurt) *Noon meal on 05/14/19 (no double protein) The facility failed to consistently implement dietary inventions, reposition Resident #30 every two hours, and complete wound care as ordered by the wound clinic. These failures resulted in increased size/tunneling of Resident #30's ischial ulcers and subjected Resident #30 to the need for continued treatments of the open wounds. - Review of Resident #31's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. * 04/18/19 at 11:00 p.m. to 11:26 p.m.: . resident left dorsal foot area has open area, due to [MEDICAL CONDITION], skin cleaned and dressing applied . measurement on left dorsal foot 2 x 1.5 cm . resident left foot has pitted [MEDICAL CONDITION] +2, wear ACE wrap in AM and off at HS (hour of sleep) . has some redness around the wound . will continue to monitor. * 04/24/19 at 5:43 p.m.: . called physician to notify of ulceration and request new treatment. Cleanse ulceration to L (left) dorsal foot with NS (normal saline) once daily. Apply [MEDICATION NAME] to slough and cover with a dry gauze dressing daily. Review of the Weekly Pressure/Non-Pressure Wound Assessment form occurred on 05/16/19. This form dated 04/24/19 showed the following: * Number of stage 3 pressure ulcers: 1 * Most severe type of tissue: slough * Ulcer/wound measurements: Site: L dorsal foot, Length 4.9 cm, Width 5.0 cm, Depth 0.0, Stage III * Notes: Facility Acquired Stage 3 pressure ulcer to dorsal L foot. Nurse states resident ulcer presented as a ripple in the skin. Noted after ace bandage was removed. Ulcer is larger than initial presentation. Wound bed with large amount of purulent drainage. Periwound reddened. Resident denies pain to area. Ace bandage removed. MD (physician) updated of change in wound and new treatment ordered. Dietician also notified. The medical record lacked evidence of wound care or monitoring from 04/19/19 to 04/24/19 which resulted in worsening and delayed treatment for [REDACTED]. During an interview the morning of 05/16/19, an administrative nurse (#7) confirmed the medical record lacked documentation of wound monitoring/treatment and acknowledged Resident #31's wound deteriorated prior to physician notification. - Review of Resident #17's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Physician orders included weekly skin assessment and treatment for [REDACTED]. Observation of Resident #17's right foot showed reddened areas with dark spots in the middle of four of his toes. Observation on 05/15/19 and 05/16/19 showed Resident #17's right foot and toes up against the foot board of his bed. During an interview on 05/15/19 at 1:40 p.m. Resident #17's wife stated she asked staff approximately a month ago about the toes. She voiced concern because he had lost one toe on his left foot due to an ulcer not healing. Staff told her the resident had to wait to see the podiatrist. The medical record failed to show facility staff completed skin assessments related to Resident #17's toes or implemented interventions to prevent ulcers to his toes. During an interview on 5/16/19 an administrative nurse (#1) confirmed the medical record lacked documentation and interventions, and/or treatment of [REDACTED].",2020-09-01
20,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2019-05-16,689,D,1,1,FA2L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide enough supervision and/or assistive devices for 3 of 10 sampled residents (Resident #35, #45, and #62) observed transferred with staff assistance. Failure to use assistive devices per policy and/or manufacture guidance to transfer a resident safely places residents at risk of accidents with/without injury. Findings include: GAIT BELTS Review of the facility policy/procedure titled Safe Lifting and Movement of Residents occurred on 05/16/19. This undated policy, stated, . 4. Staff responsible for direct care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. - Review of Resident #62's medical record occurred on (MONTH) 13-16, 2019. An admission Minimum Data Set (MDS), dated [DATE], identified extensive assistance two or more staff for transfers and toilet use. Resident #62's current care plan identified Transfers: 1 assist, FWW (front wheeled walker). Observation on 05/14/19 at 11:49 a.m., showed the certified nurse aide (CNA) (#12) lifted Resident #62 under her left arm to transfer from the wheelchair to the toilet. After the CNA (#12) provided person cares, the CNA (#12) again lifted under Resident #62's left arm to transfer from the toilet to the wheelchair. The CNA (#12) failed to utilize a gait belt to assist with Resident #62's transfers. - Review of Resident #45's medical record occured on (MONTH) 14-16, 2019. The resident's current care plan stated, . Focus . ADL (activities of daily living) Self care deficit related to physical limitations . Interventions . Transfer: extensive assistance of one with gait belt and pivot . Date Initiated: 05/02/2018 . Observation on 05/14/19 at 10:44 a.m. showed two CNAs (#8 and #13) placed a gait belt around Resident #45's waist and assisted her to transfer to bed. Observation showed the gait belt was loose and slid up the resident's back. The resident did not fully bear weight, and her knees were bent to an almost 90 degree angle. The resident sat on the edge of the bed, and a CNA (#8) stated I don't want her to fall off, as she assisted to the resident to lie down. Observation on 05/15/19 at 11:15 a.m. showed two CNAs (#8 and #9) assisted Resident #45 to sit up in bed and placed a gait belt around her waist. A CNA (#8) stated, I like to have two (staff members). She's so hard (to transfer). Observation showed as the CNAs (#8 and #9)assisted Resident #45 to stand, the resident did not fully bear weight, and her knees were bent. Each CNA (#8 and #9) placed one arm under each of the resident's arms and used their other hand to lift the resident by the waistband of her pants as they transferred her to the wheelchair. MECHANICAL LIFT Review of manufacturer's instructions titled SARA 3000 Instructions for use, occurred on 05/16/19. These instructions stated, . Warning: The sling chest support strap must always be applied and fastened when using the sling. Lower Leg Straps . used to ensure that the lower parts of the resident's legs stay close to the knee support. - Review of Resident #35's care plan occurred on all days of survey. The quarterly minimum data set, ((MDS) dated [DATE], identified extensive assistance of two staff members for transfers. [DIAGNOSES REDACTED]. The residents current care plan stated, . standing lift with two assist to transfer into bathroom. Review of an occupational therapy note dated 04/22/19 stated, . Patient and Caregiver Training: Education to pt. (patient) and CNA on continued toilet transfer without standing lift. Observation on 05/14/19 at 10:32 a.m., showed a certified nursing assistant (CNA) (#10) and a licensed practical nurse (LPN) (#6) utilize a mechanical sit-to-stand lift to transfer Resident #35 from the wheelchair to the bathroom. The CNA (#10) applied the sling under the axilla (underarms) area and then attempted to secure the sling chest support strap. Resident #35 stated, You don't need to use that, I've been here for 6 months I think I know how its done by now. They don't use that thing. The staff failed to apply the sling chest support strap and the leg straps. Observation on 05/15/19 at 9:38 a.m., showed two CNAs (#11 and #12) utilize a mechanical sit-to-stand lift to transfer Resident #35 from the wheelchair to the bathroom. The CNA (#11) applied the sling under the axilla area and then attempted to secure the sling chest support strap. Resident #35 stated, oh no you've never used that before why do you want to use it now, I'm not using it. The CNA (#11) told the resident it was for safety and the resident stated, no you've never used it before, raise me up now. The staff failed to apply sling chest support strap and the leg straps. During an interview on 05/16/19 at 9:00 a.m., a certified occupational therapy assistant (COTA) (#14) agreed that Resident #35 is unsafe using the standing lift without the sling chest support and leg straps. Failure to correctly use the sit-to-stand mechanical lift per manufacture's instructions places the resident at risk for falls and injury.",2020-09-01
21,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2019-05-16,690,G,1,1,FA2L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, the facility failed to ensure appropriate treatment and services to treat a urinary tract infection [MEDICAL CONDITION] for 1 of 4 sampled residents (Resident #30) with an indwelling urinary catheter. Failure to adequately monitor and promptly treat Resident #30's UTI resulted in an admission to the hospital for [MEDICAL CONDITION] work up, including continuous bladder irrigation (CBI) and treatment with intravenous (IV) antibiotics. Findings include: Review of Resident #30's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Nurses' notes identified the following: *02/22/19 at 10:48 p.m.: . New order from (nurse practitioner) on call for (primary medical doctor) ordered a UA/UC (urinalysis/urine culture) for blood in urine and low grade temp (temperature) of 99.9 this shift. Foley changed. Foley was clogged with dried blood and urine was bright red. New foley inserted and N[NAME] (night) nurse was updated and will collect UA/UC. *02/23/19 at 2:29 a.m.: . Resident noted to have cherry red returns from catheter bag. This writer adjusted tubing and noted the urinary returns lighten up to pink. last shift had replaced catheter and noted hematuria. *02/23/19 at 4:30 a.m.: . Resident noted to have cherry colored urine in foley bag. Specimen was sent to lab. Last nurse had noted clots after removing old catheter. *02/24/19 at 12:16 a.m.: . Urine in Foley bag continues to be reddish colored. No clots noted. *02/24/19 at 10:29 p.m.: . Resident continues to have reddish brown urine. *02/25/19 at 12:12 a.m.: . Urine in Foley bag less red tonight. *02/25/19 at 3:30 p.m.: . resident continues to have blood in urine and (physician's assistant) called and update order to do CBC (complete blood count) and BMP (basic metabolic panel) note sent ton (sic) the lab. *03/02/19 at 9:32 p.m.: . Tylenol Tablet 325 mg (milligrams) Give 2 tablet by mouth every 4 hours as needed for pain/fever . Per request back et leg pain rated 6/10. *03/03/19 at 2:15 p.m.: . Noted urine remains red in Foley collection bag. Writer called (physician's assistant) at this time et (and) above information given. Orders received for CBC with diff (differential) et BMP tomorrow a.m. (gross hematuria). Lab request faxed to (name of lab) . *03/03/19 at 2:36 p.m.: . resident foley catheter was change (sic) due to it (sic) urine leakage, urine was bloody, will continue to monitor . *03/03/19 at 7:15 p.m.: . Urine continues to be bloody red in color in Foley collection bag. Writer called (physician's assistant) at this time et updated, requested resident be seen in (hospital name) ER (emergency room ). Order received to transfer resident . Ambulance took resident at 8 p.m. *03/03/19 at 11:38 p.m.: . admitted to hospital . *03/07/19 at 6:04 p.m.: . readmitted today via stretcher from (hospital name) following hospitalization [MEDICAL CONDITION]. Antibiotics are complete. The record lacked evidence of monitoring/assessment/communication regarding Resident #30's condition after the provider ordered labs on 02/25/19 until staff contacted him again on 03/03/19 (six days later, and nine days after staff first noted blood in Resident #30's urine). Resident #30's lab results showed staff collected a UA/UC on 02/23/19 at 4:20 a.m., with results faxed to the facility on [DATE] at 5:10 a.m. UA results showed: *Urine clarity as cloudy (reference range: clear) *Leukocyte Esterase (an enzyme found in white blood cells which can indicate infection) as large (reference range: negative) *Elevated white blood cells (WBC) (can indicate infection) at >= 50 (reference range: negative, 0-2, 3-5) *Elevated red blood cells (RBC) (can indicate infection, bleeding, or trauma) at >=50 (reference range: negative, 0-2) *Elevated bacteria at Moderate (31-50) (reference range: negative, rare (0-5), or few (6-30)) The preliminary UC results, faxed to the facility on [DATE] at 1:40 p.m., showed the presence of [DIAGNOSES REDACTED] pneumoniae at 30,000 CFU/ml (colony-forming units per milliliter, less than 10,000 CFU/ml is considered normal) The final UC with sensitivity results, faxed to facility on 02/25/19 at 1:40 p.m., showed: *30,000 CFU/ml [DIAGNOSES REDACTED] pneumoniae * *With susceptibility (i.e., would inhibit the growth of the bacteria) to the following antibiotics: [MEDICATION NAME]/clavulanate, [MEDICATION NAME], [MEDICATION NAME], and [MEDICATION NAME]/[MEDICATION NAME] The CBC, collected on 02/26/19 at 6:19 a.m. with results faxed to the facility on [DATE] at 9:09 a.m., showed the following results: *Elevated WBC at 12.1 (reference range 4-11) *Low RBC (can indicate blood loss) at 4.03 (reference range 4.4-5.8) *Low Hemoglobin (HGB) (can indicate blood loss) at 11 (reference range 13.5-17.5) *Low Hematocrit (HCT) (can indicate blood loss) at 34.2 (reference range 40-50) The above lab reports were signed off on 03/04/19 (the day after Resident #30 was admitted to the hospital). The record lacked evidence staff reviewed the labs prior to this day or communicated results to Resident #30's provider. The hospital progress notes identified the following: *03/04/19 at 1:25 a.m. (admission note): . REASON FOR ADMISSION: hematuria (blood in the urine), lactic acidosis (a buildup of [MEDICATION NAME] in the bloodstream) . sent from NH (nursing home) due to hematuria which has been present for the past 1 day. workup in ER shows elevated WBC and lactic acid. hgb (hemoglobin) is down from oct (October) (YEAR). Pt is admitted for further workup [MEDICAL CONDITION]. Last Vitals: . BP (blood pressure) 86/49 . Recent Results (from the past 24 hour(s)) . WBC 18.7 (increased from 12.1 on 02/26/19) . RBC 3.83 (decreased from 4.03 on 02/26/19) . HGB 10.2 (decreased from 11 on 02/26/19) . HCT 32.3 (decreased from 34.2 on 02/26/19) . Assessment/Plan . Hematuria - urology consult .[MEDICAL CONDITION] .[MEDICAL CONDITION] protocol monitor lactic acid, continue [MEDICATION NAME] ([MEDICATION NAME]) until cultures available . *03/04/19 at 8:16 a.m. (urologist note): . Impression: hematuria . Most likely hemorrhagic [MEDICATION NAME] . Plan: . When he is discharged we will set up cysto (cystoscope) as out pt . *03/04/19 at 10:58 a.m. (hospitalist note): . The patient's catheter has been leaking this morning and he has dark red hematuria. Per nursing, patient was oriented to person but currently is orientated x 0. Unable to perform ROS (review of systems): mental status change . Assessment/Plan: Principal Problem:[MEDICAL CONDITION] . Elevated WBC 18.7, Lactic acid 2.4, [MEDICAL CONDITION] 92/58. UA showed elevated WBC >182 indicating likely UTI. Patient continues to be hypotensive with min (minimum) BP 71/45. Typically BP has been 90s/50-60s. [MEDICATION NAME] is low 2.1 replacement may help BP. Plan . [MEDICATION NAME], IV [MEDICATION NAME] x1, IVF (IV fluids) . Hematuria . Plan . Catherer (sic) has been replaced, Urology consulted, continue antibx (antibiotics) to treat UTI, IVF . *03/06/19 at 10:49 a.m. (hospitalist progress note): . admitted for Heavy hematuria + elevated wbc's, urology did see him for foley placement and heavy hematuria, currently he is getting CBI (continuous bladder irrigation), received IV [MEDICATION NAME] one dose on 03/04/19 to help his [MEDICAL CONDITION] + [MEDICATION NAME] (low [MEDICATION NAME]). Assessment/Plan . Principal problem: 1) Acute complicated UTI . Stable, improving .[MEDICAL CONDITION]: Clinically undetermined if he was [MEDICAL CONDITION] or not - resolved . [MEDICAL CONDITION] on admission time was not due [MEDICAL CONDITION], it was due to a lack of po (oral) intake + [MEDICATION NAME]: resolved post IV [MEDICATION NAME] and IV fluids, b/p continues to be stable . Confusion on 03/03/19 due to UTI c/w (consistent with) Toxi(c) metabolic [MEDICAL CONDITION] (an acute mental status change often caused by electrolyte imbalance or infection): resolved - he is back to his baseline . Gross heavy hematuria . outpatient follow up with cystoscope with Urology . *03/06/19 at 11:46 a.m. (infectious disease consult): . was admitted with heavy hematuria status [REDACTED]. On admission the urine culture is now growing [DIAGNOSES REDACTED] pneumonia and [MEDICATION NAME] species. Initially he had a very elevated white blood cell count and altered mental status but now seems to be returning back to his baseline, still on CBI but urine has cleared completely, and leukocytosis (elevated WBC) has resolved. He has received a total of 3 days of high-dose [MEDICATION NAME] ([MEDICATION NAME]). Discharge instructions, dated 03/07/19, identified a follow up urology appointment scheduled for 03/18/19. Review of Resident #30's medical record identified the resident did not go to this appointment. When asked for information regarding the above, the facility provided no additional information. The facility failed to provide appropriate monitoring and assessment of Resident #30's condition, failed to promptly monitor lab results and recognize abnormal values, and failed to communicate adequately with the provider which resulted in a deterioration in Resident #30's condition, delayed treatment for [REDACTED]. The facility also failed to provide follow up care after this hospitalization . See F658.",2020-09-01
22,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2019-05-16,695,D,1,1,FA2L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview, and family interview, the facility failed to provide necessary respiratory care and services for 1 of 2 sampled residents receiving scheduled nebulizer medications (Resident #49). Failure to ensure the availability of medications may result in worsening respiratory symptoms and/or respiratory distress. Findings include: During an interview on the afternoon of 05/13/19, a family member stated she was upset as Resident #49 had been without one of her nebulizers going on three weeks now. Review of Resident #49's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Current medications included [MEDICATION NAME] nebulizer (used to treat shortness of breath) twice per day, started on 11/30/2018. Nurses' notes identified the following: *05/01/19 at 7:34 a.m.: . [MEDICATION NAME] Nebulization Solution . Medication awaiting Prior Authorization per MD (medical doctor) at this time . *05/01/19 at 7:49 p.m.: . [MEDICATION NAME] Nebulization Solution . Product not available. Requires prior auth (authorization) . *05/02/19 at 7:04 p.m.: . [MEDICATION NAME] Nebulization Solution . not available . *05/03/19 at 7:09 a.m.: . [MEDICATION NAME] Nebulization Solution . no supply available at this time . *05/03/19 at 3:20 p.m.: . This writer contacted pharmacy at the beginning of this shift regarding [MEDICATION NAME] which has not been available for sometime now. This writer spoke with (pharmacy technician) who told this writer that they have contacted the prescribing physician for prior authorization and that they are awaiting approval. Will follow up. *05/03/19 at 7:52 p.m.: . [MEDICATION NAME] Nebulization Solution . Product not available. MD and pharmacy aware . *05/13/19 at 11:47 p.m.: . This writer contacted pharmacy and (clinic name) pulmonology department regarding pending prior authorization for [MEDICATION NAME]. Told by pharmacist (name) that they have email (sic) the provider and that they are still awaiting her response. This writer called and left message at (pulmonology department) regarding status of prior authorization. Awaiting return call. *05/14/19 at 10:37 p.m.: . This nurse received a fax from the (pulmonology clinic) for approval for [MEDICATION NAME]. A call was placed to pharmacy with an update and they stated it had not cleared insurance yet. This nurae (sic) also faxed a copy of approval to pharmacy. *05/15/19 at 6:02 p.m.: . This writer received call from pharmacy that they contacted patient insurance and the doctor office regarding [MEDICATION NAME]. According to the pharmacist Prior authorization was signed by the doctor and mailed to insurance. Awaiting delivery. During an interview on the morning of 05/16/19, a supervisory nurse (#1) identified the facility is still waiting for the medication. Resident #49's Medication Administration Record [REDACTED]. The record identified Resident #49 last received [MEDICATION NAME] on 04/30/19 and lacked evidence of facility communication/follow up regarding the unavailability of the nebulizer from (MONTH) 4 until (MONTH) 13. When asked for further information regarding the above situation, the facility provided no additional information.",2020-09-01
23,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2019-05-16,698,D,1,1,FA2L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 06/28/18. Based on observation, record review, review of facility policy, and resident interview, the facility failed to provide care and services for the provision of [MEDICAL TREATMENT] consistent with professional standards of practice for 1 of 3 sampled residents (Resident #16) receiving [MEDICAL TREATMENT]. Failure to assess and monitor the resident's condition and access site after [MEDICAL TREATMENT] and provide ongoing care/monitoring of [MEDICAL TREATMENT] may result in bleeding, loss of access site, or other complications. Findings include: Review of the facility policy titled [MEDICAL CONDITION], Care of a Resident with occurred on 05/16/19. This undated policy stated, Education and training of staff, may include the following as applicable: . The type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis . Signs and symptoms of worsening condition and/or complications of [MEDICAL CONDITIONS] . The care of grafts and fistulas . The resident's comprehensive care plan will reflect the resident's needs related to [MEDICAL CONDITION]/[MEDICAL TREATMENT] care . Review of the facility policy titled [MEDICAL TREATMENT] Access Care occurred on 05/16/19. This undated policy stated, . Care of AVFs and AVGs (Arterio-Venous Fistula and Arterio-Venous Graft) . To prevent infection and/or clotting: a. Keep the access site clean at all times. Check for signs of infection (warmth, redness, tenderness, or [MEDICAL CONDITION]) at the access site when performing routine care and at regular intervals. Do not use the access arm to take blood pressure. Check the color and temperature of the fingers, and the radial pulse of the access arm when performing routine care and at regular intervals. Check the patency of the site at regular intervals. Palpate the site to feel the thrill, or use a stethoscope to hear the whoosh or bruit of blood flow through the access. During an interview on 05/14/19 at 5:15 p.m., Resident #16 stated facility staff do not monitor/assess his [MEDICAL TREATMENT], but the [MEDICAL TREATMENT] staff members do. The resident stated he has had both sites since he came to the facility in (MONTH) 2019. Observation showed a fistula site to his left arm, and a healing central catheter site to his right chest. Review of Resident #16's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Record review identified Resident #16 received [MEDICAL TREATMENT] three days per week via central catheter until its discontinuation on 04/30/19. Record review identified Resident #16 received [MEDICAL TREATMENT] via AV fistula on (MONTH) 2, 3, 6, and 15. Resident #16's blood pressure records showed staff took his blood pressure on his left arm (the site of the AV fistula) on eight different occasions since his admission. Review of Resident #16's medical record showed no monitoring or assessment of the [MEDICAL TREATMENT] sites or the resident's condition after [MEDICAL TREATMENT] until 05/15/19, when staff completed a post [MEDICAL TREATMENT] assessment.",2020-09-01
24,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2019-05-16,725,E,1,1,FA2L11,"> Based on information provided by the complainant, observation, resident and family interviews, and group interview, the facility failed to ensure the availability of sufficient nursing staff to promptly respond to residents' needs for 5 of 10 confidential resident interviews (Resident A, B, C, F, and J). Failure to provide sufficient staffing for assistance may result in residents experiencing falls and/or incontinence and may negatively affect the residents physical, mental, and psychosocial well-being. Findings include: Observations and interviews included the following: - During an interview on 05/13/19 at 11:21 a.m., Resident B stated, I wait a long time for my call light to get answered, I've had to wait 50-60 minutes several times, weekends are the worst by far. They come in and turn the light off and say they will go get someone and no one comes back. - During an interview on 05/13/19 at 12:29 p.m., Resident A stated, They are slow answering lights, I don't make it on time to the bathroom and then I wet my pants. - An interview occurred on 05/13/19 at 4:11 p.m. Resident C and his/her family member. Resident C stated, I wait long periods of time for my call light to be answered, usually at least 25 minutes. Evenings and weekends are the worst times. Resident C's family member stated he/she had to make the bed (Resident C's bed) at 5:00 p.m. and the day before, staff failed to removed the noon meal tray until 3:00 p.m. - Observation on on 05/14/19 at 12:57 p.m. showed Resident B's call light on. At 1:01 p.m., a nurse (#2) entered Resident #40's room, did not turn call light off, and assisted the resident with cares while this surveyor observed. At 1:23 p.m., the staff nurse finished cares and exited Resident B's room with call light still on. No other staff members came to answer the call light. - During the Resident Council meeting held the afternoon of 05/14/19. Two of the nine residents stated they have experienced long wait times for call lights to be answered. Resident B stated he/she has reported call light wait times to management, and they do not take into consideration the acuity and when a resident requires two CNAs. Resident F stated, I waited 45 minutes for my call light to be answered, when the call light was answered I told the CNA that I had a headache and wanted Tylenol, the CNA was to report to the nurse. I waited another 15-20 minutes for the nurse who never came so I wheeled myself to the nurse station to get the medication for my headache. Resident F reported this occurred about two months ago. - Observation on 05/15/19 at 11:37 a.m. showed Resident J's call light was on, and the resident sat in his wheelchair in the hallway. A nursing staff member (#1) entered the resident's room, turned off his call light, and told the resident somebody would be there soon. The staff member then knocked on another resident's room and asked the staff inside if they were going to assist Resident J next. The staff member (#1) then told Resident J the staff were on their way, to which the resident responded, Yeah sure. I've heard that before. - During an interview on 05/16/19 at 10:15 a.m., Resident J stated call light response times might be only 10 minutes, but sometimes it can be up to an hour. I have waited an hour before. The resident stated this happens pretty much every day, and that's my only complaint, they don't answer the call light quickly enough. - During an interview on the morning of 05/16/19, an administrative staff member (#1) stated, staff should acknowledge call light within 5-10 minutes with needs met within 15 minutes. The facility failed to provide a policy regarding answering call lights.",2020-09-01
25,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2019-05-16,790,D,1,1,FA2L11,"> Based on record review, family interview, and staff interview the facility failed to assist in obtaining dental care to meet the needs of 1 of 1 sampled resident (Resident #49) who requested a dental appointment. Failure to assist the resident in making an appointment and/or arranging transport may result in delayed dental care and/or dental complications. Findings include: During an interview on the afternoon of 05/13/19, a family member stated she has asked staff to make Resident #49 a dental appointment, but they have not done it. The family member stated Resident #49 has been to the dentist one time in eight years and nothing changes or gets done. Review of Resident #49's medical record occurred on all days of survey. A nurses' note, dated 01/29/19, stated, . Care Conference . Also requested dental appointment, will f/u (follow up) and update mother and resident when appointments made. The record lacked evidence staff made a dental appointment for Resident #49. During an interview on the morning of 05/16/19, a supervisory nurse (#7) confirmed Resident #49 had no scheduled dental appointment prior to 05/16/19.",2020-09-01
26,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2019-05-16,803,E,1,1,FA2L11,"> Based on observation, resident interview, review of menu's, review of resident council minutes, group interview, and staff interview, the facility failed to ensure staff consistently followed dietary menus for all residents for 4 of 8 residents with food concerns (Resident #D, #G, #39 and #47). Failure to offer the residents all the menu items listed, does not allow for residents' personal food choices or follow nutritional guidelines for a balanced meal. Findings include: - During a confidential interview, on 05/13/19 at 3:31 p.m., Resident D reported the facility has run out of hotdogs five times since she/he moved into the facility. Resident D reports the facility has also run out of hamburgers and bananas. - Observation on 05/13/19 at 6:21 p.m., showed Resident #39 requested tomato juice from a certified nursing assistant (CNA). The CNA left the dining room and returned a short time later. She stated to Resident #39, We don't have tomato juice, do you want something else? and identified they were out. - Review of the Weekly Menu for (MONTH) 12-18, 2019 and Always Available Menu occurred on (MONTH) 14-16, 2019. The weekly menu showed one main entree, vegetable, fruit and/or dessert at each noon and evening meal. The Always Available Menu showed the following: hamburger or cheeseburger on a bun, hot dog on a bun, deli meat sandwich with cheese on white or wheat, grilled cheese sandwich on white or wheat, egg salad sandwich on white or wheat, chef salad, side salad, cottage cheese, yogurt, tomato soup, chicken noodle soup, vegetable beef soup, mashed potatoes and gravy. - Review of the Resident Council Meeting Minutes occurred on 05/14/19. The meeting minutes dated 04/24/19, stated, . Dietary: Compliments, comments, concerns: New menu changes going well, but don't always have everything on anytime menu per (name of resident) states there were no hamburgers one day . - During the resident council meeting, held the afternoon of 05/14/19, four of the nine residents stated the facility runs out of food items such as bananas, bacon, hamburgers, and/or other items from the always available menu. - During an interview on the afternoon of 05/14/19, Resident G stated last week he/she requested an egg salad sandwich and was told they didn't have one. - Observation on 05/16/19 at 7:53 a.m., showed Resident #47 ordering breakfast. An unidentified kitchen staff member offered scrambled eggs and bacon. Resident #47 stated, Bacon and two fried eggs. The staff member stopped the resident stating, We won't have that kind of egg until the food truck comes. Resident #47 then accepted scrambled eggs and bacon as part of the breakfast order. During an interview on 05/16/19 at 10:10 a.m., a dietary manager (#17) confirmed they had run out of food options from the always available menu on occasion and other food items for short duration.",2020-09-01
27,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2019-05-16,804,E,1,1,FA2L11,"> THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 06/28/18 Based on information received from the complainant, observation, review of facility policy, resident interview, and group interview, the facility failed to ensure residents received food and beverages that were palatable, attractive and at the proper temperatures for 5 confidential residents interviews (Resident A, C, D, H, and I) and 3 of 9 residents who attended the group interview (Resident B, F, and G). Failure to ensure residents receive food and beverages that are palatable, attractive and at proper temperature, places residents at risk of weight loss and nutritional decline. Findings include: Information received from the complainant identified concerns with food palatability. Review of the facility policy titled Food and Nutrition Services occurred on 05/16/19. This undated policy stated, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Food and nutrition services staff will inspect food trays to ensure . the food appears palatable and attractive, and it is served at a safe and appetizing temperature. Review of the facility policy titled Preventing Foodborne Illness - Food Handling occurred on 05/16/19. This undated policy stated, . Federal standards require that refrigerated food be stored below 41 (degrees) F (Fahrenheit) . - During an interview on 05/13/19 at 11:19 a.m., Resident A stated, The milk is always warm, it's never cold anymore. Turkey they served yesterday was consistency of jello. You would not even serve the food to your dog. - During a confidential interview on 05/13/19 at 3:31 p.m., Resident D reported residents can wait 30 minutes for meals to be served, then the food is cold. Resident D reported meals were consistently cold until she/he changed dining rooms. - During an interview on 05/13/19 at 5:47 p.m. Resident H stated he/she likes fried eggs for breakfast, but the eggs are cold when the breakfast tray arrives, so he/she stopped ordering eggs. - Observation on 05/13/19 at 5:25 p.m. showed cartons of milk in a plastic container with some ice. Observation showed the top layer of milk cartons were not in contact with the ice. At 6:01 p.m., near the end of meal service, the survey team took the temperature of the milk, which measured 49.8 F. - During a confidential interview on 05/14/19 at 7:55 a.m., Resident I reported the food as not good all the time and specifically mentioned the Mother's Day meal. Resident I reported no one ate the meat because no one could identify it. - During an interview on 05/14/19 at 5:16 p.m., Resident C stated, Food is terrible. It's not fit for anyone. On Sunday I found a ground up carrot in my turkey and the turkey was purplish in color. The hot food is always cold. I can't drink the milk because it's warm all the time, it's gross. - During the Resident Council interview on the afternoon on 05/14/19, Residents B, F, and G stated the turkey served on 05/12/19 (Mother's Day) looked jelled similar to canned meat. They also stated there are other meals served which do not appear to be what is listed on the menu. Resident B stated, I drank rotten milk, the cartons are in tubs with very little ice. Failure to serve food and/or fluids at palatable temperatures may negatively impact residents' meal consumption.",2020-09-01
28,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2019-05-16,880,D,1,1,FA2L11,"> Based on observation, review of facility policy, and staff interview, the facility failed to follow infection control practices for 3 of 9 sampled residents (Resident #31, #36, and #45) observed during personal cares. Failure to follow infection control practices of hand hygiene during personal cares has the potential to spread infection to other residents, personnel, and visitors. Findings include: Review of the facility policy titled Handwashing/Hand Hygiene occurred on 05/16/19. This undated policy stated, . This facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-microbial) and water for the following situations: . Before and after direct contact with residents; . Before moving from a contaminated body site to a clean body site during resident care; . After removing gloves; . - Observation on 05/14/19 at 9:35 a.m. showed a certified nurse assistant (CNA) (#15) applied gloves and washed Resident #36's face, upper body and dressed the resident's upper body. The CNA (#15) removed the resident's brief and provided incontinence care for bowel and bladder. The CNA applied barrier cream to the resident's perineal area and continued to wash, dry, and lotion the resident's legs and feet, and dressed the resident's lower body. The CNA (#15) poured mouthwash into a cup, dipped a toothette swab into the mouthwash and completed Resident #36's oral cares. The CNA placed the resident's blanket at the foot of the bed, placed the call light and overbed table next to the resident before removing gloves and performing hand hygiene. - Observation on 05/14/19 at 11:38 a.m. showed two CNAs (#13 and #15) provide incontinent care for Resident #31 after a bowel movement (BM). The CNA (#15) changed gloves and, without performing hand hygiene, placed a clean brief and then removed his/her gloves. Both CNAs positioned the resident into her wheelchair and then the CNA (#15) performed hand hygiene. - Observation on 05/15/19 at 11:15 a.m. showed two CNAs (#8 and #9) checked and changed Resident #45's brief and provided perineal care after an incontinent BM. The CNA (#9) changed gloves and, without performing hand hygiene, placed a clean brief and assisted Resident #45 to a wheelchair. During an interview on the afternoon of 05/16/19, an administrative staff member (#1) stated she expected staff to follow appropriate hand hygiene procedures for infection control.",2020-09-01
29,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2018-06-28,576,C,0,1,ROZG11,"Based on policy review, resident group interview and staff interview, the facility failed to provide mail delivery on Saturday for 7 of 7 interviewed residents (Resident A, B, C, D, E, F, and G). Failure to provide mail delivery on Saturdays infringes on the residents' rights. Findings include: Review of policy titled Mail Distribution occurred on 06/27/18. This policy, dated (MONTH) 2013, stated, . delivers mail to the patient within 24 hours of receipt to the center. The resident group interview occurred on 06/26/18 at 10:37 a.m The residents stated they did not receive mail on Saturday. During an interview on 06/27/18 at 1:45 p.m., an administrative staff member (#1) confirmed the expectation is for mail to be delivered on Saturday. She reported staff are responsible for passing out mail on Saturday.",2020-09-01
30,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2018-06-28,644,D,0,1,ROZG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the North Dakota Provider Manual for Preadmission Screening and Resident Review (PASARR) and Level of Care Screening Procedures For Long Term Care Services, and staff interview, the facility failed to complete a status change assessment for 1 of 1 sampled resident (Resident #23) with a newly diagnosed mental illness since the facility completed the initial PASARR on admission. Failure to complete a change in status assessment may result in the delivery of care and services that are inconsistent with resident's needs. Findings include: The North Dakota PASARR Provider Manual page 13 states, . Change in Status Process . Whenever the following events occur, nursing facility staff must contact Ascend (name of contracted service provider for screening process) to update the Level I screen for determination of whether a first time or updated Level II evaluation must be performed. These situations suggest that a significant change in status has occurred: . If an individual with MI, ID, and/or RC (mental illness, intellectual disability, and conditions related to intellectual disability (referred to in regulatory language as related conditions or RC)) was not identified at the Level I screen process, and that condition later emerged or was discovered. Review of Resident #23's medical record occurred on all days of survey. The record showed an initial PASARR completed on 03/12/12 and identified dementia and no mental illness. The screening stated, . The Level I Screen conducted for the above named individual determined that there was not evidence to suggest presence or known conditions of mental illness . Resident #23's medical record identified [DIAGNOSES REDACTED]. The record lacked evidence the facility completed a Level II assessment following the new [DIAGNOSES REDACTED]. During an interview on 06/28/18 at 8:40 a.m., a supervisory social service staff member (#3) confirmed the facility failed to submit a PASARR for Resident #23 following the additional [DIAGNOSES REDACTED].",2020-09-01
31,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2018-06-28,657,D,0,1,ROZG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility policy and staff interview, the facility failed to review and revise comprehensive care plans to reflect the resident's current status for 2 of 18 sampled residents (Resident #2 and #71). Failure to review/revise the care plan to reflect each resident's current status limited the staff's ability to communicate needs and ensure continuity of care for the residents. Findings include: Review of the policy titled, Interdisciplinary Care Planning occurred on 06/27/18. This policy, updated (MONTH) (YEAR) stated, . The patient's care plan is a communication tool that guides members of the interdisciplinary healthcare team in how to meet each individual patient's needs. It also identifies the types and methods of care that the patient should receive . The care plan should include patient-specific measurable objectives . identifying risk versus benefits of the current interventions . incorporate the patient's personal and cultural preferences. - Review of Resident #2's record occurred on all days of the survey. The Quarterly Minimum Data Set (MDS), dated [DATE], identified Resident #2 as requiring the assistance of two staff for transfers and toileting, assistance of one staff for dressing and eating and only set up help with personal hygiene. The current care plan stated, . activities of daily living (ADL) self care deficit . Assist with daily hygiene, grooming, dressing, oral care and eating as needed. The certified nursing assistant (CNA) care card showed, . ADL assist-usually 2 person with minimum (min) level of assist . provide assistance with toileting. Observation on 06/26/18 at 9:00 a.m., showed a CNA (#14) assisted Resident #2 from her wheelchair (WC) to her bed using a gait belt and a pivot transfer. Observation on 06/27/18 at 8:08 a.m., showed an unidentified CNA transferred Resident #2 from the toilet to her WC with a gait belt and pivot transfer. During an interview on 06/28/18 at 11:15 a.m., an administrative nurse (#2) stated Resident #2's care plan does not reflect the current ADL needs of the resident. - Review of Resident #71's record occurred on all days of the survey. The admission MDS, dated [DATE], identified Resident #71 required assist of two with bed mobility, transfers and toileting. The current care plan stated, . ADL self care deficit as evidenced by assist of one to two to complete ADLs . Transfer with sit to stand mechanical lift (EZ stand) and 2 assist . Assist with daily hygiene, grooming, dressing, oral care and eating as needed. The CNA care card showed, . ADL assist-usually 2 persons with maximum (max) level of assist . transfer with sit to stand mechanical lift (EZ stand) and 2 assist. Observation on 06/26/18 at 9:24 a.m., showed a CNA (#9) assisted Resident #71 from her WC to her bed using a gait belt and a pivot transfer. During an interview on 06/28/18 at 10:50 a.m. , a CNA (#9) stated Resident #71, transfers with a gait belt and assistance of one. No she does not use the EZ stand lift. The current care plan's failed to accurately reflect the level of assistance Resident #2 and #71 required for assistance with ADL's.",2020-09-01
32,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2018-06-28,658,D,0,1,ROZG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, review of professional reference, and staff interview, the facility failed to administer medications in accordance with acceptable standards of practice for 1 of 1 resident (Resident #16) with a physician's orders [REDACTED]. Failure to follow acceptable standards of practice for medication administration has the potential to result in medication errors and/or adverse reactions for the resident. Findings include: Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 10th Edition, (YEAR), Pearson, Boston, Massachusetts, page 776, states . Administering Oral Medications . Preparation: . 2. Check the MAR (medication administration record). Check for the drug name, dosage, frequency, route of administration, . If the MAR is unclear or pertinent information is missing, compare the MAR with the prescriber's most recent written order. Performance. 3. Obtain the appropriate medication. Read the MAR and take the appropriate medication . Compare the label of the medication container or unit-dose package against the order on the MAR . 4. Prepare the medication. While preparing the medication, recheck each prepared drug and container with the MAR again. Rationale: this second safety check reduces the chance of error. During an interview on 06/26/18 at 9:37 a.m., Resident #16 stated her digestive system problems cause some of her pills to pass through without even dissolving, so the doctor said to crush those pills. Resident #16 stated some nurses crush the pills, and others don't. It says it right on the record, but I have to keep telling staff. Review of Resident #16's medical record occurred on all days of survey. The physician's orders [REDACTED]. and recommend crushing this med. Review of the (MONTH) MAR on 06/27/18, identified the following: 6/20/18 [MEDICATION NAME] 30 mg (milligrams) po (by mouth) BID (two times a day) Crush. Observation of medication pass occurred on 06/28/18 at 7:54 a.m. The nurse (#12) placed 19 oral medications in a medication cup (for a total of 21 pills). The nurse (#12) stated one of the tablets needs to be crushed but she does not know which one and would need to ask the resident. The nurse emptied the pills from the medication cup into Resident #16's hand and asked the resident which of the pills needed to be crushed. Resident #16 initially expressed frustration and said she was not sure, but then began to identify each of the pills in her hand and found the two pills that should be crushed. The pills were identified as two 15 milligram tablets of [MEDICATION NAME]. The nurse went to the medication cart, crushed the medications, mixed them in applesauce, and administered them to the resident. During an interview on the afternoon of 06/28/18, two administrative staff members (#1) and (#2) confirmed the nurse should refer to the physician's orders [REDACTED].",2020-09-01
33,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2018-06-28,686,D,1,1,ROZG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 05/10/17 Based on information provided by the complainant, observation, record review, resident and family interview, and staff interview, the facility failed to provide the necessary care and services to prevent the development of pressure ulcers and promote healing, for 1 of 4 sampled residents (Resident #22) with pressure ulcers. Failure to evaluate risk factors that may impact the development/healing of a pressure ulcer, implement, monitor and modify interventions to reduce those risk factors, resulted in Resident #22 developing avoidable, facility acquired pressure ulcers and may result in the development of new ulcers. Findings include: The complainant identified Resident #22 was admitted to the hospital on [DATE] with multiple areas of skin breakdown. Review of Resident #22's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. During an observation on 06/26/18 at 9:45 a.m. two certified nursing assistants (CNAs), (8# and #9) assisted Resident #22 with perineal cares. While staff performed cares, Resident #22 called out in pain and moaned. His buttocks, peri area, and scrotum were excoriated, his penis reddened and ulceration noted to the foreskin. He had an indwelling foley catheter. Current physician orders [REDACTED]. A quarterly MDS (Minimum Data Set), dated 05/28/18 identified frequent incontinence of bowel and bladder, extensive assistance of two persons for bed mobility, toileting and total dependence for transfers. The current care plan stated, . Self care deficit as evidenced . hands on staff assist with bed mobility, transfers, toileting . Skin care: . At risk for alteration . related to incontinence . barrier cream to peri area, buttocks . observe skin condition with ADL(Activities of Daily Living) care daily - report abnormality . Although Resident #22 was identified as frequently incontinent of bowel and bladder, his care plan failed to address his incontinence and provide specific interventions to prevent skin breakdown. Review of a Braden Scale (an assessment for predicting pressure sore risk), dated 05/04/18 and 06/05/18, identified a risk for pressure ulcers. A facility policy on skin conditions/pressure ulcers, was requested and the facility provided a Skin Practice Guide Process Flowchart. Review of Resident #22's medical record identified facility staff failed to follow the process as indicated by the flowchart. Resident #22's progress notes identified the following: * 05/07/18 Groin is pink. Only documentation regarding skin condition for the month of May. The next entry, 33 days later identified: * 06/10/18 Open area on back of testicles, 1 cm(centimeters) x 1 cm. Open area on left buttocks returned. * 06/17/18 Excoriation on right and left buttocks. Skin red and firm. Redness blanchable. Redness and excoriation peeling. Some areas on excoriation has scant amount of thin/red drainage noted measuring approx 15 cm x 15 cm. Testicle red/firm/swelling. Redness blanchable. Wound located on right testicle 1 cm x 1 cm Edges approximated. Second wound located on right testicle measuring 2.5 cm x 1 cm. Edges approximated. Black eschar noted (tissue that adheres firmly to the wound bed or ulcer edges). Small open area on left testicle 1 cm x 1 cm. Edges approximated dark/pink/red tissue noted, scant amount of thin red drainage noted. Writer left Situation Background Assessment and Recommendation (SBAR) for Nurse Practitioner (NP) to assess areas. New order for ointment to apply topically 3 x/day and as needed (PRN) to buttocks, peri area and excoriation. * 06/18/18 Resident transferred to emergency department (ED). Blood sugar (BS) of 1085 and Sodium (Na) of 126. * 06/23/18 Resident returned from hospital. Wound recommendation was put in for wound on back of penis/testicle. Resident continent of bowel and bladder (B&B). Has a foley catheter. Uses a bedpan. Is incontinent of B&B at times. * 06/24/18 the progress note showed: 1) Open area right testicle- 1 cm x 1 cm, yellow slough present. 2) 2nd open area right testicle 3.5 cm x 2 cm. 3) open area left testicle 1 cm x 1 cm. 4) Excoriation noted left buttocks. 5) Rash noted on right and left groin - raised bumps zero drainage. 6) Open wound on top of penis/foreskin - 2 cm x 2 cm yellow slough present - scant amount red/thin drainage. * 06/24/18 Resident requested to stay in bed all shift, was repositioned at routine intervals. During an interview on 06/26/18 at 4:28 p.m., Resident #22's wife stated she is aware of him being left on a bed pan for an hour. She stated it happened about a month ago. She also indicated he was hosptalized on [DATE] for high blood sugar and an infection. During an interview on 06/28/18 at 11:15 a.m., Resident #22, who has a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact), reported sometimes he is on the bed pan for a long time because he falls asleep and staff failed to check on him after they put him on the bed pan. During an interview on 06/28/18 at 4:00 p.m. regarding Resident #22's pressure ulcers/skin breakdown, the administrative nurses (#1) and (#2) provided no further information.",2020-09-01
34,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2018-06-28,692,D,1,1,ROZG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, record review, observation and staff interview, the facility failed to provide sufficient fluid intake to maintain proper hydration and health for 1 of 1 sampled resident (Resident #22) hospitalized for [REDACTED]. Failure to frequently offer fluids placed residents at risk for dehydration, UTI, and fluid/electrolyte imbalances. Findings include: Review of the facility's Hydration Practice Guide Flowchart, dated 2012, stated: Prompting patients to consume fluids and hydrate themselves is the single most effective approach in maintaining fluid balance . prompting to drink fluids is paired with toileting activities. Review of Resident # 22's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Current physician orders [REDACTED]. Current medications included [MEDICATION NAME] (diuretic) 20 milligram (mg) 1 tablet daily by mouth. The resident's care plan identified, . Risk for alteration in hydration related to diuretics, disease process/conditions, . times of pain, times of dry mouth, states he doesn't drink enough water, . dysphagia with thickened liquids at meals and thin liquids between meals per physician/mid-level order, . offer encourage and assist patient with fluids and between meals as needed. Observation on 06/26/18 at 9:45 a.m. showed two certified nursing assistants (CNAs) (#8 and #9) assisted Resident #22 with perineal cares, however, failed to offer fluids upon completion of cares. Observation on 06/27/18 at 11:39 a.m. showed two CNAs (8# and #7) assisted Resident #22 with perineal cares, however, failed to offer fluids upon completion of cares. During an interview on 06/28/18 at 4:00 p.m., an administrative nurse (#2) stated the staff are to offer fluids with cares and throughout the day.",2020-09-01
35,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2018-06-28,698,D,0,1,ROZG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility policy and procedure, resident interview, and staff interview, the facility failed to ensure residents received the care and services consistent with professional standards of practice for 1 of 2 sampled residents (Resident #63) receiving [MEDICAL TREATMENT] outside the facility. Failure to assess the [MEDICAL TREATMENT] vascular access site (central venous catheter) can result in complications with access function, infection, and possible loss of the access site. Findings include: Review of the facility policy/procedure titled [MEDICAL TREATMENT] Guidelines occurred on 06/28/18. This policy, dated (MONTH) (YEAR), stated, . Guidelines: . A coordinated comprehensive care plan for [MEDICAL TREATMENT] treatments is developed with input from both the interdisciplinary team (IDT) and [MEDICAL TREATMENT] facility staff. Both the center and the [MEDICAL TREATMENT] facility are responsible for shared communication regarding patients receiving [MEDICAL TREATMENT] served, either onsite or offsite. Collaborative communication includes information regarding: . [MEDICAL TREATMENT] adverse reactions/complications and/or recommendations for follow up observations and monitoring including those related to the vascular access site . During an interview on 06/25/18 at 4:04 p.m., Resident #63 stated he/she has a [MEDICAL TREATMENT] catheter (a tube placed in a large central vein in the chest) and a fistula (an artery and a vein connected together under the skin to provide access to the blood) in his/her arm for [MEDICAL TREATMENT]. Observation showed a central venous catheter (CVC) with a dressing on Resident #63's upper right chest and a dressing over his/her left arm fistula. Review of Resident #63's medical record occurred on all days of survey. Resident #63's medical conditions are such that he/she requires treatment for [REDACTED].#63's current care plan failed to identify his/her central venous catheter, or the risks/complications, or care of the catheter. During an interview on the afternoon of 06/27/18, a supervisory nurse (#6) stated the nurses would assess the catheter during the weekly skin assessments. Review of the nursing progress notes and skin assessments failed to show evidence nursing staff monitored Resident #63's central venous catheter site.",2020-09-01
36,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2018-06-28,757,D,1,1,ROZG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and staff interview, the facility failed to ensure each resident's medication regimen was free of unnecessary drugs for 1 of 14 sampled residents (Resident #9) identified as having severe/moderate pain. Failure to ensure adequate indications for increasing the dosage of the drug limited Resident #9's ability to reach or maintain her highest practicable mental, physical, and psychosocial well-being. Findings include: Observation on 06/25/18 at 3:22 p.m. and 06/26/18 at 4:22 p.m. showed Resident #9 sleeping in her bed. Observation on 06/27/18 at 11:15 a.m. showed resident sleeping in her wheelchair with her head down. Observation on 06/26/18 at 12:25 p.m., showed Resident #9 in the dining room slowly eating independently. The resident fell asleep numerous times throughout the meal. Observation on 06/27/18 at 8:37 a.m. and 06/27/18 at 12:31 p.m. showed the resident asleep with food in front of her at the dining table. Observation on 06/27/18 at 11:17 a.m., showed two certified nursing assistants (CNAs) (#10 and #11) attempted to wake Resident #9, who was asleep in her wheelchair in her room. The CNAs were unable to fully wake the resident. The resident did not open her eyes or lift her head. Resident #9 responded with groans when asked if she wanted to transfer to the toilet. A CNA (#10) stated, Recently, she is hard to wake up sometimes. If she does not wake up, instead of transferring her to the toilet, we check and change her in the bed. The CNAs transferred the resident to the bed and provided cares. The resident did not open her eyes or respond verbally while cares were done. The resident followed commands and groaned. Review of Resident #9's medical record on 06/27/18 showed a daily pain assessment documented as 0 for all of (MONTH) 1-31, (YEAR). Pain/Pain Assessment in Advanced Dementia Evaluation, entered on 05/09/18, indicated pain level of 0. The quarterly Minimum Data Set, dated dated [DATE], identified no presence of pain. A review of the physician's orders [REDACTED]. (was discontinued 05/16/18) . Increase [MEDICATION NAME] to 50 mg twice daily 5/16/18. Review of a progress note, dated 04/17/18, written by an activities staff member, stated . Care conf. (conference) held. (sic) in (Resident #9's) room. This writer present. (Resident #9) is alert, smiling and talkative through out. Dietary: 4/16 128.8# (pounds). Has had significant weight loss. Intakes vary on alertness, but recently downgraded to dysphagia mech. (mechanical) soft. Activities: Cont. (continue) to attend act. (activities) such as religious services, exercise, and socials. Often falls asleep requiring cues to stay awake and engage in activity. Nsg (nursing): A/O (alert/oriented) to self only. Vitals WNL (within normal limits). No pain issues. A provider note, dated 05/16/18, stated, (Resident #9) is a [AGE] year old female who is seen today at the request of staff for concerns of a rash on her lower legs and for increased pain, not controlled by her current regime. I do not see a rash on her lower legs. She does appear uncomfortable and I did increase [MEDICATION NAME] to 50 mg twice daily. In an interview on 06/28/18 at 1:41 p.m., an administrative nurse (#6) stated she could not find documentation of increased pain for Resident #9.",2020-09-01
37,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2018-06-28,804,E,0,1,ROZG11,"Based on observation, review of facility policy, group interview, resident interview, and staff interview, the facility failed to serve food at palatable and appetizing temperatures for 7 of 7 residents attending the group interview (Resident A, B, C, D, E, F, and G) and 4 of 11 sampled residents (Resident #16, #25, #35, and #65) interviewed. Failure to serve foods at a temperature acceptable to residents may result in decreased intake, weight loss, and inadequate nutrition. Findings include: Review of the facility policy titled Food Temperatures at Point of Service occurred on 06/28/18. This policy, dated (MONTH) 2014, stated, The regulation that addresses food temperatures at point of service to the patient . 'each patient receives and the facility provides: (1) Food prepared by methods that conserve nutritive value, flavor, and appearance; (2) Food that is palatable, attractive, and at the proper temperature.' The intent . states that 'Food should be palatable, attractive and at the proper temperature as determined by the type of food to ensure patient's satisfaction.' . A temperature or range of temperatures at point of service is not defined in the regulation or Guidance to Surveyors. Patient acceptance is used as a guide and consideration is given to the time the food sits at temperatures between 135 (degrees) Fahrenheit (F) and 41 degrees F. The resident group interview occurred on 06/26/18 at 10:37 a.m. The residents who attended group reported the food is always at least 30 minutes late, can be as late as 90 minutes, and the food is always cold. - During an interview, the morning of 06/25/18, Resident #65 stated that his food is sometimes cold because his tray will come without silverware or condiments, and by the time they bring the items to him, the food is cold. - During an interview on 06/26/18 at 9:47 a.m., Resident #16 stated she is the last person to get served her meal tray and the food is cold when I get it. - During an interview on 6/26/18 at 10:55 a.m., Resident #25 stated the food is not served on time and the temperature of the food is fair. - During an interview on 06/26/18 at 1:30 p.m. Resident #35 stated the food is bad and thinks he is losing weight. Observation of tray-line occurred on 06/26/18 at 12:24 p.m. Observation showed one dietary staff member dishing the food on the plates and setting them on top of the counter. Observation showed up to 4 uncovered plates at a time on top of the counter waiting to be placed on a tray and covered with an insulated cover. During an interview on the morning of 06/28/18, an administrative dietary staff member (#12) acknowledged a problem with late meals and confirmed the plates should not sit on the counter uncovered. Failure to serve foods at palatable temperatures may negatively impact residents' meal consumption.",2020-09-01
38,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2018-06-28,809,E,0,1,ROZG11,"Based on observation, review of facility policy, resident interview, resident group interview, and staff interview, the facility failed to provide meals in a timely manner according to resident needs, preferences, and requests for 5 of 11 sampled residents interviewed (Resident #6, #16, #25, #31, and #35) and for 7 of 7 residents attending the resident group interview (Resident A, B, C, D, E, G, and F). Failure to provide timely meal service and snacks can negatively impact the dining experience and has the potential to cause adverse reactions for residents receiving medications such as short acting insulin. Findings include: Review of the facility policy titled Meal Schedules, occurred on 06/28/18. This policy, dated (MONTH) 2014, stated, . Guidelines: 1. Requests for different meal times for individual patients are reviewed and accommodated as possible. 6. According to the Investigative Protocol for Dining and Food Service from the Survey Procedures for Long Term Care Facilities, meals should arrive no later than 30 minutes past the scheduled meal time. The facility meal times for Dakota Dining were as follows: * Breakfast at 8:00 a.m. * Lunch at 12:00 p.m. * Dinner at 6:00 p.m. Observation of the noon meal in the Dakota Dining room occurred on 06/25/18 between 12:00 p.m. and 1:10 p.m. and showed numerous residents commenting about the food being late. Meal service started 45 minutes after the scheduled 12:00 p.m. meal time. During an interview on 06/25/18 at 4:06 p.m., Resident #6 reported he missed lunch today due to an appointment, and he returned to the facility at 2:30 p.m. Resident #6 was currently eating ice cream for an afternoon snack, but stated staff did not offer him a meal. Resident #6 stated this is not the first time this has happened. Observation on 6/26/18 at 8:24 a.m. showed Resident #31 in his room waiting for his breakfast tray, and 8:50 a.m. he received his breakfast tray. The resident group interview occurred on 06/26/18 at 10:37 a.m. All residents who attended group reported the food is always at least 30 minutes late, and can be as late as 90 minutes. They stated evening snacks are not always served and the facility runs out of food such as yogurt, bananas, and peanut butter. One resident stated he/she gets snacks in the evening about 2-3 times per week and states if you miss a meal they do not offer a meal when you return. -During an interview on 06/26/18 at 9:47 a.m., Resident #16 stated she is the last person to get served her meal tray and the food is cold when I get it. Resident #16 stated she received her lunch at 1:20 p.m. yesterday and the night before her tray arrived at 7:20 p.m. She stated the trays usually arrive after 7:00 p.m. and the facility runs out of food. - During an interview on 6/26/18 at 10:55 a.m., Resident #25 stated the food is not served on time and the noon and supper meals are the worst. - On 6/26/18 at 4:21 p.m., Resident #31, who eats meals in his room, stated I have to wait for for my food sometimes, it depends on the day. - During an interview on 06/26/18 at 1:30 p.m. Resident #35 stated that he is hungry most of the time and that the aids (certified nurse assistants) told him he is not allowed more food due to his special diet. He stated he gets snacks about fifty present of the time. During an interview on the morning of 06/28/18, a administrative dietary staff member (#12) acknowledged a problem with late meals and delivery of meals.",2020-09-01
39,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2018-06-28,880,D,0,1,ROZG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, record review, observation, and staff interview, the facility failed to ensure staff followed appropriate infection control practices for 1 of 3 sampled residents (Resident #6) on contact precautions. Failure to follow appropriate infection control practice related to disinfecting equipment may result in the spread of infection within the facility. Findings include: Review of the policy titled Transmission Based Precautions occurred on 06/28/18. This policy, dated (MONTH) 2013, stated, . Patient Care Equipment . Clean and disinfect equipment between patients. Review of Resident #6's medical record on 06/26/18 indicated the resident was on contact precautions due to [MEDICAL CONDITION]-resistant Staphylococcus aureus in the resident's abdominal wound. Observation on 06/26/18 at 2:10 p.m. showed two Certified Nursing Assistants (CNAs) (#4 and #5) removed a Hoyer Lift from Resident #6's room and placed it across the hall in the equipment room. The CNAs failed to disinfect the lift prior to the next use. During an interview on 06/26/18 at 2:15 p.m. with two CNAs (#4 and #5), they stated staff disinfect lifts daily. During an interview on 06/28/18 at 3:20 p.m., an administrative nurse (#6) stated she expected staff to disinfect lifts after every use when used on a resident on contact precautions.",2020-09-01
40,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2018-12-06,565,E,1,0,PNS511,"> Based on information provided by the complainant, observations, review of monthly Resident Council meeting minutes, and resident, family, and staff interviews, the facility failed to actively seek a resolution to resident grievances related to delayed responses to call lights expressed by 9 of 10 sampled residents (Residents #1, #2, #3, #4, #6, #7, #8, #9, and #10). Failure to act upon the resident/family grievances regarding staff response time to call light resulted in continued dissatisfaction. Findings include: The facility failed to provide a copy of their policies addressing call lights and resident and/or family/representative grievances upon request. Information provided by the complainants indicated they had been contacted by residents who expressed frustration waiting for staff to respond to their call lights and/or who experienced pain/discomfort related to skin breakdown due to incontinence. Observations showed the following: * On the morning of 12/06/18, a bathroom call light remained unanswered from 8:02 a.m. until 8:24 a.m. (22 minutes). * 12/06/18 at 8:25 a.m., Resident #3 lying in bed. His call light, hanging over the top of the night stand, and not within reach. * 12/06/18 at 10:35 a.m., Resident #3 lying in bed. His call light, hanging over the top of the night stand, and not within reach. Resident reached for his call light and was unable to access it. A sign, posted on the wall, stated, Please keep call light clipped to the sheet and within reach. Review of Resident Council Meeting minutes, dated June-November (YEAR), occurred on 12/06/18. The meeting minutes identified residents voiced the following concerns : * August, . certified nursing assistants (CNAs) . make roommate wait. Roommate can't use (his/her) call light. CNA refused to help another pt (patient) . * September, . CNAs don't answer call lights timely in the a.m. * October, . (Resident) - slow call lights concern form filled (out). Resident and Family/Representative interviews identified the following: * 12/05/18 at 5:05 p.m., Resident #10 (identified by the facility as interviewable) stated, Last night, I sat all night in a dirty diaper. The call light was unplugged. That's a long time . all night. That's a long time to have a dirty diaper. No one was in here at all last night. They kind of ignore me. I don't know if they don't like me or what. * 12/05/18 at 5:30 p.m., Resident #9 (identified by facility as interviewable) stated, I've had to wait 45 minutes for staff to answer my call light. It took so long that I wet my pants. * 12/05/18 at 5:42 p.m., Resident #6's family member reported often waiting 15-20 minutes for staff to respond to Resident #6's call light. The family member also reported Resident #6 is a fall risk. * 12/05/18 at 5:55 p.m. Resident #1 reported often having to wait for over an hour to use the bed pan. Resident #1 stated, I limit the amount of water I drink depending upon who is working, because I know (staff) will take a long time to answer my light. Resident #1 also reported having wet the bed waiting for staff to answer the call light. * 12/05/18 at 6:10 p.m. Resident #2 stated, I have to wait a long time, 60-90 minutes sometimes, for (staff) to answer my call light. * 12/05/18 at 6:15 p.m., Resident #4 (identified by the facility as interviewable) reported waiting multiple times, for up to an hour, for staff to answer her call light. Resident #4 then described one occurrence in detail, where she turned on her call light for a pain pill. Resident #4 reported a staff member entered her room, turned off her call light, told her she would notify the nurse, and left the room. A nurse offered her a pain pill one hour and forty-five minutes later. Resident #4 then stated she continued to have pain and turned her call light on several times throughout the evening. In frustration, she called a family member, asking them to call the facility in an effort to get someone to answer her light. * 12/06/18 at 7:50 a.m., Resident #10 pointed to her call light and stated, I rang the bell here. I finally got up and went in there (bathroom). I rang the bell in there. Took them forever. About twenty-five minutes, I was sitting there this morning. I'm so discouraged. * 12/06/18 at 8:00 a.m., Resident #7 (identified by facility as interviewable) stated, I put my call light on one day and had to wait 45 minutes before staff answered the light. Resident #7 reported being told staff failed to answer the light because a physical therapist was present in the room. * 12/06/18 at 8:15 a.m., Resident #8 (identified by facility as interviewable) reported waiting for up to one hour for staff to answer the call light. * 12/06/16 at 10:15 a.m., Resident #4's family member confirmed Resident #4 had called them at home asking them to contact the facility for assistance. * 12/06/18 at 10:50 a.m., Resident #10 shifted her weight as she laid on the bed and stated, My butt is so sore! The (staff) are getting so disgusted checking my diaper. I hate to do it (pointed towards call light). During a staff interview on 12/06/18 at 10:55 a.m., a CNA (#4) stated Resident #10 puts on (her) call light. If we're helping someone else, she will self-transfer to (the) bathroom. During a staff interview on 12/06/18 at 2:45 p.m., when asked the facility's expectation regarding staffs' response to call lights, an administrative nurse (#1) stated, I believe it's two minutes. Failure of the facility to act upon the resident/family grievances regarding call light response times resulted in resident incontinence/possible skin breakdown, safety concerns due to residents self-transferring, and continued frustration and dissatisfaction.",2020-09-01
41,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2018-12-06,657,D,1,0,PNS511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 06/28/18. Based on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise comprehensive care plans to reflect the resident's current status for 1 of 10 sampled residents (Resident #10). Failure to review/revise care plans to reflect each resident's current status limited the staffs' ability to communicate needs and ensure continuity of care for the residents. Findings include: The facility failed to provide a copy of their policy addressing resident care plans upon request. Review of the facility's policy titled Weight Assessment and Intervention occurred on 12/06/18. This policy, dated (YEAR), stated, . (Careplanned) Interventions for undesirable weight loss shall be based on careful consideration of . Resident choice and preferences . The use of supplementation . Review of Resident #10's medical record occurred on all days of survey. The record identified a [DIAGNOSES REDACTED]. - Resident #10's bathing record identified an initial bath on 11/26/18 (eight days post admission to the facility). The current care plan stated, . Focus: Resident has a potential for self care deficits . Interventions: . Assist resident with activities he/she is unable to perform independently. Encourage patient to perform minimal oral-facial hygiene as soon after rising as possible. Assist with brushing teeth and shaving, as needed. Resident #10's current care plan failed to address her bathing needs. - Resident #10's physician's orders [REDACTED]. Apply to rectum topically BID (twice daily). Donut cushion to minimize perineal discomfort with sitting. The current care plan stated, . Focus: Skin integrity impaired: redness to perineum area secondary to diarrhea r/t (related/to) [MEDICAL CONDITION] . Interventions: Maintaining clean, dry skin provides a barrier to infection. [NAME]ng skin dry instead of rubbing reduces risk of dermal trauma to fragile skin. Monitor for s/s (signs/symptoms) of infection . Notify MD (medical doctor) as needed. The care plan failed to reflect Resident #10's need for a physician-prescribed barrier cream and/or a pressure relieving device. - Resident #10's Nutritional Assessment, dated 11/20/18, identified, . Other Food Likes/dislikes . Does not drink milk. The facility provided a copy of Resident #10's current snack schedule. The schedule identified, Dislikes . Wheat Bread . Pancakes . and . All Days (receives) . Boost Vanilla Observations on (MONTH) 5-6, (YEAR) showed dietary staff placed milk on Resident #10's meal trays. Resident #10 did not drink the milk, and made several comments regarding her food preferences. The current care plan identified, . Focus: Potential for or presence of altered nutrition needs related to . selective food preferences, unwillingness to accept nutritional supplements . Interventions: Encourage food and fluid intake . Snacks provided as scheduled . The care plan failed to reflect Resident #10's choices/preferences and/or supplementation as specified in the facility's policy. During an interview on 12/06/18 at 1:30 p.m., when asked questions pertaining to Resident #10's care plan, an administrative nurse (#1) confirmed staff failed to revise her care plan to include her bathing needs, physician-prescribed barrier cream and/or a pressure relieving device, and food choices/preferences and/or supplementation as specified in the facility's policy.",2020-09-01
42,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2018-12-06,677,D,1,0,PNS511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on information provided by the complainants, record review, review of facility policy, and staff interview, the facility failed to assist with activities of daily living (ADLs) for 1 of 10 sampled residents (Resident #10) who required staff assistance for bathing. Failure to provide assistance to residents who cannot perform the bathing task independently may result in poor personal-hygiene and decreased self-esteem. Findings include: Information provided by the complainants indicated residents are not bathed regularly, and are observed with greasy hair. Review of the facility policy titled Activities of Daily Living (ADLs) occurred on 12/06/18. This policy, dated (YEAR), stated, . Appropriate care and services will be provided for resident who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with . Hygiene (bathing, dressing, grooming, and oral care) . - Review of Resident #10's medical record occurred on all days of survey. The record identified a [DIAGNOSES REDACTED]. The current care plan stated, . Focus: Resident has a potential for self care deficits . Interventions: . Assist resident with activities he/she is unable to perform independently. Encourage patient to perform minimal oral-facial hygiene as soon after rising as possible. Assist with brushing teeth and shaving, as needed. Resident #10's current care plan failed to address her bathing needs. Resident #10's bathing record identified an initial bath on 11/26/18 (eight days post admission to the facility). Staff documented not applicable and/or resident not available on four occasions during the time period between admission and her first bath. During an interview on 12/06/18 at 1:30 p.m., when asked questions pertaining to Resident #10's bathing schedule, an administrative nurse (#1) confirmed staff failed to bathe Resident #10 during the initial eight days of her stay. The nurse (#1) was unable to explain the not applicable notations in her record.",2020-09-01
43,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2018-12-06,684,G,1,0,PNS511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on information provided by the complainants, observation, record review, review of professional reference, and resident/staff interviews, the facility failed to provide the necessary care/services to treat 1 of 10 sampled residents (Resident #10) with skin breakdown and pain/discomfort. Failure to monitor Resident #10's skin condition and provide physician-prescribed interventions in a timely manner contributed to her existing skin breakdown and resulted in her experiencing avoidable pain/discomfort. Findings include: Information provided by the complainants indicated facility staff failed to identify possible risk factors contributing to residents' skin conditions and failed to provide the care/services necessary to prevent further skin breakdown. The complainants reported having been contacted by residents who were frustrated waiting for staff to respond to their call lights and/or who experienced pain/discomfort secondary to skin breakdown/being soiled. The facility failed to provide a copy of their policy addressing skin conditions/pressure ulcers upon request. Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 10th ed., Pearson Education, Inc., New Jersey, pages 828 and 862, states, . Many medications increase (skin) sensitivity . [MEDICAL CONDITION] drugs [MEDICAL CONDITION] . Several factor increase the risk for the development of pressure ulcers: immobility and inactivity, inadequate nutrition, fecal and urinary incontinence . and certain chronic medical conditions. Nursing interventions to prevent the formation of pressure ulcers include conducting ongoing assessment of risk factors and skin status, providing skin care to maintain skin integrity, ensuring adequate nutrition and hydration . providing supportive devices . - Review of Resident #10's medical record occurred on all days of survey. The record identified [DIAGNOSES REDACTED]. The current physician's orders [REDACTED]. * 11/26/18, [MEDICATION NAME] (an over-the-counter skin protectant ointment) - Apply TID (three times daily) to affected gluteal, perineal, and vulvar areas. * 12/03/18, [MEDICATION NAME] 0.2% - [MEDICATION NAME] 2% in Lipovan Rectal Cream (a prescribed cream applied to relieve pain) . Apply to rectum topically BID (twice daily). Donut cushion to minimize perineal discomfort with sitting. * Undated, Monitor skin for breakdown . Q (every) shift. * Undated, Must complete all documentation for skin alterations on Saturday . A Braden Scale (a skin assessment), dated 11/19/18 (the evening of Resident #10's admission to the facility), identified, . Rarely Moist: Skin is usually dry, linen only requires changing at routine intervals . Chairfast: Ability to walk severely limited . Cannot bear own weight and/or must be assisted into chair or wheelchair. Slightly Limited (Mobility): Makes frequent though slight changes in body or extremity position independently. Adequate (Nutrition): Eats over half of most meals. Eats a total of 4 servings of protein . Occasionally will refuse a meal, but will take a supplement when offered . No Apparent Problem (Friction/Shear): Moves in bed and in chair independently and has sufficient muscle strength to lift up. It is unclear how staff determined Resident #10's skin was usually dry, her linens only required changing at routine intervals, she ate greater than 50% of most meals, ate 4 servings of protein daily, and/or occasionally refused meals. The current care plan identified the following: * . Focus: Resident is at risk for falls/injuries . Interventions: . Encourage resident to request assist whenever needed. * . Focus: Skin integrity impaired: redness to perineum area secondary to diarrhea r/t (related/to) [MEDICAL CONDITION] . Interventions: Maintaining clean, dry skin provides a barrier to infection. [NAME]ng skin dry instead of rubbing reduces risk of dermal trauma to fragile skin. Monitor for s/s (signs/symptoms) of infection . Notify MD (medical doctor) as needed. The care plan failed to reflect Resident #10's need for a physician-prescribed barrier cream and/or pressure relieving device. The progress notes identified the following: * 11/19/18, . Patient was admitted from (hospital) with a [DIAGNOSES REDACTED]. Patient has redness in groin areas and sacrum. * 11/20/18, . She uses call light for needs . * 11/22/18, . Patient is incontinent of B/B (bowel/bladder) . Assist of one for bed mobility and transfers. Patient stays in her room most of the time. * 11/25/18, Weekly skin assessment done, noted redness to her bottom and continuing with feces d/t (due/to) her illness. cleansed the area and treatment done as directed. * 11/26/18, Patient returned from (cancer center) with new orders to discontinue ammonium [MEDICATION NAME]. Start [MEDICATION NAME] to apply to gluteal/perianal and the vulvar areas three times a day. monitor skin for breakdown every shift. * 11/27/18, . Her coccyx area is excoriated from frequent diarrhea. Lac-Hydrine cream is burning her, so it will be d/c (discontinued) and [MEDICATION NAME] started. * 11/28/18, . Receiving [MEDICAL CONDITION] therapy and continuous chemo infusion for [MEDICAL CONDITION]. * 11/29/18, . Incontinent of B/B (bowel/bladder) maximum assist with all cares. Extensive assist with transfers and bed mobility. Pain management effective with Tylenol as when needed. * 11/30/18, . She is checked et (and) changed/repositioned on a routine basis. * 12/02/18, . She is routinely checked at night. Is able to direct own cares and does ask for assistance appropriately as needed. Assist with toileting needs. Assist with transfers, pt. did remain in room . resident is thin and skin intact with redness to the perirectal area do (sic) to stool, treatments and incontinences (sic) treatment to area bid and prn (as needed). * 12/03/18, Pt . is slightly confused/forgetful at times. Assist with toileting needs, is incontinent at times. Transfers with assist. Pt. does remain in room . Extensive assist with toileting needs. Patient is HOH (hard of hearing) but can make needs known. patient ask (sic) for assistance appropriately. * 12/04/18, . makes needs known to staffs (sic). Extensive assist with care and toileting needs. No new open areas noted in the button (sic) and the perineal area. Pt. does remain in room . Pain management was effective with Tylenol when needed. In the (care) conference more attention to be paid to patient care and diet. No new skin areas of concern noted by this writer after lasted (sic) treatment was done at HS (hour of sleep) this shift. Though patient is noted to have more than 3-4 bathroom trips during one shift. One assist using her walker for toileting. During an interview on 12/05/18 at 5:05 p.m., Resident #10 (identified by the facility as interviewable) stated, Last night, I sat all night in a dirty diaper. The call light was unplugged. That's a long time . all night. That's a long time to have a dirty diaper. No one was in here at all last night. Resident #10 also reported a staff member working the evening/night shift had directed her to put the cream on herself. Observation showed Resident #10 lying in bed on a pressure-guard mattress, with her wheelchair next to the bed, a square (versus donut-shaped) pressure-relief cushion in place. During an interview on 12/06/18 at 7:50 a.m., Resident #10 pointed to her call light and stated, I rang the bell here. I finally got up and went in there (bathroom). I rang the bell in there. Took them forever. About twenty-five minutes, I was sitting there this morning. She then repeated her concern regarding the evening/night shift staff member who directed her to put the cream on herself. Observation showed Resident #10 lying in bed, squirming from side to side. When asked if she required assistance, she pointed towards her buttocks and stated, It itches. Then it hurts. It's irritated. It hurts so bad! A different med (medication) is coming from Pharmacy today. During an interview on 12/06/18 at 10:50 a.m., Resident #10 shifted her weight as she laid on the bed and stated, My butt is so sore! The girls are getting so disgusted checking my diaper. I hate to do it (points towards call light). During an interview on 12/06/18 at 10:55 a.m., when asked questions pertaining to Resident #10's toileting needs, a CNA (#4) stated Resident #10 puts on (her) call light. If we're helping someone else, she will self-transfer to (the) bathroom. When we provide toilet cares, (we) gently wipe (the) little sore on her buttocks. Just redness to her buttocks, but very painful! Put a little ointment on the rash. The CNA then showed the surveyor the tube of Peri-Guard ointment located in Resident #10's dresser drawer. The CNA (#4) also reported offering to assist Resident #10 to the bathroom if needed. Observation showed no personal cares or assistance to the bathroom from 7:50 a.m. and 10:55 a.m. When asked questions pertaining to the progress notes referencing changing and/or routinely repositioning Resident #10, the CNA (#4) reported staff chart at the end of their shift. She confirmed staff are not required to chart after each interaction. Observation on 12/06/18 at 12:48 p.m., showed a CNA (#4) assisted Resident #10 into the bathroom and provided toileting cares. Resident #10's coccyx appeared darkened, and her perineal/rectal area appeared reddened/raw-looking. Resident #10 voiced discomfort when the CNA (#4) applied Peri-Guard ointment to the reddened area. During an interview on 12/06/18 at 1:30 p.m., when asked questions pertaining to Resident #10's prescribed skin cream, an administrative nurse (#1) reported the facility received the physician's orders [REDACTED]. The nurse (#1) explained the pharmacy did not have that particular cream in stock and therefore contacted a second pharmacy to see if they had it in their inventory. The administrative nurse (#1) reported the Pharmacy delivered the cream on 12/05/18. Review of the Medication Administration Record [REDACTED]. When asked questions regarding the discrepancy, the administrative nurse (#1) stated, It (Lipovan rectal cream) may have hit the building late in the day. It should have been here (12/03/18). Staff should have called (her physician) that evening, and checked into another medication until it came in. During an interview on 12/06/18 at 3:40 p.m., an administrative nurse (#1) reported the facility currently does not have a policy regarding skin issues/pressure ulcers. The administrative nurse (#1) then stated he would expect nursing staff to complete the Braden Scale upon admission, weekly for three weeks, and every three months thereafter. After identifying Resident #10 as having [MEDICAL CONDITION] and skin breakdown, the facility failed to: * Develop a policy outlining staff expectations for providing skin care, * Identify the risk factors impacting Resident #10's ability to heal, including her need for high calorie foods/supplementation, prompt transfer/toileting assistance following each episode of incontinence, and a physician-prescribed barrier cream/pressure relieving device, * Accurately document Resident #10's baseline risk factors for developing a facility-acquired pressure ulcer, * Continue to monitor Resident #10's skin until they were able to determine no concerns existed for the development of a facility-acquired pressure ulcer, * Care plan Resident #10's need for a physician-prescribed barrier cream and specific pressure relieving device, and/or * Provide the care/services necessary to prevent further skin breakdown and/or avoidable pain/discomfort; including scheduled and/or prompt transfer/toileting assistance, Lipovan rectal cream, donut cushion, etc. See F565 and F692.",2020-09-01
44,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2018-12-06,692,D,1,0,PNS511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on information provided by the complainants, observation, record review, review of the professional references, review of facility's policy, and resident/staff interviews, the facility failed to address the needs and monitor weight for 1 of 1 sampled resident (Resident #10) already experiencing impaired nutrition. Failure to develop and implement interventions in a timely manner may result in Resident #10 experiencing impaired wound healing, a decline in function, and/or unplanned weight loss. Findings include: Information provided by the complainants indicated facility staff failed to provide snacks and/or supplements to residents at high risk for weight loss. The complainant also reported families/representatives were directed to purchase snacks for residents. Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 10th ed., Pearson Education, Inc., New Jersey, page 862, states, . Several factor increase the risk for the development of pressure ulcers: . inadequate nutrition . Nursing interventions to prevent the formation of pressure ulcers include . ensuring adequate nutrition and hydration . Review of the facility's policy titled Weight Assessment and Intervention occurred on 12/06/18. This policy, dated (YEAR), stated, . The nursing staff will measure resident weights on admission, and monitor until no weight concerns noted. The . multidisciplinary team may identify conditions . that may be . increasing the risk of weight loss. For example . Increased need for calories and/or protein . (Careplanned) Interventions for undesirable weight loss shall be based on careful consideration of . Resident choice and preferences . The use of supplementation . Review of Resident #10's medical record occurred on all days of survey. The record identified [DIAGNOSES REDACTED]. The current physician's orders [REDACTED]. * 11/19/18, [MEDICATION NAME] (an appetite stimulant) 40 mg/ml (milligrams/milliliters) suspension take 10 ml (400 mg) by mouth once daily. * Undated, Nepro supplement twice a day. The current Medication Administration Record [REDACTED]. A handwritten note stated, See P[NAME] (Plan of Care). The record lacked evidence Resident #10 received Nepro twice daily per order, that the order for Nepro had been discontinued after 11/20/18, and/or that another supplement had been ordered. A Braden Scale, dated 11/19/18 (the evening of Resident #10's admission to the facility), identified, . Adequate (Nutrition): Eats over half of most meals. Eats a total of 4 servings of protein . Occasionally will refuse a meal, but will take a supplement when offered . It is unclear how staff determined she ate greater than 50% of most meals, ate 4 servings of protein daily, and/or occasionally refused meals. A Nutritional Assessment, dated 11/20/18, identified, . Height . 60 (inches or 5 feet)Admitting Weight in LBs (pounds) . 86 . BMI (Body Mass Index) . 16.7 (Underweight = The facility provided a copy of Resident #10's current snack schedule. The schedule identified the following: * Dislikes . Wheat Bread . Pancakes * 11/20/18, MWF (Monday, Wednesday, Friday) EV (Evenings): 1 Bag Cheez-its * 11/26/18, Su, Tu, Th, Sa (Sunday, Tuesday, Thursday, Saturday) AM: 4 oz (ounces) 2% Milk (The schedule failed to reflect Resident #10's dislike of milk.) . EV: 4 oz Vanilla Ice Cream . MWF EV: 4 oz Grape Juice . PM: 4 oz Vanilla Ice Cream * 11/30/18, Su, Tu, Th, Sa PM: 1/2 cup Cheese Cubes . EV: 3 Packs Saltine Crackers * 12/04/18, MWF AM: Margarine & Mayo w (with)/Sandwich . 1/2 [NAME] Meat and Cheese Sandwich * 12/05/18, All Days . BR (Breakfast): [NAME] Toast, PB (peanut butter), Jelly . PM: 8 oz (ounces) Boost Vanilla The current care plan identified, . Focus: Potential for or presence of altered nutrition needs related to . selective food preferences, unwillingness to accept nutritional supplements, BMI (body mass index) The progress notes identified the following: * 11/19/18, . Dinner was served . Consumed about 50%. * 11/20/18, . appetite is fair . Snacks . encouraged. * 11/21/18, New orders per (Physician) for Boost Liquid Supplement four times daily. The current physician's orders [REDACTED].>* 11/28/18, Nutrition Admission Assessment . (Staff re-entered data from the nutritional assessment completed on 11/20/18, nine days prior to this entry. The progress note failed to accurately reflect Resident #10's weight, current physician's orders [REDACTED].) * 12/02/18, . appetite is fair. resident is thin . * 12/04/18, . wt 86# (pounds), eats 50-100% of meals on an enhanced diet, on an appetite stimulant. Receiving scheduled snacks. Dislikes most nutritional supplements. In the (care) conference more attention to be paid to . diet. Patient appetite fair most of the time. Encouraged . snacks. Observation showed the following: * 12/05/18 at 6:05 p.m., Resident #10 received a supper tray containing a pimento (pepper) and cheese with mayonnaise sandwich, green beans, pudding, coffee, milk (despite her dislike for milk), and grape juice. Resident #10 ate the crust off her sandwich. When asked about her meal, she stated, What is this? I don't like it (sandwich). I'd rather have toast. That's cold. I don't want them (beans). I don't eat that (pudding). * 12/06/18 at 8:10 a.m., Resident #10 reported an administrative staff member (#2) entered her room the night before and stated, Oh, you don't like Mexican (food), and returned with a bowl of chicken noodle soup. Resident #10 then made the comment, My stomach hurts. When asked what was causing her discomfort, she stated, I'm just hungry. She asked the surveyor for assistance opening a snack-pack of mandarin oranges, which she reported her two friends brought her. * 12/06/18 at 9:22 a.m., Resident #10 received a breakfast tray containing an egg, English muffin, oatmeal, prunes, coffee, milk (despite her dislike for milk), and orange juice. Resident #10 stated, I don't like these (English muffins), and asked the Certified Nursing Assistant (CNA) (#3) to bring her a piece of toast. She ate the toast and half an egg, and drank half a glass of juice. * No observations were made of staff members offering Resident #10 snacks on either day of survey. During an interview on 12/06/18 at 10:55 a.m., a CNA (#4) assisted Resident #10 prior to [MEDICAL CONDITION]-treatment appointment. When asked if she planned on sending a snack with Resident #10, the CNA (#3) stated, (Resident #10) ate breakfast, so I don't think she needs anything. During an interview on the afternoon of 12/06/18, an unidentified dietary staff member reported Resident #10's guardian recently talked her into taking the supplement Boost. The staff member also reported there is no documentation reflecting Resident #10's actual intake, as staff are only required to document whether she accepts or refuses the snacks offered. After identifying Resident #10 as malnourished and at risk for weight loss, the facility failed to: * Provide supplements as ordered, * Accurately document Resident #10's baseline weight, * Continue to monitor Resident #10's weight until they were able to determine no weight concerns existed, * Care plan Resident #10's choices/preferences or supplementation as specified in the facility's policy, * Supply Resident #10 with snacks prior to transport to appointments scheduled over the noon hour, and/or * Monitor/document Resident #10's snack intake in an effort to determine their caloric benefits.",2020-09-01
45,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2018-12-06,697,D,1,0,PNS511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on information provided by the complainants, observation, record review, review of facility policy, and resident/staff interviews, the facility failed provide treatment and services in a manner that maintained the highest practicable physical well-being for 1 of 10 sampled residents (Resident #10) observed experiencing pain during cares. Failure to carry out physician's orders [REDACTED].#10 experiencing avoidable pain/discomfort. Findings include: Information provided by the complainants indicated residents contacted family members/representatives when they experienced pain/discomfort secondary to skin breakdown/being soiled. Review of the facility's policy titled medication orders [REDACTED]. This undated policy stated, . The prescriber is contacted for direction when delivery of a medication will be delayed or the medication is not or will not be available. - Review of Resident #10's medical record occurred on all days of survey. The record identified [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Apply to rectum topically BID. The progress notes identified the following: * 11/19/18, . Patient was admitted from (hospital) with a [DIAGNOSES REDACTED]. * 11/22/18, . Patient is incontinent of B/B (bowel/bladder) . * 11/25/18, Weekly skin assessment done, noted redness to her bottom and continuing with feces d/t (due/to) her illness. * 11/26/18, Patient returned from (cancer center) with new orders to discontinue ammonium [MEDICATION NAME]. Start [MEDICATION NAME] to apply to gluteal/perianal and the vulvar areas three times a day. monitor skin for breakdown every shift. * 11/27/18, . Her coccyx area is excoriated from frequent diarrhea. Lac-Hydrine cream is burning her, so it will be d/c (discontinued) and [MEDICATION NAME] started. * 11/28/18, . Receiving [MEDICAL CONDITION] therapy and continuous chemo infusion for [MEDICAL CONDITION]. * 11/29/18, . Incontinent of B/B (bowel/bladder) . * 12/02/18, . redness to the perirectal area do (sic) to stool, treatments and incontinences (sic) treatment to area bid and prn (as needed). Observation showed the following: * 12/06/18 at 7:50 a.m., Resident #10 lying in bed, squirming from side to side. When asked if she required assistance, she pointed towards her buttocks and stated, It itches. Then it hurts. It's irritated. It hurts so bad! A different med (medication) is coming from Pharmacy today. * 12/06/18 at 10:50 a.m., Resident #10 shifted her weight as she laid on the bed and stated, My butt is so sore! During an interview on 12/06/18 at 10:55 a.m., when asked questions pertaining to Resident #10's toileting needs, a certified nursing assistant (CNA) (#4) stated, When we provide toilet cares, (we) gently wipe (the) little sore on her buttocks. Just redness to her buttocks, but very painful! Put a little ointment on the rash. The CNA then showed the surveyor the tube of Peri-Guard ointment located in Resident #10's dresser drawer. Observation on 12/06/18 at 12:48 p.m., showed a CNA (#4) assisted Resident #10 into the bathroom and provided toileting cares. Resident #10's coccyx area appeared darkened, and her perineal/rectal area appeared reddened/raw-looking. Resident #10 voiced discomfort when the CNA (#4) applied Peri-Guard ointment to the reddened area. During an interview on 12/06/18 at 1:30 p.m., when asked questions pertaining to Resident #10's prescribed skin cream, an administrative nurse (#1) reported the facility received the physician's orders [REDACTED]. The nurse (#1) explained the pharmacy did not have that particular cream in stock and therefore contacted a second pharmacy to see if they had it in their inventory. The administrative nurse (#1) reported the Pharmacy delivered the cream on 12/05/18. Review of the Medication Administration Record [REDACTED]. When asked questions regarding the discrepancy, the administrative nurse (#1) stated, It (Lipovan rectal cream) may have hit the building late in the day. It should have been here (12/03/18). Staff should have called (her physician) that evening, and checked into another medication until it came in. The progress notes failed to reflect staff notified Resident #10's physician regarding the unavailable Lipovan rectal cream, the delayed delivery of the cream depending upon whether it was available through the second pharmacy, and/or that they had asked for direction/a replacement cream until it arrived. Failure to carry out the physician's orders [REDACTED].#10 experiencing avoidable pain/discomfort.",2020-09-01
46,THE MEADOWS ON UNIVERSITY,355024,1315 S UNIVERSITY DR,FARGO,ND,58103,2018-12-06,761,D,1,0,PNS511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure accurate labeling of medications for 1 of 10 residents (Resident #6) observed during medication pass. Failure to have undamaged and legible medication labels may result in residents receiving the wrong medication and dose. Findings include: Review of the facility policy titled, Medication 0rdering and Receiving from Pharmacy; Medication Labels occurred on 12/06/18. This undated policy stated, . medication containers having damaged, incomplete, illegible, confusing labels are returned to the dispensing pharmacy for relabeling . in accordance with the medication destruction policy . medication labels are not altered or marked in anyway by nursing personnel . Review of resident #6's medical record occurred on all days of survey. The current physician orders included [MEDICATION NAME], inject 2-12 units subcutaneous three times a day with meals per sliding scale, and Tresiba insulin injection 10 units subcutaneous every morning. Observation on 12/06/18 at 8:18 a.m. showed a nurse (#2) administered insulin to Resident #6 with an insulin pen with the label rubbed off. The label failed to show the medication dose, open date, ordering physician, and expiration date. An interview with an administrative nurse (#1) in the afternoon of 12/06/18, agreed the necessary information on the insulin pen was illegible, and for medication error prevention, illegible insulin pen labels should be replaced per policy.",2020-09-01
47,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2019-06-11,550,E,1,0,HFFF11,"> THIS IS A REPEAT DEFICIENCY FROM SURVEYS COMPLETED ON 08/16/18. Based on information received from the complainants, observation, review of facility policy, and staff interview, the facility failed to provide care for 3 of 16 sampled residents (Resident #4, #13, and #15) and 2 supplemental residents (Resident #20 and #21) in a manner and environment that maintained, enhanced, and respected each resident's dignity and individuality. Failure to knock on doors, announce themselves, and wait for permission prior to entering residents' rooms, identify/honor resident preferences, and provide dining assistance/feed residents in a dignified manner does not preserve the residents' personal dignity or enhance their quality of life and places them at risk of embarrassment and/or emotional harm. Findings include: Information provided by the complainants indicated nursing staff failed to assist residents leaving them in soiled clothing and/or a dirty environment. Review of facility policy titled Quality of Life - Dignity occurred on 06/10/19. This policy, revised (MONTH) 2009, stated, . Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Staff will knock and request permission before entering residents' rooms . - Observations showed the following: * 06/04/19 at 10:37 a.m., Resident #21 utilized the bathroom with the bedroom and bathroom doors open, and unclothed/exposed to the hallway. Staff were not present in the room to assist her with transfer/toileting. * 06/04/19 at 2:51 p.m., Resident #21 utilized the bathroom with the bedroom and bathroom doors open, and unclothed/exposed to the hallway. An unidentified nurse attempted to close the bathroom door. The unidentified nurse left the room after Resident #21 refused to allow her to close the door. Review of Resident #21's medical record occurred on 06/04/19. The current care plan stated, . self care deficit . Break . tasks into sub-task for easier patient performance . Cares in Pairs . Transfer with one assist with gait belt . The care plan failed to identify Resident #21's preference for the bathroom and bedroom doors to be left open. - Observation on 06/04/19 at 11:20 a.m., showed Resident #4 sat in his room as an unidentified laundry staff member entered the room without knocking or identifying himself/herself. - Observation on 06/04/19 at 12:10 p.m., showed Resident #20 held a bowl up to his mouth and ate spaghetti directly from the bowl. Wrapped silverware laid on the table beside the resident. An unidentified staff member walked passed Resident #20's table several times without offering assistance. After all thr trays had been passed, the unidentified staff member sat down to assist Resident #20. During an interview on 06/06/19 at 9:05 a.m., an administrative nurse (#5) stated he expected staff to set up trays for those residents who are able to feed themselves. The staff member then added residents who require assistance should be served when the staff member is able to sit down and assist them. - Observation on 06/04/19 at 3:21 p.m. showed Resident #15 sat in her wheelchair. Crumbs and stains covered Resident #15's T-shirt, pants, and wheelchair and debris covered the left foot pedal. - Observation on 06/05/19 at 12:12 p.m. showed a certified nursing assistant (CNA) (#3) standing next to Resident #13's wheelchair as she fed her. The CNA (#3) also scraped food residue from Resident #13's face with a glass. The CNA failed to sit next to the resident throughout the meal and failed to utilize a napkin to wipe residue from her face.",2020-09-01
48,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2019-06-11,580,E,1,0,HFFF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on information received from the complainants, record review and staff interview, the facility failed to notify the resident's physician and/or family member of a change in condition for 2 of 16 sampled residents (Resident #3 and #16) and 2 discharged residents (Resident #17 and #18) reviewed during the complaint survey. Failure to notify the physician of a resident's change in condition may result in complications to the resident and prevented the physician from evaluating the effectiveness of the current treatment plan. Findings include: Information provided by the complainants indicated facility staff failed to consistently notify them of changes in their family members' condition. Upon request, the facility failed to provide a copy of their policy addressing physician and/or family notification of a change in the resident's condition. - Review of Resident #3's medical record occurred on all days of survey. The current care plan stated, Diagnosis . unspecified dementia without behavioral disturbance . muscle weakness . repeated falls . At risk for falls due to: history of falls . Review of progress notes showed the following: * 02/28/19 at 2:20 p.m., Resident found on floor . Family has been notified . Will update MD (medical doctor) at this time . * 03/13/19 at 1:50 p.m., Will update MD and family. Resident had a missed fall . * 05/28/10 at 2:05 p.m., Late entry. Will update MD and family. Resident had a witnessed fall . - Review of Resident #16's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Medications included, [MEDICATION NAME] (insulin) 20 units two times a day and [MEDICATION NAME] (insulin) 10 units three times a day. A physician's orders [REDACTED]. [MEDICATION NAME] . Inject as per sliding scale . 426+ = 7 units Call MD for blood glucose less than 50 and greater than 426 . Review of the blood sugars showed a blood sugar reading of 426 on 02/08/19 and 430 on 02/09/19. The facility failed to notify Resident #16's physician of the blood sugar readings. During an interview on 06/05/19 at 3:54 p.m. an administrative nurse (#5) agreed the facility failed to notify the physician of a blood sugar readings that fell outside of ordered parameters. - Review of Resident #17's medical record occurred on all days of survey. The record identified [DIAGNOSES REDACTED]. The progress notes, dated 10/02/18-05/05/18, identified the following: * 12/06/18 at 7:00 a.m. and 12/07/18 at 10:13 a.m., Will update MD . her second rt (right) toe has a 2 cm (centimeter) wt (width) by 1.2 cm Lt (left) pressure area. Skin is intact and without drainage. Site is red, resident denies sensation or pain . The facility failed to notify Resident #17's family of the pressure area to her toe. * 12/11/18 at 3:26 p.m., This nurse paged (physician) regarding resident sore toe. He ordered Keflex (antibiotic) 500 mg (milligram) PO (by mouth) TID (three times per day) for 10 days. The facility failed to notify Resident #17's physician in a timely manner, paging him five days after they discovered the ulcer on her toe. * 01/12/19 at 9:19 p.m., Resident is on follow up for: Un witnessed fall in her bathroom. Resident is unable to transfer self back and fort (sic) (to) the bathroom. Will update MD . The facility failed to inform Resident #17's physician and family of her fall. * 03/22/19 at 2:42 p.m., Resident returned from appointment with nephrologist . New orders to continue same medications, get a U[NAME] A microbiology report, dated 03/24/19, identified Escherichia coli (E-coli) and Proteus mirabilis (types of bacteria) present in Resident #17's urine. The facility failed to notify the physician and family of Resident #17's positive urine culture. Resident #17's progress notes also identified the following: * 03/31/19, . -7.5% change . Wt (weight) triggers for significant change. She is eating * 03/31/19 at 11:50 a.m., Will update family and MD (physician): Resident was hypoglycemic (low blood sugars) with a blood sugar of 52 mg/dl (Level 2 [DIAGNOSES REDACTED]). She was non verbal, clammy and lethargic. [MEDICATION NAME] administered by this nurse, ambulance called. When ambulance crew arrived, resident sugar level was up to 60 mg/dl (Level 1 [DIAGNOSES REDACTED]). Her vitals was (sic) stable, she verbally refused going to the hospital . The facility failed to inform Resident #17's physician and family of her hypoglycemic episode. * 04/09/19 at 6:03 p.m., Resident's daughter . concerned that resident's right 2nd toe diabetic vascular ulcer is not improving. I note that right 2nd toe has a very thick necrotic black 0.8 cm circular scab dry (and) intact. No drainage. Surrounding toe is slightly red. Right foot is slightly cool to touch with pedal pulses palpable. Resident denies any pain or discomfort to the right foot. Daughter . requests that a f/u (follow up) appointment be made ASAP (as soon as possible) with podiatrist . * 04/17/19 at 2:25 p.m., Made an appointment with . podiatry to see if resident scabbed to her right second toe can be debride (sic). The facility failed to schedule an appointment with Resident #17's podiatrist in a timely manner, contacting his office eight days after the family made their request. * 05/02/19 at 5:45 p.m., Resident is pale (and) diaphoretic. Blood glucose is 52 mg/dl (Level 2 [DIAGNOSES REDACTED]). No emisis or c/o (complained of) nausea. (Physician) on call . paged (and) gave new order to administer [MEDICATION NAME] 1 mg intramuscularly now (and) recheck blood glucose in 15 minutes. Order observed. The facility failed to inform Resident #17's primary physician of her hypoglycemic episode. * 05/03/19 at 1:14 a.m., Resident was found pale, diaphoretic and unresponsive (symptoms of Level 3 [DIAGNOSES REDACTED]). Unresponsive to sternum rub. BS (blood sugar) was 35 (Level 2 [DIAGNOSES REDACTED]). [MEDICATION NAME] 1 mg given. 15 mins later, resident continued to be unresponsive and pale. Her BS was 44. Another [MEDICATION NAME] 1 mg injected. 15 mins later her BS was 85. Nurse gave another sternum rub and resident pushed away hands. (Physician) whom is taking call . gave order to administer the [MEDICATION NAME] 1 mg x (times) 2. Primary MD will be notified via fax. The facility failed to inform Resident #17's primary physician and family of her hypoglycemic episode. * 05/05/19 at 5:00 p.m., Resident was found unresponsive (symptom of Level 3 [DIAGNOSES REDACTED]) to sternum rub. BS was 67 mg/dL . [MEDICATION NAME] 1 mg given. Blood sugar rechecked 15 mins later was 106. Resident was responsive . Informed (Physician) on call . and he ordered to decrease dosage of [MEDICATION NAME] . The Primary MD will be notified . The facility failed to inform Resident #17's primary physician and family of her hypoglycemic episode. - Review of Resident #18's medical record occurred on all days of survey, and identified [DIAGNOSES REDACTED]. Progress notes identified the following: * 08/02/18 at 3:38 p.m., Resident has a firm area to the left lower buttock, it is not raised, it has no discoloration, resident states it is very painful when palpated, (Physician) called . The facility failed to inform Resident #18's family of her skin issue. * 09/12/18 at 4:35 a.m., Nurse was sitting at the nursing station when she heard, 'help I'm slipping.' 'help.' 'help me.' This nurse and other nurse on duty went running into her room. This nurse saw resident slide out of her chair and onto the floor. Faxed communication to MD regarding fall. The facility failed to inform Resident #18's family of her fall.",2020-09-01
49,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2019-06-11,584,E,1,0,HFFF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on information received from the complainants, and observations, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior on 1 of 2 floors (first floor). Failure to maintain a clean and sanitary environment does not provide a comfortable living area for residents. Findings include: Information provided by the complainants indicated facility staff failed to provide a clean, comfortable environment for the residents to live in. Upon request, the facility failed to provide a copy of their policy addressing a clean, comfortable and homelike environment. - Observations on the morning of 06/05/19 of the resident living area on first floor showed the following: * room [ROOM NUMBER]: torn wallpaper border near ceiling, glove laying on the sink, shirt laying on top of a dresser * room [ROOM NUMBER]: breakfast tray on bedside table at 11:00 a.m., clean brief laying on the bed, used towel on the sink, clothing on the floor (bra, socks, shirt), closet door open, shirt on the floor in closet * room [ROOM NUMBER]: cereal, popcorn, and soda can boxes on the floor, clothes and open popcorn bag on the bed, dirty plate on the bedside table, a used towel on the sink * room [ROOM NUMBER]: closet doors open, used towel on the sink, sink dripping * room [ROOM NUMBER]: unopened package of Procare wipes on the floor underneath the sink, opened package of Procare wipes on the floor behind the door, urinal tipped over behind the door * room [ROOM NUMBER]: pants and shirt draped over the back of a recliner, strong urine odor in the room * room [ROOM NUMBER]: dirty wheelchair foot pedals, uneaten breakfast tray on the sink at 11:20 a.m. * room [ROOM NUMBER]: torn wallpaper above the bed, tooth brush laying on a towel on the sink, sink dripping, paper towel on the floor by a wastebasket * room [ROOM NUMBER]: used washcloth laying in the sink",2020-09-01
50,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2019-06-11,585,E,1,0,HFFF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on information provided by the complainant, observations, review of Resident Council Meeting minutes, review of facility policy, and resident interviews, the facility failed to provide reasonable accommodation of needs regarding call lights for 6 of 16 confidential and/or sampled residents (Resident A, B, C, #5, #6, and #7). Failure to place call lights within the residents' reach and/or respond to the call lights in a timely manner does not allow residents to request/obtain assistance and may result in avoidable incontinence/falls, increased behaviors, and/or a decreased quality of life. Findings include: Information provided by the complainants indicated nursing staff failed to respond to call lights in a timely manner (waiting up to 55 minutes) resulting in residents and/or family members searching the halls for staff and indicated they found call lights that were not functioning properly. Review of the facility policy titled Call Light, Use of occurred on 06/10/19. This policy, dated (MONTH) (YEAR), stated, . Answer ALL call lights promptly whether or not you are assigned to the resident . Never make the resident feel you are too busy to give assistance. Offer further assistance before you leave the room. When providing care to resident, be sure to position the call light conveniently for the resident to use. Be sure all call lights are placed on the bed at all times, never on the floor or bedside stand. Review of Resident Council Meeting minutes, dated (MONTH) 22-May 23, 2019, occurred on 06/07/19. The meeting minutes identified the following concerns were discussed with the facility: * 03/22/19, . Call lights taking long to be answered . * 04/25/19, . Call lights around meal times taking a long time . * 05/23/19, . Call light times in general . Random interviews identified the following: * 06/05/19 at 12:05 p.m., resident (A) stated, I've had to wait up to 45 minutes for someone to answer my light. * 06/05/19 at 1:30 p.m., resident (B) stated, I've waited up to an hour for help. * 06/05/19 at 1:40 p.m., resident (C) said he/she has had to wait 15 minutes-to-one hour for someone to answer the light. - Review of Resident #6's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The current care plan stated, . Resident is at risk for falls r/t (related to) Decondition/weakness . Encourage the Resident to always call for assistance. Observation on 06/04/19 at 11:00 a.m. and 06/05/19 at 11:15 a.m. showed Resident #6 asleep on his bed. Observation showed the call light clipped to the cord, hanging on the wall out of reach of the resident. - Review of Resident #5's medical record occurred on all days of survey. A progress note, dated 05/08/19 at 7:45 p.m., stated, This nurse was alerted by CNA (certified nurse aide) at (7:30 p.m.) that resident was found lying on the floor near his bed. This nurse went to go assess the situation and found resident lying on the floor near the foot of his bed on his left side. Resident had shoes and socks on. The wheelchair was three feet away. Call light was on. This nurse asked resident what happened, resident said, I'm tired of waiting, I've been waiting 30 minutes so I tried putting myself to bed. - Review of Resident # 7's medical record occurred all days of survey. A progress note, dated 05/12/19 at 7:28 a.m., stated, CNA found resident in bed at 640 AM when she screamed for help. Found blood all over her face and holding a baseball size blood clot in her hand. Resident stated to CNA that she had been screaming for help for a while during early morning. Found call-light clipped onto curtain out of reach from resident. Immediately called 911 and informed ER (emergency room ). Resident is alert and slightly confused. Refer to F689 and F690.",2020-09-01
51,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2019-06-11,657,E,1,0,HFFF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > THIS IS A REPEAT DEFICIENCY FROM SURVEY COMPLETED ON 08/16/18. Based on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise the comprehensive care plan to reflect the current status for 4 of 16 sampled residents (Resident #1, #5, #13, #14) and 1 discharged resident (Resident #17). Failure to revise the care plan limited the ability of staff to communicate care needs and ensure continuity of care for each resident. Findings include: Review of the facility policy titled Care Plans - Comprehensive occurred on 06/10/19. This undated policy stated, . develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain . Incorporate identified problem areas . Incorporate risk factors associated with identified problems . Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident . care plans are revised as information about the resident and the resident's condition change . - Review of Resident #1's medical record occurred on all days of survey. The current physician order stated, Oxygen at 2 L/M (liters per minute) to maintain O2 (oxygen) saturations > (less than) 90%. Check each shift. Observations on 06/04/19 at 11:05 a.m. and 06/05/19 at 10:08 a.m., showed Resident #1 wearing a nasal cannula attached to an oxygen concentrator set at 1 liter per minute. The facility failed to review/revise the care plan to reflect Resident #1's respiratory status. During an interview on 06/06/19 at 9:05 a.m., an administrative nurse (#5) stated he/she would expect staff to address O2 use/interventions on the careplan. - Review of Resident #5's medical record occurred on all days of the survey. The current care plan stated, ADL (activities of daily living) self care deficit as evidenced by unsteady gait related to lumbar L2 fracture. Transfer with extensive assist of one with gait belt. Observation on 06/04/19 at 11:30 a.m. showed Resident #5 ambulated independently with a front wheeled walker into the bathroom. The facility failed to accurately identify Resident #5's level of assistance and toileting on the care plan. - Review of Resident #13's medical record occurred on all days of survey. The current physician order stated, House supplement three times daily. The current care plan stated, Nutritional status wt (weight) loss . Need for assistance at meals and altered textures . Refuses meals or takes poor . Provide diet as ordered - Pureed small portions per family request. Fortified cereal, pudding, cereal and magic cup . Review of progress notes showed the following: * 02/28/19 at 2:02 p.m. - Doctor started resident on [MEDICATION NAME] to help with weight gain * 02/28/19 at 3:56 p.m. - Resident declining and failing to thrive. Resident has been losing weight and does not have an appetite. * 04/02/19 at 12:05 p.m. - Family is aware of wt loss and does not want comfort measure or tube feeding support * 04/18/19 at 3:15 p.m. - Resident continue with failure to thrive and refusing to eat Resident #13's current physician's order stated, . Clean area to right clavicle . Clean large skin tear to RFA (right forearm) . Clean small skin tear to RFA . The care plan stated, At risk for alteration in skin integrity related to . impaired mobility . Encourage fluids . Float heels . Observe skin condition daily with ADL care daily: report abnormalities . Pressure redistributing device on bed/chair . Provide preventative skin care routinely and PRN (as needed) . Toileting program as indicated . Use pillows/positioning devices as needed . Review of the nursing progress notes showed the following: * 05/20/19 at 10:00 p.m. - Abrasion on right clavicle is small and superficial * 05/23/19 at 3:30 p.m. - Alerted nurse to a large skin tear to right inner elbow area measuring 7 centimeters (cm) x 2 cm (open area bright red wound bed) and another skin tear to right forearm measuring 1 cm x 1 cm. Resident #13's care plan failed to identify current skin issues with treatment and the current weight loss approaches. - Review of Resident #14's medical record occurred on all days of survey. The current physician order stated, [MEDICATION NAME] to open areas on bottom. Change every MWF (Monday, Wednesday, Friday) until healed . [MEDICATION NAME] type bandage change daily . Rt (right) foot wound .Wound to right lower extremity . Change daily. Wound nurse to follow . Review of Resident #14's medical record showed resident has fallen six times in the last six months. A progress note, dated 03/06/19 at 7:44 a.m., stated, . Requesting to place floor mats at bedside . All observations during survey showed Resident #14 with no fall mats in place while in bed. Observation on 06/04/19 at 10:59 a.m. showed two certified nursing assistants (CNAs) (#9 and #10) checked Resident #14's brief and provided incontinent cares for Resident #14 after a bowel movement (BM) while in bed. The current care plan stated, At risk for alteration in skin integrity related to: history of pressure ulcer . Transfer with two assist with gait belt . Resident #14's care plan to failed to identify current skin issues, toileting method, and fall interventions. - Review of Resident #17's medical record occurred on all days of survey, and identified a 37 pound weight loss between 12/03/18-05/05/19. Documentation failed to show staff identified Resident #17's food preferences and/or obtained orders for/implemented other interventions such as fortified foods/supplements. Staff failed to individualize Resident #17's care plan identifying specific preferred foods/supplements. During an interview on 06/04/19 at 3:30 p.m., when asked how the facility addresses residents experiencing weight loss, a managerial dietary staff member (#12) reported monitoring residents for gradual/significant weight loss, and stated, First, I would give the resident fortified foods, and then supplements. I try to do things like cookies, chocolate milk, whole milk, cheese and crackers, cereal, magic cup, sherbet, and peanut butter. If they need help, I ask them to be moved to an assisted table. During an interview on 06/05/19 at 3:00 p.m., a managerial nurse (#5) confirmed the care plan failed to reflect Resident #17's food preferences and/or the fortified foods, supplements, and snacks recommended for her. Resident #17's progress notes identified the following: * 03/10/19 at 9:49 p.m., Resident's daughter approached this recorder and stated, 'my Mom's toe is infected' . On exam 2nd toe on rt foot is light red, no swelling noted, has a dry callous type lesion of DP (sic) joint area, no drainage noted, residents (sic) states it does not hurt . Callous is dry measures 0.9 cm x 1 cm. * 03/12/19 at 4:41 a.m., . received first dose of [MEDICATION NAME] . Toe is [DIAGNOSES REDACTED] and slightly warm to touch. Skin is intact. No drainage noted. She stated only has pain when blanket is laying on the foot. Blanket was pulled back and she stated she had relief. and at 9:11 p.m., . Right 2nd toe is red (and) swollen. Anterior distal tip of toe has a small circular open area with no drainage. Resident denies any pain or discomfort to toe. The care plan failed to address removing pressure from the top of Resident #17's feet.",2020-09-01
52,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2019-06-11,658,D,1,0,HFFF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > THIS IS A REPEAT DEFICIENCY FROM SURVEYS COMPLETED ON 08/16/18. MEDICATION ADMINISTRATION 1. Based on information received from the complainants, observation, review of facility policy, and staff interview, the facility failed to ensure staff followed professional standards of practice for 2 of 2 sampled residents (Resident #1 and #2) on insulin and 1 supplemental resident (Resident #20) observed during medication administration. Failure to follow physician's orders for Resident #1 and #2 and failure to ensure Resident #20 consumed his/her medication may result in adverse health consequences. Findings include: Information provided by the complainants indicated family members questioned nursing staff regarding changes in the residents' medication/treatment regimen. Review of facility policy titled Administering Medications occurred on 06/10/19. This policy, revised (MONTH) 2012, stated, Medications must be administered in accordance with the orders . If a dosage is believed to be inappropriate or excessive for a resident . contact the resident's Attending Physician . If a drug is withheld . update physician and family . Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. Review of facility policy titled Administering Oral Medications occurred on 06/10/19. This policy, revised (MONTH) 2010, stated, . Remain with the resident until all medication have been taken . - Review of Resident #1 occurred on all days of survey. Review of Resident #1's Medication Administration Record [REDACTED] * 04/14/19 at 7:36 a.m.: [MEDICATION NAME] Flex Pen . Inject 3 units . BS (blood sugar) 90, held per nursing judgement. * 04/22/19 at 7:16 a.m.: [MEDICATION NAME] Flex Pen . Inject 3 units . held BS 99, per nursing judgement. * 04/27/19 at 9:53 a.m.: [MEDICATION NAME] Flex Pen . Inject 3 units . held per nursing judgment, BS 85. * 05/11/19 at 10:25 a.m.: [MEDICATION NAME] Flex Pen . Inject 3 units . held per nursing judgement, BS 85. - Review of Resident #2 occurred on all days of survey. Review of Resident #2's medication administration documentation identified the following: * 03/10/19 at HS: (bedtime) [MEDICATION NAME] Flex Pen Solution . Inject 14 units . Resident ate less than 50% of supper. HS bs 115. [MEDICATION NAME] held. * 05/10/19 at 7:30 a.m.: [MEDICATION NAME] Flex Pen Solution . Inject 5 units . held per nursing judgement. BS 87. - During observation of the noon meal on 06/05/19 at 12:20 a.m., an unidentified nurse reported he/she dissolved Resident #20's medication in hot chocolate because the resident usually refuses medications. The nurse then handed the cup of hot chocolate to Resident #20, watched the resident take a couple swallows and left. Staff failed to observe the resident consume all the medication, failed to obtain physician orders to disguise medications and/or orders for resident to self medicate. During an interview on 06/06/19 at 10:43 a.m., an administrative nurse (#5) stated that he/she would expect staff to notify the physician if insulin is held and to stay with residents until all medication is consumed. INSULIN PREPARATION AND ADMINISTRATION 2. Based on information received from the complainants, observation, policy review, and review of manufacturer's guidelines, the facility failed to follow professional standards of practice when preparing and administering insulin for 2 of 4 observations of insulin administration. (Resident #5 and #8 ). Failure to cleanse the rubber [MEDICATION NAME] before applying a new needle, cleanse the injection site prior to administration, and failure to keep the needle inserted into the skin for at least 6 seconds may result in the resident receiving an infection and an inaccurate amount of insulin. Findings include: Information provided by the complainants indicated nursing staff failed to consistently cleanse the injection site prior to administering insulin. Review of the facility policy titled Insulin Administration occurred on 06/05/19. This policy, revised (MONTH) (YEAR), stated, . Remove the cap from the pen and wipe the rubber [MEDICATION NAME] with an alcohol wipe. Cleanse skin with an alcohol wipe using circular motion form (sic) the center of the chosen injection site until an area about three inches in diameter has been prepared. Keep the needle in the skin for up to 10 seconds. Review of manufacturer's guidelines for [MEDICATION NAME]stated, . Pull off the tamper resistant cap. Wipe the rubber [MEDICATION NAME] with an alcohol swab. Choose your injection site and wipe the skin with an alcohol swab. Insert the needle into your skin. Push down on the plunger to inject your dose. Needle should remain in the skin for at least 6 seconds to make sure you have injected all the insulin. - Observation on 06/05/19 at 8:40 a.m. showed a licensed nurse (#1) removed the cap from the insulin pen and placed a new needle without cleansing the rubber [MEDICATION NAME] with an alcohol swab. The nurse primed the insulin pen, dialed the correct dose, then administered the insulin to Resident #5 without cleansing the injection site prior to the injection. The nurse pushed down the plunger to administer the insulin, then removed the needle from the skin after 3 seconds. - Observation on 06/05/19 at 8:48 a.m. showed a licensed nurse (#1) removed the cap from the insulin pen and placed a new needle without cleansing the rubber [MEDICATION NAME] with an alcohol swab. The nurse primed the pen, dialed the correct dose, then administered the insulin to Resident #8 without cleansing the injection site prior to the injection. The nurse pushed down the plunger to administer the insulin, then removed the needle from the skin after 3 seconds.",2020-09-01
53,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2019-06-11,677,E,1,0,HFFF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > THIS IS A REPEAT DEFICIENCY FROM SURVEYS COMPLETED ON 08/16/18. Based on information received from the complainants, observation, record review, and staff interview, the facility failed to provide dining assistance for 2 of 16 sampled residents (Resident #1 and #14) and 3 supplemental resident (Resident #22, #23, and #24) observed during meals. Failure to reposition, cue, and/or assist dependent residents may result in decreased intake and/or unwanted weight loss. Findings include: Information provided by the complainants indicated nursing staff failed to provide cues/assistance for residents with vision and/or mobility deficits. Upon request, the facility failed to provide a copy of their policy addressing dining assistance. Staff indicated they provide standard of practice based on resident's individualized needs. - Review of Resident #1's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The current care plan stated, . self care deficit . requires assistance related to: disease process, physical limitation, [MEDICAL CONDITION] . Assist with daily . grooming . oral care . and eating as needed . Upper and lower dentures. Observation on 06/05/19 at 8:35 a.m., showed Resident #1 sitting in bed holding a piece of toast with a breakfast tray in front of her. Resident #1's eyes had yellowish crusty matter around the eye lids. The resident stated, my eyes are blurry. Resident #1 asked for assistance obtaining her dentures. Resident #1's dentures were located on the sink. During an interview on 06/05/19 at 8:40 a.m., a certified nursing assistant (CNA) (#4) stated the CNA's try to do morning cares before the residents eat, but will try again after breakfast if they refuse. The CNA (#4) acknowledged she set-up Resident #1's breakfast tray. The CNA (#4) failed to give Resident #1 her dentures prior to providing tray set-up. - Review of Resident #14's medical record occurred on all days of survey. The current care plan identified, . self care deficit as evidenced by requires assistance related to: disease process dementia, physical limitations. Assist with . eating as needed . Nutritional status as evidenced by mechanically altered diet and varying intakes that are overall poor. I need more assistance at meals . Encourage as needed to consume foods and/or supplements and fluids offered . Observation on 06/04/19 at 12:25 p.m. showed a CNA (#9) giving Resident #14 sips of cocoa from a cup. Resident #14's alertness level varied throughout the meal and she sat leaning heavily to her right side (with her head directly over the arm rest of her chair). The CNA (#9) failed to ensure Resident #14 was alert enough to safely eat/drink and failed to reposition her. - Review of Resident #22's medical record occurred on all days of survey. The current care plan identified, . self care deficit as evidenced by: need for increased assistance with . tasks related to: disease process, [MEDICAL CONDITION] with physical limitations . Assist with . eating as needed . At risk for nutritional status wt. (weight) change r/t (related to) variable oral intake . Encourage and assist as needed to consume foods and/or supplements and fluids offered . Observations showed the following: * 06/04/19 at 12:25 p.m., Resident #22 sat at an assisted table and stared straight ahead. She made no effort to eat. Staff failed to cue and/or assist Resident #22 throughout the meal. Total intake consisted of a cup of cocoa. * 06/05/19 at 12:12 p.m., Resident #22 sat at an assisted table and stared straight ahead. She made no effort to eat. An office staff member (#14) sat down to assist Resident #22 with her meal approximately fifteen minutes into the meal. - Review of Resident #23's medical record occurred on all days of survey. The current care plan identified, . self care deficit as evidenced by requires assistance related to: disease process, physical limitations . Assist with . eating as needed . Resident need to be positioned at 90 degree angle during . oral intake . Nutritional status increase need related to open areas Hospice care . Encourage and assist as needed to consume foods and/or supplements and fluids offered . Observation on 06/04/19 at 12:25 p.m. showed Resident #23 sat at an assisted table and leaned heavily to his right side (with his head directly over the arm rest of her chair) with his left hand wrapped with gauze. Resident #23 dropped food onto his clothing protector/pants while attempting to feed himself. The CNAs sitting at the table failed to reposition and/or assist the resident. An unidentified staff member repositioned Resident #23 and sat down to assist him approximately eleven minutes into the meal. - Review of Resident #24's medical record occurred on all days of survey. The current care plan identified, . self care deficit as evidenced by: need for staff performance of cares related to: disease process advanced dementia . Reposition at routine intervals before . meals . Requires total assist with . eating . Nutritional status as evidence by weight gain related to improved eating and inactivity. He . has a need for assistance or cueing at meals . Assist as needed to consume foods and/or supplements and fluids offered . Observation on 06/04/19 at 12:25 p.m. showed an unidentified CNA feeding Resident #24. Staff had raised the back of Resident #24's chair to an approximate 60 degree angle. The CNA (#9) failed to reposition the resident and left him in a reclined position throughout the meal. Staff failed to ensure alertness, reposition, cue, and/or assist dependent residents who were at risk for aspiration, decreased intake, and/or unwanted weight loss. Refer to F692.",2020-09-01
54,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2019-06-11,684,D,1,0,HFFF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > THIS IS A REPEAT DEFICIENCY FROM SURVEYS COMPLETED ON 08/16/18. AREAS OF SKIN BREAKDOWN 1. Based on information received from the complainants, record review, review of facility policy, and staff interview, the facility failed to provide the necessary care and services to prevent the development and promote healing of skin breakdown for 2 of 4 sampled residents (Resident #13 and #15) and 1 discharged resident (Resident #18) at risk of developing or with known abrasions, skin tears, and burns. Failure to reassess and/or consistently utilize interventions contributed to Resident #13, #15, and #18 developing new wounds and/or healing of their various areas of skin breakdown. Findings include: Information provided by the complainants indicated nursing staff failed to consistently utilize physician ordered interventions to prevent and/or heal areas of skin breakdown. Review of the facility policy titled Skin Management System occurred on 06/10/19. This undated policy stated, . Pressure Ulcers, Venous Ulcers, and Arterial Ulcers, and surgical sites will be documented on . form or EMR (electronic medical record). Use one form per wound. Wound progress is to be documented each week with measurement and wound descriptions. Daily treatments are also documented on the same form. Skin issues such as skin tears, bruises, rashes, abrasions,[MEDICAL CONDITION]. will be documented . - Review of Resident #13's medical record occurred on all days of survey. The current physicians order stated the following: * Started 05/21/19, . Clean area to right clavicle with NS (normal saline), apply triple antibiotic cream and cover with [MEDICATION NAME] every day shift . * Started 05/25/19, . Clean large skin tear to RFA (right forearm) with NS and applied antibiotic ointment and xeroform gauze, cover with boarder foam gauze. Clean small skin tear to RFA with NS and apply paper tape. Change Q (every) 3 days until healed . A progress note, dated 05/23/19 at 3:30 p.m., stated . CNA (certified nursing assistant) alerted nurse to a large skin tear to rt (right) inner elbow area . 7cm (centimeters) x 2cm wide skin tear unable to approximate, is open area bright red wound bed, no active bleeding noted, edges of wound dried looking. Also has a small 1 cm x 1cm skin tear on rt forearm . Review of Resident #13's progress notes and skin/wound assessments identified the facility failed to document weekly on the progress of the skin including measurements and descriptions. Nurses' notes and wound assessments stated the following: * 05/18/19 - Abrasion measuring 1.0 cm x 1.5 cm on right clavicle area * 05/20/19 at 10:00 p.m. - Abrasion on right clavicle is small and superficial * 05/25/19 - Abrasion measuring 1.0 cm x 1.5 cm on right clavicle area Review of progress notes and skin/wound assessments identifies the facility failed to document weekly on the progress of the skin including measurements and descriptions. - Review of Resident #15's medical record occurred on all days of survey. The current physicians order stated, . Skin evaluations weekly . Nurses' notes and wound assessments stated the following: * 01/18/19 at 10:34 a.m. - . Skin is intact. Potential for skin breakdown due to limited mobility . * 01/23/19 - Has 2 skin tears on her left leg, well approximated cleaned with NS, applied triple antibiotic and covered with appropriate dressing. Resident did not know what had happened * 01/24/19 - Skin tears noted to the left lower leg, cover with tape, redness around the area * 02/07/19 - Skin intact * 02/14/19 - Skin intact * 02/20/19 at 7:37 a.m. - . notification of skin tear to left lateral calf of resident. Family is concerned that resident may have attempted independent transfer to the toilet as this is what has been observed in the past. Informed that resident will be monitored for safety and care staff will provide ADL assist. * 02/21/19 - Skin tear on left lower leg measuring 10 cm x 2 cm x 0.1 cm with bordered gauze and non-adherent dressing applied. Change daily after cleaning with NS and PRN (as needed). * 02/28/19 - Skin tear covered * 03/08/19 10:38 a.m. - Area to lower left extremity still not healed . * 03/13/19 at 10:34 a.m. - Writer noted a new skin tear to left lower leg, above present one, measuring 1cm x 1.2cm. Writer asked resident what happened, she stated well I don't know. Area was cleaned with normal saline, sterile boarder gauze dressing applied . * 03/28/29 - Skin tear * 04/11/19 - Healing to pre-existing skin tear to left lower leg * 04/18/19 - Skin intact * 04/18/19 7:44 p.m. - . left lower leg . Area is now healed . Review of progress notes and skin/wound assessments identifies the facility failed to document weekly on the progress of the skin including measurements, description, and identify the date the skin areas had healed. - Review of Resident #18's medical record occurred on all days of survey, and identified [DIAGNOSES REDACTED]. RIGHT LOWER LEG The Admission Evaluation, dated 07/07/18, identified, . 6.5 x 6 cm [MEDICAL CONDITION] sore to the front of the right lower leg and 2 x 1 cm [MEDICAL CONDITION] sore to the front/2.2 x 2 cm [MEDICAL CONDITION] sore to the back of the left lower leg . Resident #18's care plan identified, . Date Initiated: 07/07/18 . Scabbed areas at (bilateral lower extremeties) r/t (related to) recent [MEDICAL CONDITION] treatment . Encourage and assist as needed to turn and reposition, use assistive devices as needed, Follow up care with MD (medical doctor) as ordered, Report evidence of infection such as purulent drainage, swelling, localized heat, increased pain, etc. Notify MD PRN, Use pillows and/or positioning devices as needed . The orders identified the following: * Start Date 07/14/18, . Skin evaluation weekly on Saturday Days - complete weekly skin review under assessments one time a day every Sat (Saturday) . The facility failed to perform this task on a weekly basis. * Start Date 07/27/18, . Keep area to right lower extremity clean and dry. (MONTH) use soap/water, enxymatic (sic) cleanser, or saline washes as needed. (MONTH) use non-stick dressing/[MEDICATION NAME] if area oozes or bleeds temporarily. DO NOT routinely apply lotion or cream. as needed Resident #18's progress notes identified the following: * 07/30/18 at 12:56 p.m., Resident continues with dry area of [MEDICAL CONDITION] on her right shin . * 08/28/18 at 4:39 p.m., New order received to swab and culture wound to RLE (right lower extremity) to R/O (rule out)[MEDICAL CONDITION] (antibiotic resistant organism) and Wound care Nurse to follow for possible debridement. The facility failed to reassess the wound since it was first identified on 07/07/18. * 08/30/18 at 5:00 p.m., . call to (Physician) . due to preliminary report on wound culture and extensive bacteria present . resident's decreased tolerance with physical therapy over the past few days, and malodorous smell from wound bed . requests to send patient to ED (emergency department) for further workup due to concerns of systemic infection . and at 7:38 p.m., . returned back into facility . Received new orders saline wet to dry dressing daily . continue the Batruim (sic) DS . should be effective in treating her infection to her open wound to lower right extremities . * 09/01/18 at 4:27 p.m., Dressing to Right lower extremity changed using wet to dry with NS. Wound bed is tan with slough. A nickle (sic) sized scab came of (sic) with dressing, no bleeding present. * 09/03/18 at 9:59 a.m., . Dressing to Right lower leg . no drainage noted. The only weekly skin review provided by the facility, dated 09/03/18, identified, . left lower buttock . site with dressing. Right mid-lower leg wound with wet to dry dressing changed daily. Resident #18's progress notes also identified: * 09/05/18 at 10:31 a.m., Wound to Right lower leg has wet to dry dressing. Wound looks to be healing and getting smaller in size, no drainage noted. * 09/08/18 at 6:48 p.m., . dressing to rt leg . no active drainage noted, no signs of infection noted. * 09/09/18 at 12:42 p.m., . dressing changed, wet to dry applied . * 09/14/18 at 10:58 a.m., Wound to Right to lower anterior leg appears to be healing, it is getting smaller in size . and at 3:59 p.m., Dressing to Right lower leg changed . Wound is 7 x (times) 6 cm in diameter. NO drainage noted. The facility failed to measure the wound since it was first identified on 07/07/18. * 09/19/18 at 6:27 p.m., . Dressing to Right lower leg changed using [MEDICATION NAME] and [MEDICATION NAME]. The orders identified, Start Date 09/26/18, . Cleanse RLE with NS, pat dry, apply [MEDICATION NAME] AG, wrap with kerlix, change daily, one time a day for Wound care . The facility failed to perform this task on a daily basis. Progress notes also identified: * 10/03/18 at 7:09 p.m., This nurse informed (Physician's) clinic that right lower leg does not improve with the current dressing management . stated we can do the Dakins Half Strength 0.25% topical solution, apply to right lower leg open wound BID (twice daily) wet to dry dressing x 1 week. * 10/08/18 at 7:17 p.m., Received orders . discontinue dakins, apply Santyl to right lower leg wound Q (every) 12 hrs (hours) until appointment with vascular surgeon . cover with gauze and Kerlix . The orders identified the following: * Start Date 10/09/18, . Apply santyl to right lower leg every 12 hours two times a day related to unspecified open wound, right lower leg . until 10/23/18 . Cover with gauze and kerlix . Follow up with vascular surgeon . The facility failed to perform this task on a daily basis. The Medication Administration Record [REDACTED] * Start Date 10/08/18, . [MEDICATION NAME] 500 mg (milligrams) PO (by mouth) every 24 hrs (hours) for 10 days. The chart showed staff administered six doses of the antibiotic. (The tenth dose was due the day after she was discharged from the facility.) The progress note, dated 10/09/18 at 10:30 p.m., identified, Resident started first dose of [MEDICATION NAME] tonight. Wound to right lower leg has yellow slough present in wound bed. Wound has purulent yellow drainage that is soaked onto the kerlix covering her legs. Wound has an odor to it. Dressing changed . The physician placed Resident #18 on an antibiotic six days after staff first noted her leg was not improving under the current treatment program. The care plan identified, . Date Initiated: 10/10/18 . Infection of wound/skin . Administer meds as ordered, Record temperature as clinically indicated . The progress notes also identified the following: * 10/12/18 at 10:00 p.m., . taking [MEDICATION NAME] . Wound has a fishy smell to it. Wound has yellow sloth throughout it with purulent yellow drainage. Resident states it is painful when doing dressing changes. Wound . dressed in santyl cream, guaze and kerlix . Will continue to monitor. * 10/14/18 at 12:25 p.m., . on [MEDICATION NAME] . Some yellow drainage noted. Drsg (dressing) changed . * 10/15/18 at 1:00 a.m., . continues taking [MEDICATION NAME] . Dressing changed . Scant amount of yellow slough in middle of wound bed. Also had scant amount of yellow drainage noted on old dressing. The facility failed to measure the wound since it was first identified on 09/14/18. * 10/16/18 at 9:10 p.m., . transport to . (another facility out of state) . LEFT LOWER BUTT[NAME]KS Resident #18's care plan identified, . Date Initiated: 07/07/18 . Administer treatment per MD orders, Encourage and assist as needed to turn and reposition, use assistive devices as needed, Follow up care with MD as ordered, Report evidence of infection such as purulent drainage, swelling. Localized heat, increased pain, etc. Notify MD PRN, Toileting program as indicated. The progress notes identified the following: * 08/02/18 at 3:38 p.m., Resident has a firm area to the left lower buttock, it is not raised, it has no discoloration, resident states it is very painful when palpated, (Physician) called . * 08/03/18 at 7:36 p.m., Assessed area to left buttock. Area not raised but more of a moveable nodule. Patient unable to differentiate pain from this side versus the other side at this time. This area is the same in color as the other side on examination. We will continue to monitor and contact the MD if necessary. Patient does have an appointment scheduled on Tuesday . * 08/06/18 at 2:39 p.m., . continues with hardened area to her left buttock, she states it hurts only when palpated, it is with no change in color, resident has appointment tomorrow . * 08/07/18 at 5:49 p.m., . (Physician) findings were: Left buttocks mass, no [MEDICAL CONDITION]. New order was to get ultrasound. * 08/14/18 at 4:37 p.m., . ultrasound done on Monday. states that she (has) discomfort when she is seated. Left buttock has no discoloration/no redness, no swelling but has a palpable and movable mass, no warmth noted. * 08/27/18 at 4:00 p.m., Patient had an Incision and Drainage done at (Hospital) by (Physician), with the following orders: Bactrim DS 800 mg-160 mg oral tab 1 tab PO BID x 7 days, [MEDICATION NAME] 5 mg-325 mg (milligram) po tab 1 tab PO (by mouth) Q (every) 4 hr (hour) PRN for pain, Also, to change left buttock dressing daily, pack with 1/4 [MEDICATION NAME], cover with gauze and tape. * 09/01/18 at 4:27 p.m., . Incision to Left lower buttock packed with approximately 3 CM of Iodaform gauze, wet with NS and dry gauze. * 09/05/18 at 10:31 a.m., . Incision to Left lower buttock packed with about 2 cm Iodaform and wet to dry using NS. NO drainage noted. * 10/03/18 at 7:09 p.m., This nurse . asked for an order to D/C (discontinue) the current dressing on resident's left buttock area. stated we can do the Dakins Half Strength 0.25% topical solution, apply to right lower leg open wound BID wet to dry dressing x 1 week. The chart lacked assessment of the wound since it was first identified on 09/05/18. * 10/16/18 at 9:10 p.m., . transport to . (another facility out of state) . During an interview on 06/06/19 at 8:00 a.m., when asked questions pertaining to the facility's care expectations, the managerial nurse (#5) stated, What (staff) were supposed to do was complete a weekly wound tracker. The weekly skin assessment would catch any other type of skin issue, non-pressure sore. so we know it's there. The facility failed to: * Accurately identify/document observations of Resident #18's [MEDICAL CONDITION] sore on her leg and mass on her buttocks, * Administer medications as per physician's order, * Treat Resident #18's infected leg sore and buttock mass in a timely manner, * Treat Resident #18's infected leg sore and buttock mass as per physician's order, and * Measure Resident #18's the [MEDICAL CONDITION] sore and mass in a timely manner/weekly per facility policy. BLOOD SUGAR PARAMETERS 2. Based on information received from the complainants, record review, and review of professional reference, the facility failed to establish individualized blood glucose parameters for 1 of 1 resident discharged from the facility (Resident #17) who experienced repeated hypoglycemic (low blood sugar) episodes. Failure to establish high/low blood glucose parameters has the potential to place all diabetic residents at risk for serious adverse events. Findings include: Information provided by the complainants indicated nursing staff failed to provide care/services to a resident who experienced a hypoglycemic episode and failed to communicate information regarding the resident's condition to other staff members. Review of the American Diabetes Association website occurred on 06/10/19. The article entitled, Glycemic targets: Standards of Medical Care in Diabetes - 2019 stated, . Glucose monitoring allows patients to evaluate their individual response to therapy and assess whether glycemic targets are being safely achieved. Integrating results into diabetes management can be a useful tool for . preventing [DIAGNOSES REDACTED], and adjusting medications . Level 1 [DIAGNOSES REDACTED] is defined as a measurable glucose concentration - Review of Resident #17's medical record occurred on all days of survey and identified [DIAGNOSES REDACTED]. The physician's orders identified Resident #17 received the following: * [MEDICATION NAME] injections three times daily per sliding scale with meals * 100 mg [MEDICATION NAME] daily * 100 unit/ml [MEDICATION NAME] twice daily, and * 1000 mg [MEDICATION NAME] twice daily. The care plan identified, Endocrine system r/t (related to) insulin dependent diabetes . Obtain glucometer readings and report abnormalities as ordered . Report symptoms of [DIAGNOSES REDACTED]: weakness, pallor, diaphoresis, vision changes, change in consciousness. The progress notes identified the following: * 03/31/19 at 11:50 a.m., Will update family and MD (physician): Resident was hypoglycemic with a blood sugar of 52 mg/dl (Level 2 [DIAGNOSES REDACTED]). She was non verbal, clammy and lethargic. [MEDICATION NAME] administered by this nurse, ambulance called. When ambulance crew arrived, resident sugar level was up to 60 mg/dl (Level 1 [DIAGNOSES REDACTED]). Her vitals was (sic) stable, she verbally refused going to the hospital . It's unclear who ordered the [MEDICATION NAME]. The chart lacked evidence staff informed Resident #17's primary physician of her hypoglycemic episode. * 05/02/19 at 5:45 p.m., Resident is pale (and) diaphoretic. Blood glucose is 52 mg/dl (Level 2 [DIAGNOSES REDACTED]). No emisis or c/o (complained of) nausea. (Physician) on call . paged (and) gave new order to administer [MEDICATION NAME] 1 mg intramuscularly now (and) recheck blood glucose in 15 minutes. Order observed. The chart lacked evidence staff informed Resident #17's primary physician of her hypoglycemic episode. * 05/03/19 at 1:14 a.m., Resident was found pale, diaphoretic and unresponsive (symptoms of Level 3 [DIAGNOSES REDACTED]). Unresponsive to sternum rub. BS (blood sugar) was 35 (Level 2 [DIAGNOSES REDACTED]). [MEDICATION NAME] 1 mg given. 15 mins later, resident continued to be unresponsive and pale. Her BS was 44. Another [MEDICATION NAME] 1 mg injected. 15 mins later her BS was 85. Nurse gave another sternum rub and resident pushed away hands. (Physician) whom is taking call . gave order to administer the [MEDICATION NAME] 1 mg x (times) 2. Primary MD will be notified via fax. The chart lacked evidence staff informed Resident #17's primary physician of her hypoglycemic episode. * 05/03/19 at 2:34 p.m., Resident had a blood sugar of 32 mg/dl (Level 2 [DIAGNOSES REDACTED] with symptoms of Level 3 [DIAGNOSES REDACTED]) this morning. Called the on-call Doctor . Emergency [MEDICATION NAME] was administered on Right deltoid. Check glucose level 15 min (minutes) later and went up to 78 mg/dl. He gave an order to put and (sic) IV (intravenously) and give fluids . This nurse tried to insert . IV twice but was not able to get it. Called ambulance and they came an (sic) inserted a 22 gauge (IV) on her right arm. Immediately started fluids. Resident became alert and responsive. Called (Primary Physician) and informed him of residents current status. * 05/05/19 at 5:00 p.m., Resident was found unresponsive (symptom of Level 3 [DIAGNOSES REDACTED]) to sternum rub. BS was 67 mg/dL . [MEDICATION NAME] 1 mg given. Blood sugar rechecked 15 mins later was 106. Resident was responsive . Informed (Physician) on call . and he ordered to decrease dosage of [MEDICATION NAME] . The Primary MD will be notified . It's unclear who ordered the [MEDICATION NAME]. The chart lacked evidence staff informed Resident #17's primary physician of her hypoglycemic episode. During an interview on 06/05/19 at 3:00 p.m., a managerial nurse (#5) confirmed the facility failed to consistently notify Resident #17's primary physician of her hypoglycemic episodes and failed to obtain blood glucose parameters from her physician identifying when he should be notified of her condition. Failure to establish individualized parameters to treat low blood glucose levels for unresponsive residents has the potential to place residents at risk of developing a life-threatening hypoglycemic reaction.",2020-09-01
55,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2019-06-11,686,G,1,0,HFFF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on information received from the complainants, observation, record review, and staff interview, the facility failed to provide the necessary care and services to prevent the development and promote healing of pressure ulcers for 2 of 2 sampled residents (Resident #3 and #14) and 1 discharged resident (Resident #17) at risk of developing and/or with known ulcers. Failure to implement, monitor, and modify interventions to reduce risk factors and consistently provide treatment to prevent the development of new pressure ulcers and/or heal current pressure ulcers resulted in Resident #14 and #17 developing avoidable facility-acquired pressure ulcers and had the potential to result in other residents (Resident #3) developing skin breakdown. Findings include: Information provided by the complainants indicated nursing staff failed to consistently utilize physician ordered interventions in a timely manner to prevent and/or heal ulcers. Review of the facility policy titled Skin Management System occurred on 06/10/19. This undated policy stated, . Pressure Ulcers, Venous Ulcers, and Arterial Ulcers, and surgical sites will be documented on . form or EMR (electronic medical record). Use one form per wound. Wound progress is to be documented each week with measurement and wound descriptions. Daily treatments are also documented on the same form. Skin issues such as skin tears, bruises, rashes, abrasions,[MEDICAL CONDITION]. will be documented . - Review of Resident #14's medical record occurred on all days of survey. The Significant Change Minimum Data Set (MDS), dated [DATE], identified extensive assistance from two or more people for bed mobility, one Stage II pressure ulcer, and one venous and arterial ulcer. Right Lower Leg Resident #14's current physician order stated, .Wound to right lower extremity: Apply santyl ointment to dark eschar tissue. Apply hydrogel gauze over santyl (not on good tissue). Cover with non-adherent dressing. Wrap with gauze and with tape. Apply protective ointment to peri-wound area. Change daily. Wound nurse to follow (started 05/17/19) . Resident #14's progress notes showed the following: * 03/06/19 at 7:44 a.m. - Resident has a wound on lower right calf. cleansed with NS. Patted dry. TAO (triple antibiotic ointment) applied and covered . MD (physician) notified. * 03/06/19 at 12:43 p.m. - New orders for wound to lower right leg. Apply steri strips to wound, apply gauze and [MEDICATION NAME]. Change gauze and [MEDICATION NAME] BID (twice per day). * 03/08/19 skin assessments shows open area to right lower leg (RLL) 11 centimeters (cm) x 4 cm No further documentation regarding right lower leg until 05/04/19 *05/04/19 at 11:41 a.m. - Writer was dressing RLL and noted open areas that were weeping and swelling from ankle to mid-leg. Area is red, no warmth noted. MD notified via phone, ordered [MEDICATION NAME] over open areas, change MWF (Monday, Wednesday, Friday). Ace wraps to be put on from foot to mid leg and taken off at HS (night) . * 05/06/19 at 10:05 a.m. - Resident RLL (right lower extremity) continues to be weeping and writer noted bleeding. CNA (certified nursing assistant) reported foul odor when removing dressing for shower. Area is red, warm and tender to touch, no swelling noted . MD has been updated via fax. * 05/07/19 at 6:13 p.m. - . Dressing change to right lower lateral leg. Area is red, cool to touch et draining clear fluid . * 05/08/19 at 3:32 a.m. - Resident has a treatment to RLE (right lower extremity) for swelling and weeping . some redness present which may be related to dressing changes and ACE wrap. at (sic) this time RLE is not wrapped with bandage. Will continue to monitor and notify md of any changes or worsening. * 05/09/19 at 5:47 a.m. - . discoloration to area scattered. some redness and purplish skin present which may be related to dressing changes and ACE wrap. at (sic) this time RLE is not wrapped with bandage . Will continue to monitor and notify md of any changes or worsening. Review of record showed the doctor responded to fax on 05/09/19. The physician stated he/she would see the resident tomorrow (4 days after symptoms reported). * 05/10/19 at 12:37 p.m. - . Ulcer on right leg is red, with darken area small amount of clear fluids was seen draining at left lateral aspect of wound . * 05/10/19 at 7:21 p.m. - . rt lower leg wound- dakens wet to dry BID until healed . wound nurse to follow, [MEDICATION NAME] 100mg (milligrams) po (oral intakes) BID X 7 days. * 05/11/19 at 2:29 p.m. - Resident's ulcer on right leg is blackish in color . minimal serosanguineous drainage . * 05/12/19 at 11:07 a.m. - . Eschar/scabbing is resolving. Yellow purulent drainage . * 05/13/19 at 9:50 p.m. - . area has some debrided areas and some dark colored tissue . * 05/15/19 at 10:49 p.m. - Continues on an antibiotic for RLE wound. wound (sic) area is around lower ankle, dark tissue, with some small areas of debridement . * 05/16/19 at 2:43 p.m. - Order received from (doctor name) . apply santyl to dark eschar tissue, apply hydrogel gauze over eschar, cover with non-adherent [MEDICATION NAME] dressing, wrap with gauze and secure with tape . Wound nurse to follow. * 05/19/19 at 1:01 p.m. - . Wound on her right lower extremity drains has a serosanguinuous drainage, black skin tissue softens and easily removed. * 05/20/19 at 2:47 p.m. - . (doctor name) recommended resident be seen in the emergency department due to [MEDICAL CONDITION] . * 05/20/19 at 6:17 p.m. - Resident admitted to . Trinity Health hospital . * 05/24/19 at 11:28 a.m. - Resident returned to facility . New orders for [MEDICATION NAME] 250mg PO every other day x3 days . Right lower leg has minimal eschar and slough present, wound bed is pink . Review of Resident #14's Admission/Readmission Evaluation on 05/24/19 identified a Stage III vascular ulcer to right lower leg (front). The record showed no further documentation after 05/24/19 regarding the progress of the wound. Review of progress notes and skin/wound assessments identified the facility failed to document weekly measurements. Coccyx Resident #14's current physician order stated, . [MEDICATION NAME] to open areas on bottom. Change every MWF until healed (started 05/01/19) . Resident #14's progress notes showed the following: * 04/27/19 at 1:50 p.m. - Writer noted three open areas to resident's bottom. the (sic) first one measures 0.8cm x 1cm on the left buttock and the second one measures 0.5cm x 0.8cm on the left buttock, and the third one measures 0.4 cm x 0.5cm on the right buttock. Foam dressings applied. Writer also noted redness around anal area, calmo applied. Will update MD at this time and continue to monitor. * 04/29/19 at 9:31 a.m. - MD would like areas on bottom to be treated with [MEDICATION NAME], change every MWF . Physician's order to start [MEDICATION NAME] on 04/29/19 to the open area on bottom. Review of (MONTH) 2019 Treatment Administration Record (TAR) showed Resident #14's treatment failed to be started until 05/01/19. Review of progress notes and skin/wound assessments showed the facility failed to document weekly on the progress of the wounds including measurements and descriptions. Right Toe The current physician order stated, . Paint wound on RT 1st MTPJ (metatarsophalangeal joint) wound, with [MEDICATION NAME] and cover with a [MEDICATION NAME] type bandage change daily (started 02/28/19) . Resident #14's progress notes showed the following: * 02/19/19 9:17 p.m. - (Doctor name) here to round on resident, order rec'd (received) to continue [MEDICATION NAME] dressing to rt MTP joint ulcer until healed. Change every 3 days and prn. Appt with podiatry for evaluation. * 02/27/19 7:33 p.m. - Resident went out to a podiatry appt. (appointment) today, recommends paint wound with [MEDICATION NAME] and cover with [MEDICATION NAME] type dressing daily. No soaking. * 05/11/19 6:39 p.m. - .Ulcer on right phalangeal region . * 05/28/19 3:01 p.m. - Has vascular wound on her toe. Review of progress notes and skin/wound assessments identified the facility failed to document weekly on the progress of the wound including measurements and descriptions. - Review of Resident #17's medical record occurred on all days of survey and identified [DIAGNOSES REDACTED]. Right Second Toe The progress notes identified the following: * 12/06/18 at 7:00 a.m. and 12/07/18 at 10:13 a.m., Will update MD Resident rt (right) great toe (nail) came off during showers . her second rt toe has a 2 cm (centimeter) wt (width) by 1.2 cm Lt (left) pressure area. Skin is intact and without drainage. Site is red, resident denies sensation or pain . * 12/11/18 at 3:26 p.m., This nurse paged (physician) regarding resident sore toe. He ordered Keflex 500 mg (milligram) PO (by mouth) TID (three times per day) for 10 days. First dose given by this nurse. The facility notified Resident #17's physician five days after discovering the pressure area on her right second toe. The facility failed to notify Resident #17's physician in a timely manner, paging him five days after they discovered the ulcer on her toe. * 12/12/18 at 10:39 a.m., . Pharmacy called and reported a different dosage, Author contacted (Physician), and confirmed dosage with (Physician) and pharmacy . and at 8:48 p.m., Resident continues with Keflex abt (antibiotic) 250 mg po Tid x 10 days for infection [MEDICATION NAME] to right great toe nail bed where toenail came off . Right great toe nail bed is dark pink (and) without any drainage. Right 2nd toe distal joint has a 2 cm (W) (width) x 1/2 cm (L) (length) red area that blanches. Resident denies any pain to the toes . * 12/13/18 at 3:58 a.m., Resident great toe and distal middle toe assessed. No drainage, swelling or signs of infection observed. Resident denied pain. * 12/14/18 at 9:33 p.m., Resident continues with alert charting for infection to right second toe distal joint. Right 2nd toe is red with a small yellow hardened area to anterior aspect. No drainage. Site blanches. Resident denies having any pain. Right great toe nail bed . has no redness or drainage. * 12/17/18 at 9:18 p.m., . continues on Keflex . 2nd toe right foot distal joint has a red area with a firm yellow center that has a scab forming. No drainage. Area left OTA (open to air). Resident denies any pain or discomfort to the right foot (and) toes. * 12/18/18 at 9:07 p.m., . remains on Keflex . Right 2nd toe distal joint is slightly red (and) blanches with palpation. Center of red area has a small circular hard white area with scab forming. No drainage (and) OT[NAME] Resident denies any pain or discomfort to her toes. * 12/19/18 at 9:00 p.m., . continues with Keflex . Right second toe distal joint has a slightly red area with small circular yellow center with scab formed. No drainage. The care plan identified, . Date Initiated: 12/17/2018 . Infection of wound/skin (Right great toe) . Administer meds as ordered, Diagnostic tests as ordered, Maintain precautions as indicated, Obtain labs as ordered and notify MD of results, Record temperature as clinically indicated. Date Initiated: 12/19/2018 . Scab at right 2nd toe r/t (related to) friction, impaired mobility, diabetes . Administer treatment per MD orders, Diet and supplements per MD orders, Encourage and assist as needed to turn and reposition, use assistive devices as needed, Float heels as able, Follow up care with MD as ordered, Report evidence of infection such as purulent drainage, swelling. Localized heat, increased pain, etc. Notify MD PRN (as needed). Progress notes also identified the following: * 12/20/18 at 8:00 p.m., . continues with Keflex . Right 2nd toe is slightly red with small white center forming a scab. No drainage. no c/o pain to toe. * 12/21/18 at 4:16 p.m., Wound nurse assessed the open area to resident's right foot 2nd toe. The wound measures 1.1 cm x 0.9 cm. The wound bed contains 100% hard slough. No drainage. No odor. No c/o pain. The wound nurse recommends that the area be cleansed with normal saline. Apply Antisept, and wrap in gauze. Change daily. The facility failed to measure the wound for nine days. * 12/22/18 at 1:06 p.m., . continues with Keflex . Right 2nd toe is slightly red with small white center forming a scab. No drainage. * 12/25/18 at 8:00 p.m., . completed . Keflex . right 2nd toe distal joint has a small scab dry (and) intact (and) base of toe is slightly red (and) warm to touch. This note faxed to Dr. * 12/26/18 at 10:05 p.m., . Right 2nd toe distal joint has a small brown scab dry (and) intact. Base of right 2nd toe is slightly red (and) warm to touch. denies any pain or discomfort. The chart lacked evidence that the ulcer resolved, as staff failed to document further observations of the toe. The quarterly MDS, dated [DATE], identified the resident was at risk of developing pressure ulcers and had moisture associated skin damage. The physician's orders identified, Start Date 03/07/19 . Skin evaluation every Thursday AM, every day shift every Thu (Thursday) . The next set of progress notes addressing Resident #17's toe identified the following: * 03/10/19 at 9:49 p.m., Resident's daughter approached this recorder and stated, my Mom's toe is infected . On exam 2nd toe on rt foot is light red, no swelling noted, has a dry callous type lesion of DP (sic) joint area, no drainage noted, residents (sic) states it does not hurt . Callous is dry measures 0.9 cm x 1 cm. The facility failed to identify the observable changes to Resident #17's toe prior to family voicing their observations/concerns. * 03/11/19 at 2:54 p.m., . Resident has Dx (diagnosis) of [MEDICAL CONDITION] to right 2nd toe. New orders for . [MEDICATION NAME] 100 mg tab po Bid x 7 days . Apply [MEDICATION NAME] daily to right 2nd toe. The significant change MDS, dated [DATE], identified the resident was at risk of developing pressure ulcers and infection of the foot (e.g., [MEDICAL CONDITION], purulent drainage). A progress noted, dated 03/12/19 at 4:41 a.m., identified, . received first dose of [MEDICATION NAME] . Toe is [DIAGNOSES REDACTED] and slightly warm to touch. Skin is intact. No drainage noted. She stated only has pain when blanket is laying on the foot. Blanket was pulled back and she stated she had relief. and at 9:11 p.m., . Right 2nd toe is red (and) swollen. Anterior distal tip of toe has a small circular open area with no drainage. Resident denies any pain or discomfort to toe. The facility failed to measure the open area on the tip of Resident #17's toe. The care plan identified, . Date Initiated: 03/12/2019 . Infection of wound/skin (right 2nd toe) . Administer meds as ordered, Maintain precautions as indicated, Record temperature as clinically indicated. The care plan failed to address removing pressure from the top of Resident #17's feet. Progress notes also identified the following: * 03/17/19 at 2:52 a.m., . continues taking [MEDICATION NAME] . No drainage. Denies of (sic) any pain. Foot elevated while in bed. * 03/18/19 at 9:05 p.m., . took last dose of Doxycycine . Right 2nd toe is dark pink with small circular scab to the anterior tip of toe. No drainage. Resident denies any pain or discomfort. * 03/29/19 at 1:27 p.m., Received new order from podiatry . Continue [MEDICATION NAME] treatment to right second toe for 7 days then discontinue. * 04/03/19 at 11:19 a.m., Note received from (Physician) with addendum made to specify painful calluses and ulceration to right 2nd toe, left foot hammer toe deformity and callus the left big toe. * 04/09/19 at 6:03 p.m., Resident's daughter . concerned that resident's right 2nd toe diabetic vascular ulcer is not improving. I note that right 2nd toe has a very thick necrotic black 0.8 cm circular scab dry (and) intact. No drainage. Surrounding toe is slightly red. Right foot is slightly cool to touch with pedal pulses palpable. Resident denies any pain or discomfort to the right foot. ROM (range of motion) (and) sensation is intact to right foot (and) toes when palpated (sic). Daughter . requests that a f/u (follow up) appointment be made ASAP (as soon as possible) with podiatrist . Staff failed to identify the observable necrosis to Resident #17's toe prior to family voicing their observations/concerns. The facility failed to measure/assess the ulcer since it was first identified on 03/12/19. * 04/17/19 at 2:25 p.m., Made an appointment with . podiatry to see if resident scabbed to her right second toe can be debride (sic). Staff failed to schedule an appointment with Resident #17's podiatrist in a timely manner, contacting his office eight days after the family made their request. * 04/22/19 at 2:00 p.m., Resident returned from appointment with podiatrist . No new orders. Dr. report states improving [MEDICAL CONDITION] right 2nd toe. Continue observation . The only weekly skin review provided by the facility, dated 05/02/19, identified, Skin intact, dry. Four days later, a progress note, dated 05/06/19 at 1:41 a.m., identified, Medial right great toe is not blanchable, black in color, redness present at ankle to black area at base of the toe. redness measures 22 cm in length from above the ankle to base of toe. blackened area on toe is 5 cm x 2 cm. Areas between the toes are flesh colored. 2nd toe has 1 cm x 1 cm area previously noted to be discolored and is in notes from podiatry. 3rd toe has reddened area 1 cm x 1 cm right lowere extremity is warm and dry, no [MEDICAL CONDITION] present, dorsal part of foot is cool to touch as are the toes, reflexes in expremity and foot present. telephone order OK to transfer resident to ER and treat per family request. Family in facility requesting resident be transferred to hospital for eval and treatment related to recent [DIAGNOSES REDACTED] and discolored toe. On 04/09/19, staff described a very thick necrotic black 0.8 cm circular scab. The chart lacked documentation regarding the toe until 05/06/19, at which time staff described a blackened area on toe, is 5 cm x 2 cm. During an interview on 06/06/19 at 8:00 a.m., when asked questions pertaining to Resident #17's ulcer, a managerial nurse (#5) stated, Originally, it was due to pressure, then they decided it was a diabetic ulcer, and then it became necrotic. She was put on antibiotics when she went to the hospital. When asked questions pertaining to the facility's care expectations, the managerial nurse (#5) stated, What they were supposed to do was complete a weekly wound tracker. Every week the Nurse Manager measures pressure sores. I would assume they started a wound tracker as soon as they found the sore. They would document the size, color, drainage, and stuff. I couldn't find a weekly skin assessment either. The weekly skin assessment would catch any other type of skin issue, non-pressure sore. so we know it's there. The facility failed to: * Notify physician in a timely manner after discovering the ulcer on Resident #17's toe, * Accurately identify/document observations of the infected area, * Measure Resident #17's toe ulcer in a timely manner/weekly per facility policy, * Document if/when Resident #17's ulcer resolved, * Assess/identify observable color changes/necrosis on Resident #17's toe, * Care plan the need to remove pressure from the top of Resident #17's feet, and * Schedule an appointment with the podiatrist in a timely manner after discovering the necrosis on Resident #17's toe. - Review of Resident #3's medical record occurred on all days of survey. A Significant Change MDS, dated [DATE], identified a risk for pressure ulcer, no pressure ulcer present, pressure reducing device for chair, and pressure reducing device for bed. The current care plan, dated 04/10/19, stated, . resident has suspected deep tissue injury to buttock, coccyx area r/t (related to) immobility during recent hospital stay . The resident requires an APM (air pressure mattress)for her bed . Observation on 06/05/19, at 9:55 a.m., showed two CNAs (#3 and #4) assisted Resident #3 from the wheelchair to the bed, performed ADL's (activities of daily living) and exited Resident #3's room. Resident #3's air mattress pump was unplugged from the electrical outlet. The CNAs failed to assure the air mattress was on and fully inflated. During an interview on 06/06/19 at 9:05 a.m., an administrative nurse stated he/she would expect staff to make sure the air mattress was on and lying on the bed frame would create a problem because there is nothing soft to prevent the resident from lying on the steel frame.",2020-09-01
56,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2019-06-11,689,D,1,0,HFFF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > THIS IS A REPEAT DEFICIENCY FROM SURVEYS COMPLETED ON 07/26/17 and 08/16/18. GAIT BELT USE 1. Based on observation, record review, review of facility policy, review of a professional reference, and staff interview, the facility failed to provide adequate supervision and assistive devices necessary to prevent accidents for 3 of 4 (Resident #3, #14, and #15) observed during a gait belt transfer. Failure to properly use a gait belt during transfers placed the resident at risk of accidents and injury. Findings include: Review of the facility Gait Belt Skill Checklist occurred on 06/10/19. This list stated, . properly position gait belt low on resident waist . Properly grasp belt for effective use . Assist resident from a sit to stand position grasping gait belt properly. - Observation on 06/04/19 at 10:59 a.m. showed two certified nursing assistant (CNAs) (#9 and #10) placed a gait belt around Resident #14's waist and assisted her to transfer from her chair to bed. The CNAs (#9 and #10) held the gait belt with one hand and lifted under the resident's arm axilla with the other hand. The resident did not fully bear weight, and her knees bent to an almost 90 degree angle. - Observation on 06/05/19 at 9:55 a.m. showed two CNAs (#3 and #4) transferred Resident #3 from the wheelchair to bed with assist of two and a gait belt. CNA (#4) failed to properly use the gait belt during transfer and lifted Resident #3 under her right arm pit. - Observation on 06/05/19 at 1:55 p.m. showed a CNA (#6) transferred Resident #15 from the wheelchair to the toilet with assist of one with a gait belt. Review of Resident #15's medical record occurred on all days of survey. The current care plan stated, . Transfer with two staff assist with gait belt . During an interview on 06/06/19 at 9:05 a.m., a managerial nurse (#5) stated, if the resident requires assistance from two staff members, he expected one staff member to stand on each side of the resident with one hand on the back of the gait belt and one hand on the front of the gait belt. TOILETING ASSISTANCE 2. Based on information received from the complainants, record review, review of a professional reference, the facility failed to provide adequate supervision/assistance for 2 of 2 sampled residents (Resident #11 and #14) and 1 discharged resident (Resident #17) who fell while attempting to self-transfer to the bathroom. Failure to provide adequate supervision/assistance resulted in residents experiencing preventable falls with/without injury. Findings include: Information provided by the complainants indicated nursing staff failed to provide adequate supervision/assistance resulted in residents' attempts to self-tranfer to the bathroom. Berman, Snyder, and Frandsen's, Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 10th edition, Pearson Education, Inc., New Jersey, page 651, stated, . Risk Factor and Preventative Measures for Falls: Urinary frequency or receiving diuretics, Weakness from disease process or therapy, Current medication regimen that includes sedatives, hypnotics, tranquilizers, narcotic [MEDICATION NAME], diuretics. Assist with voiding on a frequent and scheduled basis. Findings include: - Review of Resident #11's medical record occurred on all days of survey. The current care plan identified, . Urinary incontinence r/t (related to) Disease process (dementia), functional incontinence, [MEDICAL CONDITIONS] . Provide assistance with toileting every two hours at minimum. At risk for falls due to: history of falls, impaired balance/poor coordination. Interventions: Increased toileting during nighttime hours (every 2-3 hours). Progress notes identified the following: * 05/02/19 at 6:30 p.m., . Light sounding . Lying on back next to foot of his bed .Was sitting in recliner prior . Incontinent of urine . * 05/04/19 at 6:41 a.m., . Kneeling on floor by bed . Incontinent of urine . * 05/30/19 at 9:57 a.m., . Lying on floor in front of recliner . Large loose incontinent BM (bowel movement) . * 05/31/19 at 12:46 p.m., . Found on floor next to bathroom . Had incontinent BM . Toileting documentation identified staff assisted Resident #11 as follows: * 05/02/19 at 2:42 a.m. and 9:56 p.m. * 05/04/19 at 4:05 a.m., 7:51 a.m., and 8:45 a.m. * 05/30/19 at 2:11 a.m., 10:26 a.m., and 9:47 p.m. * 05/31/19 at 2:13 a.m., 10:24 a.m., and 9:02 p.m. - Review of Resident #14's medical record occurred on all days of survey. The current care plan identified, . Urinary incontinence r/t: disease process dementia, impaired mobility . provide incontinent care as needed . At risk for falls due to: impaired balance/poor coordination . anticipate resident needs; assess comfortable for positioning in bed; reposition and provide incontinent cares at routine times . Progress notes identified the following: * 03/17/19 12:34 a.m., . found on the floor . lying on her back with her lower extremities under the bed . call light . sounding when staff arrived . found incontinent of bladder and incontinent of a small BM . * 04/07/19 at 10:34 p.m., . resident was sitting on the floor by her bed . incontinent of bowel . Toileting documentation identified staff assisted Resident #11 as follows: * 04/07/19 at 9:27 a.m. * 03/17/19 at 12:48 a.m., 9:53 a.m., and 8:57 p.m. - Review of Resident #17's medical record occurred on all days of survey. The record identified [DIAGNOSES REDACTED]. The care plan identified, . requires assistance related to physical limitations, visual impairment . CNA (certified nursing assistant) to assist to toilet prior to and following meals. Offer toileting on last rounds for night shift. Progress notes identified the following: * 01/12/19 at 9:19 p.m., Resident is on follow up for: Un witnessed fall in her bathroom. Resident is unable to transfer self back and fort (sic) (to) the bathroom. Resident educated to wait for assistance after activating call light, can't transfer self. Failure to offer residents supervision/assistance with toileting on a more frequent basis may have resulted in Resident #11, #14, and #17 experiencing preventable falls. Refer to F585 and F690.",2020-09-01
57,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2019-06-11,690,E,1,0,HFFF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > INCONTINENCE 1. Based on information received from the complainants, record review, and review of the facility policy, the facility failed to assess the residents' bowel and bladder patterns to maintain continence for 2 of 16 sampled residents reviewed (Resident #11 and #14) and 2 discharged residents (Resident #17 and #19). Failure to assess bowel and bladder patterns and implement routine toileting consistent with these patterns may result in avoidable incontinence, urinary tract infections (UTIs), and/or falls and does not allow residents to attain/maintain their highest practicable physical and psychosocial well-being. Findings include: Information provided by the complainants indicated nursing staff failed to toilet residents on a frequent basis resulting in residents' observed in soiled clothing/bedding. Review of the facility policy titled Incontinence Prevention Program occurred on 06/11/19. This undated policy stated, . Based upon the results of the Evaluation of Continence . Prompted voiding is a scheduled toileting program . Residents are offered toileting assistance at regular intervals while awake and as needed at night. Habit training is a scheduled bladder management program designed according to the patient's/resident's individual voiding pattern. Routine Toileting . A scheduled bladder management program will be designed to toilet an incontinent patient/resident when a voiding pattern cannot be established or for a patient/resident who is unable to communicate the need to void . - Review of Resident #11's medical record occurred on all days of survey. The current care plan identified, . Urinary incontinence r/t (related to) Disease process (dementia), functional incontinence, [MEDICAL CONDITIONS] . Provide assistance with toileting every two hours at minimum. At risk for falls due to: history of falls, impaired balance/poor coordination. Increased toileting during nighttime hours (every 2-3 hours) . Review of toileting documentation, dated 05/01/19-06/03/19, showed staff toileted Resident #11 one-to-four times per day. The progress notes further identified staff found Resident #11 on the floor incontinent of urine and/or stool on four occasions. - Review of Resident #14 medical record occurred on all days of survey. The current care plan identified, . Urinary incontinence r/t: disease process dementia, impaired mobility . provide incontinent care as needed . At risk for falls due to: impaired balance/poor coordination . anticipate resident needs; assess comfortable for positioning in bed; reposition and provide incontinent cares at routine times . Review of toileting documentation, dated 03/01/19-04/30/19, showed staff toileted Resident #14 one-to-four times per day. The progress notes further identified staff found Resident #14 on the floor incontinent of urine and/or stool on two occasions. - Review of Resident #17's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The care plan identified, . requires assistance related to physical limitations, visual impairment . CNA (certified nursing assistant) to assist to toilet prior to and following meals. Offer toileting on last rounds for night shift. Review of toileting documentation, dated 04/10/19-05/15/19, showed staff toileted Resident #17 zero-to-seven times per day at random times throughout the day. The facility failed to consistently toilet Resident #17 prior to/following meals as care-planned. The progress notes further identified staff found Resident #17 on the floor of her bathroom on one occasion. - Review of Resident #19's medical record occurred on all days of survey. The care plan identified, . At risk of urinary incontinence r/t Disease process [MEDICAL CONDITIONS] . Remind and assist as needed with toileting at routine times such as upon arising in AM, before/after meals, activities, therapy and at bedtime . Review of toileting documentation, dated 10/01/18-11/19/18, showed staff assisted/toileted Resident #19 two-to-six times per day at random times throughout the day. The facility failed to consistently toilet Resident #19 prior to/following meals as care-planned. Facility staffs' failure to assist/toilet Resident #11, #17, and #19 in a timely manner may have resulted in their experiencing incontinence/avoidable falls. Refer to F585 and F689. URINE CULTURES 2. Based on record review and staff interview, the facility failed to provide services to treat urinary tract infections (UTIs) for 1 of 1 resident discharged from the facility (Resident #17) with a history of UTIs. Failure to contact the physician immediately after being notified of a positive urine culture resulted in Resident #17 receiving delayed treatment for [REDACTED]. Findings include: Upon request, the facility failed to provide a copy of their policy addressing urinary tract infections. Staff indicated they use the McGeers Criteria. - Review of Resident #17 medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The care plan identified, . requires assistance related to physical limitations, visual impairment . CNA (certified nursing assistant) to assist to toilet prior to and following meals. Offer toileting on last rounds for night shift. The progress notes identified the following: * 03/22/19 at 5:43 a.m., . Resident lowered to her knees after resident stated her right knee became weak . * 03/22/19 at 2:42 p.m., Resident returned from appointment with nephrologist . New orders to continue same medications, get a U[NAME] A microbiology report, dated 03/24/19, identified Escherichia coli (E-coli) and Proteus mirabilis (types of bacteria) present in Resident #17's urine. The report further indicated the bacteria as susceptible to [MEDICATION NAME]/Tazobactam, and [MEDICATION NAME]/Sulfa (antibiotics). The chart lacked evidence that staff notified the physician of Resident #17's positive urine culture. The progress notes identified the following: * 03/26/19 at 7:00 p.m., CNA reports that when he was transferring resident from w/c (wheelchair) to toilet with gait belt, resident's legs buckled (and) she had to be lowered to the floor . * 04/01/19 at 5:00 p.m., Resident's hands (and) arms are shaking. Her cheeks are red (and) flushed . Resident had a large food filled emesis . (Physician) paged. New orders to get UA/UC (urinalysis/urine culture). Start resident on [MEDICATION NAME] (antibiotic) . During an interview on the morning of 06/06/19 at 8:00 a.m., the managerial nurse (#5) confirmed staff should have immediately contacted the physician after being notified of her positive urine culture. Facility staff failed to contact Resident #17's physician for eight days after being notified of her positive urine culture, delaying her antibiotic treatment.",2020-09-01
58,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2019-06-11,692,D,1,0,HFFF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > HYDRATION 1. Based on information provided by the complainants, observation, review of facility policy, record review, and staff interviews, the facility failed to offer fluids 3 of 16 sampled residents (Resident #6, #15 and #16) who required staff assistance for fluid intake and were at risk for dehydration. Failure to provide assistance with fluid intake may result in dehydration, constipation, and urinary tract infections (UTIs). Findings include: Information provided by the complainants indicated nursing staff failed to provide dependent residents assistance with fluid intake. Review of facility policy titled, Hydration Policy occured on 06/11/19. This policy, dated 01/2017, stated, . each resident receives adequate fluids to maintain proper hydration . - Review of Resident #6's medical record occurred on all days of the survey. [DIAGNOSES REDACTED]. The current care plan stated, . Encourage and assist as needed to consume foods and/or supplements and fluids offered . Observation on 06/04/19 at 11:15 a.m., showed a CNA (#13) provided cares for Resident #6 and exited the room. The CNA failed to offer the resident fluids. - Review of Resident #15's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The current care plan stated, . Encourage and assist as needed to consume foods and/or supplements and fluids offered . Observation on 06/05/19 at 1:55 p.m. showed a certified nursing assistant (CNA) (#6) provided cares for Resident #15 and exited the room. The CNA failed to offer the resident fluids. - Review of Resident #16's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The care plan stated, . Encourage as needed to consume foods and/or supplements and fluids offered . Observation on 06/04/19 at 3:42 p.m. showed two CNA (#7 and #8) provided cares for Resident #16 and exited the room. The CNAs failed to offer the resident fluids. During an interview on 06/06/19 at 10:00 a.m., an administrative nurse (#5) stated he/she expected facility staff to provide fluids during cares. NUTRITION 2. Based on information provided by the complainants, record review, and staff interview, the facility failed to address the nutritional needs for 1 of 1 resident discharged from the facility (Resident #17) who experienced significant weight loss. Failure to identify Resident #17's food preferences and obtain orders for/implement other interventions (i.e.: fotrified foods/supplements) in a timely manner contributed to Resident #17 experiencing significant unplanned weight loss. Findings include: Information provided by the complainants indicated nursing staff failed to put interventions in place to prevent residents from experiencing significant weight loss. Upon request, the facility failed to provide a copy of their policy addressing weight loss. During an interview on 06/04/19 at 3:30 p.m., when asked how the facility addresses residents experiencing weight loss, a managerial dietary staff member (#12) reported monitoring residents for gradual/significant weight loss, and stated, First, I would give the resident fortified foods, and then supplements. I try to do things like cookies, chocolate milk, whole milk, cheese and crackers, cereal, magic cup, sherbet, and peanut butter. If they need help, I ask them to be moved to an assisted table. Review of Resident #17's medical record occurred on all days of survey, and identified [DIAGNOSES REDACTED]. The weight record identified: * 12/03/18, 210 pounds * 01/08/19, 208 pounds (2 pound weight loss) * 02/12/19, 200 pounds (10 pound weight loss) * 04/04/19, 190 pounds (20 pound weight loss) * 05/05/19, 173 pounds (37 pound weight loss) The physician's orders [REDACTED]. * 03/05/19, Consistent Carbohydrate (CCD) diet Ground Meat texture, Regular/Thin consistency, Low Sodium * 03/06/19, [MEDICATION NAME] Tablet 40 mg. * 03/22/19, Fluid restriction as directed by cardiologist . Not > (greater than) 1750 ml in 24 hours. * 04/11/19, Speech evaluation - weight loss. The progress notes, dated 10/02/18-05/05/19, identified the following: * 01/08/19, Quarterly Assessment - (Resident #17) is on a carbohydrate controlled diet with ground meats. Her intakes vary averaging * 01/18/19, Care Plan Progress Note . Dietary was not present. (Resident #17) weighs 208 pounds and usually eats 0-25% of meals. * 03/08/19, . Eats less than 50% of meals Weight Stable . * 03/11/19, . Eats 50% to 75% of meals Weight Stable . * 03/21/19, Care Plan Progress Note . Dietary was not present. (Resident #17) weighs 191 pounds (down 17 pounds since 01/18/19) and usually eats 51-25% of meals. * 03/22/19, . Eats 75%-100% of meals Weight Stable . It is unclear how staff determined Resident #17's weight was stable, when the record showed a 17 pound weight loss the day before. * 03/26/19, . Eats 50% to 75% of meals Weight Stable . * 03/29/19, . (Resident #17) is on a carbohydrate controlled diet/1.5 gm (gram) sodium with ground meats and 1750 ml fluid restriction. Her intakes vary averaging * 03/31/19, . -7.5% change . Wt triggers for significant change. Has been stable for past 2 weeks. Continues on low sodium carbohydrate controlled diet with ground meat and 1750 ml fluid restriction. She is eating * 04/01/19, . Eats 50% to 75% of meals Weight Stable . * 04/23/19, . -10.0% change . (Resident #17) continues to have a wt loss. She averages less than 50% of meals. She takes fluids well. She is on a fluid restricted diet carbohydrate controlled with ground meats. Some of loss maybe r/t (related to) fluid losses. Offer alternates when not eating her meals. She is taking her snacks well. Has [MEDICAL CONDITION] at this time. Continue to monitor. * 05/05/19, . Eats 50% to 75% of meals Weight Stable . The care plan identified, . Encourage and assist as needed to consume foods and/or supplements and fluids offered, Honor food preferences, Provide diet as ordered carbohydrate controlled low sodium ground meat, Review weights and notify MD and responsible party of significant weight loss. The facility failed to individualize Resident #17's care plan identifying specific preferred foods/supplements. During an interview on 06/05/19 at 3:00 p.m., a managerial nurse (#5) confirmed the care plan failed to reflect Resident #17's food preferences and/or the fortified foods, supplements, and snacks recommended for her. After identifying Resident #17 as at risk for significant weight loss, the facility failed to: * notify the physician of Resident #17's significant weight loss, * identify, care plan, and provide preferred foods, fortified foods, supplements, and/or snacks, and * monitor/document Resident #17's intake in an effort to identify which interventions were beneficial and her remaining caloric needs. Refer to F677.",2020-09-01
59,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2019-06-11,695,D,1,0,HFFF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on information provided by the complainants, observation, record review, review of professional reference, and staff interview, the facility failed to provide the necessary care and services for 2 of 3 residents (Resident #1 and #13) receiving oxygen. Failure to provide oxygen as ordered has the potential for residents to experience complications related to inadequate oxygen saturation levels. Findings include: Information provided by the complainants indicated nursing staff failed to ensure oxygen was administered per physician's order. Review of the facility policy titled Oxygen Administration occurred on 06/10/19. This policy, revised (MONTH) (YEAR), stated, . Validate physician orders for oxygen and set liter flow according to physician order. Berman and Synder, S., Kozier & Erb's Fundamentals of Nursing Concepts, Process, and Practice, 9th ed., Pearson Education, Inc., New Jersey, page 1397, stated, OXYGEN THERAPY . Like any medication, oxygen is not completely harmless to the client. Clients receive an inadequate amount or an excessive amount of oxygen and both can lead to a decline in the client's condition. An inadequate amount of oxygen ([MEDICAL CONDITION]) will lead to cell death, and if left untreated can ultimately lead to death. - Review of Residents #1's medical record occurred on all days of survey. A physician's order stated, . Oxygen at 2 L/M (liters per minute) to maintain O2 (oxygen) sats (saturations) >90%. Check each shift. Observation on 06/04/19 at 11:05 a.m., and 06/05/19 at 10:08 a.m., showed Resident #1 wearing a nasal cannula attached to an oxygen concentrator set at 1 liter per minute. The facility failed to consistently provide Resident #1 oxygen at the ordered concentration per nasal cannula. - Review of Resident #13's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. A current physician's order stated, Oxygen at 2L (liters) to keep sats greater than 90% prn as needed . Review of Resident #13's oxygen sats since (MONTH) 2019 showed resident oxygen sat levels remained above 90% daily with oxygen applied. The current care plan stated, . Has/At risk for respiratory impairment related to: history of recurrent pneumonia . Oxygen per MD orders . All observations during survey showed Resident #13 with oxygen on continuously at 2L. During an interview on 06/06/19 at 10:00 a.m., an administrative nurse (#5) stated Resident #13's family requests oxygen on continuously and confirmed the facility should obtain a continuous oxygen order.",2020-09-01
60,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2019-06-11,712,D,1,0,HFFF11,"> Based on record review, the facility failed to ensure the physician visits the resident at least once every 30 days for the first 90 days after admision, and at least once every 60 thereafter for 1 of 1 sampled resident (Resident #15). Failure to ensure residents receive the required phsyician visits may result in negative outcome and delay treatment. Findings include: Review of Resident #15's medical record occurred on all days of survey. Resident was admitted on (MONTH) 2019 and the medical record lacked evidence the resident received the required physician visits per the regulations.",2020-09-01
61,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2019-06-11,760,D,1,0,HFFF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and review of facility policy, the facility failed to ensure residents remained free of significant medication errors for 1 of 1 resident discharged from the facility (Resident #17) with a significant medication error. Failure to administer an antibiotic as stated in the physician's orders may result in a negative outcome for the resident. Findings include: Review of the facility policy titled Administering Medication occurred on 06/10/19. This policy, revised (MONTH) 2012, stated, . Medications must be administered in accordance with the orders, including any required time frames. - Review of Resident #18's medical record occurred on all days of survey, and identified [DIAGNOSES REDACTED]. The Medication Administration Record [REDACTED]. [MEDICATION NAME] 500 mg (milligrams) PO (by mouth) every 24 hrs (hours) for 10 days. The progress notes identified the following: * 10/09/18 at 10:30 p.m., Resident started first dose of [MEDICATION NAME] tonight. Wound to right lower leg has yellow slough present in wound bed. Wound has purulent yellow drainage that is soaked onto the kerlix covering her legs. Wound has an odor to it. * 10/16/18 at 9:10 p.m., . transport to . (another facility out of state) . The facility failed to administer the medication for the first time twenty-four hours after receiving the order and only administered six of nine recommended doses of the antibiotic. (The tenth dose was due the day after she was discharged from the facility.) The facility failed to administer Resident #18's antibiotic per the physician's order.",2020-09-01
62,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2019-06-11,801,D,1,0,HFFF11,"> Based on staff interview, the facility failed to ensure the dietary manager received the necessary education to obtain the required qualifications to hold the director of food and nutrition for 1 of 1 dietary manager (#2). Failure to ensure qualified staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition services has the potential to result in adverse consequences for resident. During an interview on 06/05/19 at 4:25 p.m., a dietary manager (#2) stated, I have started the process of getting my CDM (certified dietary manager). Upon request, on 06/05/19, the facility failed to provide evidence of staff member (#2) completing the required education of CDM, certified food service manager, or a national certification for food service management and safety from a national certifying body. The facility failed to provide the necessary training in food and nutrition services to carry out daily operation duties.",2020-09-01
63,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2019-06-11,880,E,1,0,HFFF11,"> THIS IS A REPEAT DEFICIENCY FROM SURVEYS COMPLETED ON 08/16/18. Based on observation, review of facility policy, and staff interview, the facility failed to follow infection control practices for 6 of 16 sampled residents (Resident #1, #3, #4, #13, #14, and #16) observed during personal cares. Failure to follow infection control practices of hand hygiene during toileting/personal cares has the potential to spread infection to other residents, personnel, and visitors. Findings include: Review of the facility policy titled Handwashing/Hand Hygiene occurred on 06/10/19. This undated policy stated, . Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice) . Before and after assisting a resident with toileting (hand washing with soap and water) . The use of gloves does not replace handwashing/hand hygiene . Review of the facility policy titled Infection Prevention and Control Manual Standard Precautions occurred on 06/10/19. This undated policy stated, . Sterile gloves and examinations gloves are removed . As soon as practical when contaminated . Between resident contacts . Before touching uncontaminated surfaces or other areas of the same resident's body that may be contaminated . Observations showed the following: * 06/04/19 at 10:59 a.m., two certified nursing assistants (CNAs) (#9 and #10) applied gloves and provided incontinent cares for Resident #14 after a bowel movement (BM). The CNA (#10) changed gloves and, without performing hand hygiene, placed a clean brief, removed his/her gloves, and then both CNAs positioned the resident into his/her wheelchair. The CNA (#10) failed to remove gloves and perform hand hygiene after incontinent cares. * 06/04/19 at 3:42 p.m., two CNAs (#7 and #8) applied gloves and provided incontinent cares for Resident #16 after a BM. The CNA (#8) failed to remove gloves or perform hand hygiene before placing a clean brief, and then both CNAs positioned the resident into his/her wheelchair. * 06/05/19 at 9:55 a.m., two CNAs (#3 and #4) gloved and assisted Resident #3 from wheelchair to bed. One of the CNAs (#3) removed her gloves, failed to perform hand hygiene and exited the room. While wearing gloves, CNA (#4) checked the resident's brief and stated, it's not wet. The CNA (#4) removed her gloves, lowered the bed, adjusted the bedspread and attached the call light to the bed. Without performing hand hygiene the CNA (#4) assisted Resident #1 in the same room. The CNA raised Resident #1's bed, closed the window blinds and donned gloves. The CNA (#4) performed perineal care after a bowel movement (bm) for Resident #1. Without performing hand hygiene or changing gloves, the CNA picked up a spray bottle (Peri fresh) and sprayed the Resident's perineal area. The CNA removed her soiled gloves, and applied clean gloves. The CNA (#4) failed to complete hand hygiene between glove changes, prior to other tasks, and after perineal cares. * 06/05/19 at 11:50 a.m., two CNAs (#3 and #4) assisted Resident #4 from bed to wheelchair. The Resident #4's feeding tube became lodged and disconnected underneath him. Contents of the feeding tube (gastric secretions) leaked onto the floor and onto CNA's (#3) ungloved hands. The CNA (#3) failed to don gloves prior to performing cares. * 06/05/19 at 3:20 p.m., two CNAs (#7 and #11) applied gloves and provided incontinent cares for Resident #16 after a BM. The CNA (#7) failed to remove gloves or perform hand hygiene before placing a clean brief, and then both CNAs positioned the resident into his/her wheelchair. * 06/05/19 at 3:33 p.m., two CNAs (#7 and #11) applied gloves and provided incontinent cares for Resident #13. Without removing his/her gloves CNA (#7) removed the resident's oxygen, positioned the resident into his/her wheelchair and replaced the resident's oxygen. The CNA (#7) failed to remove gloves and perform hand hygiene after incontinent cares. During an interview on 06/06/19 at 9:05 a.m., an administrative nurse (#5) stated he/she expected staff to perform hand hygiene/change gloves before, after, and in between cares.",2020-09-01
64,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2017-07-26,157,D,0,1,GH6U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure notification of the health care provider for 1 of 1 sampled resident (Resident #7) regarding medication held for numerous days. Failure to notify the resident's health care provider when holding [MEDICATION NAME] (fluid medication) for numerous days limited the physician's ability to make an informed decision regarding the resident's care. Findings include: Review of Resident #7's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Review of Resident #7's Medication Administration Record [REDACTED]. The medical record failed to identify staff notified the resident's physician. During an interview on 07/26/17 at 11:00 a.m. an administrative nurse (#3) stated she would expect staff to notify the physician when holding medication that frequently.",2020-09-01
65,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2017-07-26,274,D,0,1,GH6U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, and staff interview, the facility failed to complete a significant change in status assessment (SCSA) for 1 of 13 sampled residents (Resident #3) reviewed. Failure to determine the need for and complete a SCSA in response to the resident's decline limited the facility's ability to accurately assess the resident's status, and identity and implement appropriate care approaches. Findings include: The Long-Term Care Facility RAI 3.0 User's Manual (Version 1.14), dated (MONTH) (YEAR), page 2-22 stated, . A significant change is a decline or improvement in a resident's status that: 1. Will not normally resolve itself without staff intervention . 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan. and page 2-25 stated, A SCSA is appropriate if there are either two or more areas of decline or two or more areas of improvement. Review of Resident #3's medical record occurred on all days of survey. The quarterly Minimum Data Set (MDS), dated [DATE], identified: * walking in room did not occur * extensive assistance with locomotion on the unit * extensive assistance with locomotion off the unit * frequently incontinent of bowel * one unstageable pressure ulcer The admission MDS, dated [DATE], identified the following changes: * limited assistance with walking in room * supervision with locomotion on the unit * supervision with locomotion off the unit * occasionally incontinent of bowel * no pressure ulcers The facility failed to complete a SCSA following Resident #3's decline in four areas, plus the development of a pressure ulcer.",2020-09-01
66,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2017-07-26,280,E,0,1,GH6U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 01/12/17. Based on observation, record review, and staff interview, the facility failed to review and revise the comprehensive care plan to reflect the current status for 4 of 13 sampled residents (Resident #2, #3, #4, and #13). Failure to revise the care plan limited the ability of staff to communicate care needs and ensure continuity of care for each resident. Findings include: - Review of Resident #2's medical record occurred on all days of survey. The record included a fax from the physician, dated 06/22/17, which stated, . Thank you for the update. Please advance diet to regular textured diet . The record also included a fax to the physician, dated 07/05/17, which requested the use of Prevalon (pressure-reducing) boots at night. The physician responded, yes, agree (with) above. Review of Resident #2's care plan on 07/24/17 identified a mechanical soft diet and failed to include the use of Prevalon boots. Observations throughout the survey showed staff served Resident #2 a regular textured diet. - Review of Resident #3's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. physician's orders [REDACTED]. Medications included [MEDICATION NAME] and [MEDICATION NAME] at bedtime to facilitate sleep. Nurses' notes, reviewed from 01/12/17 to 07/25/17, stated Resident #3 failed to sleep well on multiple occasions. A nurse's note, dated 05/03/17, stated, . not slept . Dr (doctor) increased the [MEDICATION NAME] from 5 to 10 mg (milligrams). Dr wants psych evaluation for anxiety and [MEDICAL CONDITION]. The current care plan stated, . Focus: Resistive/noncompliant with treatments/cares. On Honey Thickened liquids. Focus: At risk for nutritional status change . Nectar thick liquids . Observation throughout the survey showed Resident #3 wore bilateral hearing aids and received oxygen at 2 liters per minute (L/min) per nasal cannula. During an interview on the afternoon of 07/26/17, an administrative nurse (#3) verified Resident #3's care plan failed to include the use of hearing aids and oxygen, and was inconsistent regarding thickened liquids. Resident #3's care plan failed to include problems and/or interventions related to hearing aids, oxygen, and [MEDICAL CONDITION]. The care plan stated inconsistencies related to thickened liquids. - Review of Resident #4's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. A physical therapy plan of care, dated 06/29/17, identified, . Weight bearing status, right LE (lower extremity) . current level . non weight bearing . Transfers, bed/chair . total assist (100% assist) . The current certified nursing assistant (CNA) kardex, dated 07/26/17, identified . Transfer with full body sling and full mechanical lift and two staff. Use care with moving right leg. Immobilizer to remain in place at all times. The current care plan stated, . At risk for falls due to weakness, history of falls . Provide assist to transfer and ambulate as needed . Immobilizer to remain in place at all times . Ostomy r/t (related to) . impaired mobility, loss of bladder muscle tone . During an interview on 07/25/17 at 2:40 p.m., a physical therapy manager (#5) verified Resident #4 is currently unable to ambulate due to a [MEDICAL CONDITION] femur. During an interview on 07/26/17 at 2:00 p.m., an administrative staff member (#3) verified Resident #4's care plan focus/intervention regarding ambulation, and ostomy is not appropriate and staff need to update the care plan. The facility failed to review and revise the comprehensive care plan to reflect the resident's current status. - Review of Resident #13's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The current physician order, dated 06/26/17, identified, oxygen @ 2L/NC (liters per nasal cannula) to maintain O2 (oxygen) SATS (saturation level) check each shift. Review of Resident #13's care plan on 07/26/17 showed the facility failed to include the focus and interventions for the oxygen. Observations on 07/26/17 showed: * 12:15 p.m., Resident #13 sat in the wheel chair in the dining room with continuous oxygen on at 2L/NC. * 2:05 p.m., Resident #13 laid in bed with continuous oxygen on at 3L/NC. During an interview on 07/26/17 at 2:00 p.m., an administrative staff member (#3) verified Resident #13's care plan failed to include the focus and/or interventions related to the oxygen.",2020-09-01
67,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2017-07-26,281,D,0,1,GH6U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** MEDICATION VIA GASTROSTOMY TUBE 1. Based on observation, record review, review of facility policy, and staff interview, facility staff failed to provide care and services according to professional standards for 1 of 1 sampled resident (Resident #8) observed receiving medications via gastrostomy ([DEVICE]). Failure to flush the [DEVICE] between medications may affect the efficacy of the medications. Findings include: Review of the facility policy titled, Administering Medications through an Enteral Tube occurred on 07/26/17. This policy, not dated, stated, . Equipment and Supplies . 26. If administering more than one medication, flush with 15 ml (milliliters) (or prescribed amount) warm sterile or purified water between medications. Review of Resident #8's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Liquid medications included [MEDICATION NAME] (laxative) and UTI (Urinary Tract Infection) Heal (cranberry supplement). Observation on 07/25/17 at 9:20 a.m. showed a licensed staff nurse (#7) checked placement of Resident #8's [DEVICE] and administered [MEDICATION NAME] mixed in 120 cubic centimeters (cc) of water, and without flushing the [DEVICE] with water, the nurse administered the UTI Heal mixed in 120 cc of water. During an interview on 07/26/17 at 11:00 a.m., an administrative nurse (#3) stated she would expect staff to flush the [DEVICE] with water between medications. INSULIN ADMINISTRATION 2. Based on observation and review of professional reference, the facility failed to follow professional standards of practice regarding insulin administration for 1 of 3 residents (Resident #7) observed receiving rapid-acting insulin. Failure to ensure food is offered within the recommended time frame after insulin administration may result in [DIAGNOSES REDACTED] (low blood sugar). Findings include: The Nursing (YEAR) Drug Handbook, 37th Edition, Wolters Kluwer, Pennsylvania, pages 789-790 stated, . [MEDICATION NAME] . (5 to 10 minutes) before a meal. Observation on 07/24/17 at 5:25 p.m. showed a licensed staff nurse (#7) administered 4 units of [MEDICATION NAME]to Resident #7. Resident #7 sat at the dining room table with only a glass of water until 6:02 p.m. when he received his meal tray (37 minutes later). MEDICATION TRANSCRIPTION 3. Based on observation, record review, review of facility policy and review of professional reference, the facility failed to ensure accurate transcription of medication orders for 1 of 13 sampled residents (Resident #6). Failure to ensure the medication administration record (MAR) and medication label contain the same information as the physician's order may lead to medication errors. Findings include: Berman and Snyder, Kozier & Erb's Fundamentals of Nursing Concepts, Process, and Practice, 10th ed., Pearson Education Inc., New Jersey, page 761, stated, . Communicating a Medication Order . A drug order is written on the client's chart by a primary care provider or by a nurse receiving a telephone or verbal order from a primary care provider. The nurse or clerk then copies the medication order to a Kardex or medication administration record (MAR). CLINICAL ALERT . If your assigned client receives new medication orders, double-check the transcribed information with the primary care provider's order. This ensures client safety. Review of the facility policy titled Labeling of Medication Containers occurred on 07/26/17. This policy, revised (MONTH) 2007, stated, . Any medication packaging or containers that are inadequately or improperly labeled shall be returned to the issuing pharmacy. The nursing staff must inform the pharmacy of any changes in physician orders for a medication. Review of Resident #6's medical record occurred on all days of survey. A physician's order, dated 07/21/17, stated, [MEDICATION NAME] (a pain reliever) 5 mg (milligrams) - 325 mg oral tablet . Instructions: 0.5 (one half) tab (tablet) q8h (every eight hours) PRN (as needed) for severe pain. Review of Resident #6's (MONTH) MAR showed a hand written entry, dated 07/22/17, that identified [MEDICATION NAME] 5 mg - 325 mg every eight hours for severe pain. The MAR failed to identify the correct dose of half a tablet. Observation of the medication cart on the afternoon of 07/25/17 showed Resident #6's [MEDICATION NAME] contained a label on the package which identified the frequency as twice per day, not every eight hours as ordered on [DATE]. Failure to ensure the MAR and medication label accurately reflect the physician's order may result in medication errors.",2020-09-01
68,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2017-07-26,323,D,0,1,GH6U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure adequate supervision and assistive devices to prevent accidents for 1 of 2 sampled residents (Resident #4) who required extensive assistance with transfers using a mechanical lift. Failure to use the proper transfer lift sling and provide adequate supervision with transfers/cares placed the resident at risk for sustaining a fall or injury. Findings include: Review of Resident #4's medical record occurred on all days of survey. Medical [DIAGNOSES REDACTED]. The significant change Minimum Data Set (MDS), dated [DATE], identified severely impaired cognition and extensive assistance of two for transfers. Review of the physical therapy plan of care, dated 06/29/17, identified, . Transfers, Bed/Chair . total assist (100%) . The current care plan identified, . Pathological fracture right . femur . NWB (nonweight bearing) to right leg . Transfer with full body sling and full mechanical lift and two staff. Use care with moving right leg. Immobilizer to remain in place at all times . Review of the certified nursing assistants (CNA's) kardex, dated 07/26/17, identified, . transfer with full body sling and full mechanical lift and two staff. Use care with moving right leg. Immobilizer to remain in place at all times. Observation on 07/24/17 at 3:10 p.m., showed two CNAs (#8 and #9) entered Resident #4's room, completed cares and placed a partial lift sling underneath her. The CNA (#9) pulled Resident #4's right leg outward to the side while she lay in bed. The resident yelled out, ouch ouch, when the CNA (#9) pulled the transfer sling straps up between her legs. The CNA (#8) raised Resident #4 up off the bed with the mechanical lift. Resident #4's right leg hung down with the immobilizer on it and she yelled out, ouch ouch, as the CNA (#9) lowered her down into the wheel chair/recliner. The facility staff failed to transfer Resident #4 with the full body sling and support the right leg during the transfer. Observation on 07/25/17 at 8:05 a.m., showed two CNAs (#10 and #11) placed a partial lift sling underneath Resident #4 and transferred her from the bed to the reclining wheel chair with a mechanical lift. During the transfer, the resident grimaced and moaned aloud. The CNA (#11) stated, I think we used the wrong lift sheet on this resident. The CNA (#11) left the room and returned with a full body lift sling. The CNAs (#10 and #11) transferred Resident #4 from the reclining wheel chair back to the bed with the partial lift sling mechanical lift and her right leg hung down with the immobilizer on. The facility staff failed to transfer Resident #4 with the proper lift sling and support the right leg during the transfer. During an interview on 07/25/17 at 8:30 a.m., a CNA (#11) verified Resident #4 should be transferred with the full body lift sling to keep her legs together and support provided to the right fractured leg. During an interview on 07/26/17 at 2:00 p.m., an administrative staff member (#3) verified Resident #4 should be transferred with a full body lift sling.",2020-09-01
69,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2017-07-26,325,D,0,1,GH6U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to maintain acceptable nutritional status for 1 of 3 residents (Resident #2) identified with weight loss. Failure to consistently implement weight loss interventions may result in poor nutrition and avoidable weight loss. Findings include:Review of Resident #2's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The current Minimum Data Set (MDS), dated [DATE], identified extensive assistance from one person for eating. Resident #2's care plan stated, . At risk for nutritional status change r/t (related to) wt. (weight) loss. Intakes less than estimated need . Interventions . assist to consume foods and/or supplements and fluids offered . A dietary assessment, dated 05/09/17, stated, . Visited with (Resident #2) and spouse about preferences. Her UBW (usual body weight) 150#. She dislikes; all potato but French fries, all vegetables except green beans and corn . Dietary progress notes stated the following: *05/23/17 at 1:58 p.m.: . Fortified cereal daily and fortified soup at supper. Staff set up and assist her at meals. *06/04/17 at 10:49 a.m.: . receiving fortified items at meals for additional nutrition and finger foods offered as much as possible. Recent weight loss is noted. Review weight 140, will add high calorie snacks at 10 am and 3 pm. Will continue to provide a fruit cup at hs (bedtime) per her request. *07/11/17 at 10:01 a.m.: . Fortified pudding at 10 AM provides approx. (approximately) 250 calories and 6 gms (grams) pro. (protein) Ice cream at 3 PM and fruit cup at HS per her request. *07/11/17 at 3:03 p.m.: . Current wt. 133.6# 3% loss in 1 month. Continues to lose wt. Continue fortified items and supplements. Try fortified mashed potato. Resident #2's dietary assessment, dated 05/09/17, identified the resident did not like potatoes. *07/25/17 at 11:33 a.m.: . receiving fortified items at meals for additional nutrition and high calorie snacks between meals. Refused fortified potatoes tried last week. Refuses approximately 75% of snacks. Resident #2's weight records identified a weight of 156.4 pounds (lbs) on 05/02/17, and a current weight on 07/24/17 of 133 lbs. This represents a 23.4 lb (15%) weight loss over twelve weeks. Observation on 07/24/17 at 3:45 p.m. showed Resident #2 asleep in her bed. An unopened container of ice cream sat on her bedside table. At 4:55 p.m., observation showed the resident out of bed and in her wheelchair, and the container of ice cream in the garbage with the lid still on. Snack intake charting for the afternoon of 07/24/17 failed to show a snack offered to Resident #2. Observation of the evening meal on 07/24/17 showed Resident #2 received her tray at 6:10 p.m. Staff failed to assist the resident with the tray set up, including removing the lid from her bowl of soup or unwrapping her silverware. The resident made no attempt to feed herself and received no cuing from staff until 6:21 p.m. when a staff member sat by the resident and assisted her to eat. Observation during the noon meal on 07/25/17 showed staff served Resident #2 a piece of fish, mixed vegetables (containing vegetables the resident identified she did not like), diced peaches, and eight ounces of milk. The meal failed to contain any fortified items and was the same food served to other residents. Review of Resident #2's snack intake records showed from 06/05/17 through 07/25/17, staff failed to document the 10:00 a.m. snack nine times and the 3:00 p.m. snack 38 times. Failure to accurately record snack intakes/refusals may misrepresent the actual amounts consumed by Resident #2 and may delay further dietary intervention. During an interview on the morning of 07/26/17, a supervisory nurse (#10) agreed the snack intakes were not accurately recorded and that Resident #2 needed assistance with meals.",2020-09-01
70,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2017-07-26,328,D,0,1,GH6U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of professional reference, review of facility policy, and staff interview, the facility failed to provide the necessary care and services for 2 of 5 sampled residents (Resident #4 and #13) receiving oxygen therapy. Failure to follow the physician's orders and provide guidance to facility staff on oxygen usage does not allow the facility or the health care provider to assess the effectiveness of the resident's oxygen therapy. Findings include: Berman and Snyder, S., Kozier & Erb's Fundamentals of Nursing Concepts, Process, and Practice, 10th ed., Pearson Education, Inc., New Jersey, page 1259 states, . Like any medication oxygen is not completely harmless to the client. Clients can receive an inadequate amount or an excessive amount of oxygen and both can lead to a decline in the client's condition. Review of the facility policy titled Oxygen Administration occurred on 07/26/17. This policy, dated (MONTH) 2010, stated, . Review the physician's orders or facility protocol for oxygen administration. Adjust the oxygen delivery device so that . the proper flow of oxygen is being administered. - Review of Resident #4's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The significant change Minimum Data Set (MDS), dated [DATE], identified severely impaired cognition and oxygen use. The current care plan identified, . O2 (oxygen) on at 2L/min (liters per minute) via nasal cannula to keep sats (oxygen saturation) > (greater than) 90%. Monitor O2 SATS q (every) shift. respiratory impairment related to: history of hospitalization for pneumonia, [MEDICAL CONDITIONS] . evaluate lung sounds and VS (vital signs) . A current physician order, dated 06/29/17, identified, oxygen @ 2L/MIN via NC (nasal cannula) to keep O2 SATS > 90%. Monitor SATS every shift. A progress note, dated 07/18/17, stated, . admitted to hospital . [MEDICAL CONDITION] . left sided pleural effusion . The Treatment Administration Record (TAR) and weights and vitals summary, dated (MONTH) 01-24, (YEAR), identified no documentation on Resident #4's oxygen usage for the following dates/times: * 07/02/17 day shift * 07/06/17 night shift * 07/11/17 day shift * 07/20/17 night shift * 07/21/17 day and night shift Observations showed the following: * 07/24/17 at 10:20 a.m., Resident #4 laid in bed without oxygen on. Staff failed to continuously provide oxygen to Resident #4. * 07/24/17 at 3:55 p.m., two certified nursing assistants (CNAs) (#8 and #9) provided perineal cares for Resident #4. One CNA (#8) removed the oxygen nasal cannula tubing from the resident and then the two CNAs (#8 and #9) transferred Resident #4 into her wheel chair/recliner. One CNA (#8) asked Resident #4 if she wears oxygen when she is up in the chair. Resident #4 stated she was unsure. The CNA (#8) shut off the oxygen concentrator and both CNAs exited the room. The CNA failed to clarify with a staff nurse if Resident #4 required oxygen continuously. * 07/24/17 at 5:40 p.m. and 6:00 p.m , Resident #4 sat in the wheel chair/recliner in the dining room without oxygen on. * 07/25/17 at 8:05 a.m., two CNAs (#11 and #12) entered Resident #4's room, removed the oxygen nasal cannula from the resident, shut off the oxygen concentrator, transferred her from the bed to the wheel chair/recliner, and brought her to the dining room. The CNAs failed to reapply the oxygen. * 07/25/17 at 8:50 a.m. and 9:20 a.m., Resident sat in wheel chair/recliner without oxygen on. * 07/25/17 at 11:55 a.m., two CNAs (#11 and #13) entered Resident #4's room, removed the oxygen nasal cannula tubing from the resident, shut off the oxygen concentrator, transferred her from the bed to the reclining wheelchair, and exited the room. The CNAs failed to reapply the oxygen. * 07/25/17 at 12:25 p.m., Resident #4 sat in the wheel chair/recliner in the dining room without oxygen on. * 07/26/17 at 11:07 a.m., Resident #4 laid in bed without oxygen on. A CNA (#15) and a staff nurse (#16) entered Resident #4's room, provided wound cares, and then exited the room. The facility staff failed to apply and provide oxygen to Resident #4. 07/26/17 at 12:00 p.m., 1:00 p.m., and 2:00 p.m., Resident #4 laid in bed without oxygen on and the oxygen concentrator turned off. During an interview on 07/25/17 at 11:30 a.m., a nurse manager (#14) confirmed staff should ensure Resident #4's oxygen is administered at 2L/MIN and on at all times per nasal cannula. Resident #4's oxygenation levels drop down to 80% when the oxygen is not administered continuously. The nurse manager (#14) stated she expects the staff nurse to document oxygen use for Resident #4 every shift. During an interview on 07/26/17 at 2:00 p.m., an administrative staff member (#3) verified staff are expected to ensure the consistency in delivery of Resident #4's oxygen at 2L/NC continuously. The facility failed to consistently provide Resident #4's oxygen. - Review of Resident #13's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. A current physician order, dated 06/26/17, identified, oxygen @ 2L/NC to maintain O2 SATS check each shift. Observations on 07/26/17 showed: * 12:15 p.m., Resident #13 sat in a wheel chair in the dining room with continuous oxygen on at 2L/NC per portable oxygen tank. * 2:05 p.m., Resident #13 laid in bed with continuous oxygen on at 3L/NC per oxygen concentrator. During an interview on 07/26/17 at 2:00 p.m., an administrative staff member (#3) verified staff are expected to ensure the consistency in delivery of Resident #13's oxygen at 2L/NC continuously. The facility failed to consistently provide Resident #13's oxygen at the ordered flow rate.",2020-09-01
71,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2017-07-26,431,E,0,1,GH6U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, facility record review, and staff interview, the facility failed to ensure proper labeling and storage/disposal of medications on 3 of 3 days of survey (July 24-26, (YEAR)). Failure to ensure correct labeling of insulin pens (4 observations), lock an unattended medication cart (North Cart Second Floor), and properly dispose of a fentanyl patch (narcotic pain patch) may result in medication errors and allow access of unauthorized personnel, visitors, and/or residents to medications. Findings Include: LABELING OF MEDICATION Review of the facility policy titled Labeling of Medication Containers occurred on 07/26/17. This policy, dated (MONTH) 2007, stated, . 9. The nursing staff must inform the pharmacy of any changes in physician orders for a medication. - Observation during a medication pass on 07/24/17 at 5:25 p.m. showed a licensed staff nurse (#7) administered Novolog 4 units, as stated on the Medication Administration Record [REDACTED]. The current physician orders, dated 07/06/17, stated, decrease Novolog to 4 units three times daily with meals. The facility failed to update the medication label to coincide with the physician's order. - Observation on 07/25/17 at 8 a.m. showed a licensed staff nurse (#7) administered 20 units of Levemir insulin, as stated on the MAR, to Resident #7. The medication label stated, inject 30 units subcutaneously. The current physician order dated 07/08/17, stated, decrease Levemir to 20 units. The facility failed to update the medication label to coincide with the physician order. An interview occurred on 07/24/17 during the medication pass; a licensed nurse (#7) stated when an insulin dose changes pharmacy does not change the label. - Observation during a medication pass on 07/25/17 at 8:46 a.m. showed a staff nurse (#1) administered Levemir insulin 15 units, as stated on the MAR, to Resident #16. The medication label stated inject 10 units subcutaneously at bedtime. The current physician orders, dated 07/03/17, stated, increase Levemir insulin to 15 units subcutaneously twice a day. The facility failed to update the medication label to coincide with the physician's order. On 07/26/17 at 9:45 a.m. two staff nurses (#1 and #2) identified nursing staff should contact the pharmacy to get new labels for the insulin when the order is changed. STORAGE OF DRUGS Review of the facility policy titled Administering Medications occurred on 07/26/17. This policy, revised (MONTH) 2012, stated, . During administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse or aide. Observation on 07/24/17 at 5:21 p.m. showed an unlocked medication cart on the north hallway of the 2nd floor, and the nurse seated at the nurses' station (not in view of the cart). Observations at 5:27 p.m., 5:39 p.m., 5:46 p.m., and 5:53 p.m. showed the cart remained unlocked and the nurse was not in view of the cart. Observation at 6:02 p.m. showed the cart locked. DISPOSAL OF MEDICATION Review of the facility policy titled, Administering Topical Medications occurred on 07/26/17. This policy, dated (MONTH) 2010, stated, . Trans-dermal patches . Discard all disposable items into designated containers. Review of Resident #4's medical record occurred on all days of survey. Medical [DIAGNOSES REDACTED]. The current physician's order, dated 06/29/17, identified Fentanyl 12 MCG (micrograms)/HR (hour) patch. Apply 2 patch (sic) every 3 days for pain. Check placement daily. Discard old patch. Observation on 07/25/17 at 3:40 p.m. showed a staff nurse (#6) applied gloves, removed a Fentanyl patch (trans-dermal patch) from the right side of Resident #4's chest, disposed of it in the garbage can next to the resident's bed, and exited the room. During an interview on 07/26/17 at 8:45 a.m., an administrative staff member (#3) verified she expected staff to dispose the trans-dermal patch in the sharps container located on the medication cart along with another nurse to witness the disposal of the patch.",2020-09-01
72,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2018-08-16,550,E,0,1,B0I611,"Based on observation and staff interview, the facility failed to provide care for 6 of 18 sampled residents (Resident #6, #8, #14, #15, #35, and #46) in a manner and environment that maintained, enhanced, and respected each resident's dignity and individuality. Failure to speak respectfully, knock on doors/announce themselves, and wait for permission prior to entering residents' rooms, does not preserve the residents' personal dignity or enhance their quality of life and placed them at risk of embarrassment and/or emotional harm. Findings include: The facility failed to provide a policy regarding dignity per request. Observations on 08/14/18 showed the following: * At 9:52 a.m., two certified nursing assistants (CNAs) (#8 and #9) entered Resident #35's room to provide personal cares. A third unidentified CNA entered the room without knocking, and addressed the other two CNAs before exiting the room. The staff member failed to knock /announce herself and/or wait for permission to enter. * At 11:40 a.m., an unidentified CNA assisted Resident #14 to the bathroom. The CNA left the bathroom door wide open and failed to pull the privacy curtain between the bathroom and Resident #6's side of the room while she sat in the wheelchair facing bathroom. The CNA assisted Resident #14 with cares, then opened door for Resident #6 to leave the room while Resident #14 remained in bathroom. * At 4:20 p.m., observation showed Resident #46 seated in a wheel chair beside her bed with her call light sounding. Observation revealed a large brown stain approximately 6 by 8 inches on a white sheet covering the center of the bed. A CNA (#23) responded to call light, transferred the resident to her bed onto the soiled sheet, changed her brief, and left the room. A second CNA (#11) entered and transferred the resident back to her wheel chair, then changed the soiled sheet. During an interview on 08/15/28 at 2:30 p.m. two administrative nurses (#16 and #17) confirmed staff should have changed the sheet on Resident #46's bed at the time it became soiled. Observations on 08/15/18 showed the following: * At 9:11 a.m., two CNAs (#10 and #11) entered Resident #35's room to provide personal cares. A third unidentified CNA knocked on the door as she entered the room, and asked to use the mechanical lift before exiting the room. The staff member failed to announce herself and/or wait for permission to enter. * At 3:59 p.m., Resident #8 sat on the commode next to her bed drinking coffee and holding a cookie. She told the CNA (#4), who was washing his hands in the sink in her room, that she had a bowel movement. An unidentified CNA opened the door to Resident #8's room and said, Knock. Knock. She spoke briefly to the other CNA (#4) before exiting the room. A few minutes later, an unidentified nurse opened the door to Resident #8's room, saw the surveyor, and backed out of the room. Two staff members failed to knock/announce themselves and/or wait for permission to enter. * At 4:19 p.m., two CNAs (#4 and #7) entered Resident #15's room to provide personal cares. One of the CNAs (#4) walked over to the resident, who was lying in bed, and stated, We are going to change your diaper. I'm going to change your diaper right quick, so we can get you up for dinner. As the two CNAs (#4 and #7) performed pericares, a third CNA knocked on the door to Resident #15's room, entered, and asked his coworkers how they were doing. After transferring the resident to her wheel chair, the second CNA (#7) asked Resident #15 if she wanted her blankie or a drink of water. One staff member failed to knock/announce himself and/or wait for permission to enter, and two staff members failed to address the resident with age-appropriate terminology.",2020-09-01
73,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2018-08-16,578,D,0,1,B0I611,"Based on record review, facility policy, and staff interview, the facility failed to ensure the medical record for 1 of 16 sampled residents (Resident #38) accurately reflected the resident's Advanced Directive regarding code status. Failure to ensure the resident's medical record accurately reflected her wishes may prevent emergency personnel from knowing the resident's choices in the event of a medical emergency. Findings include: Review of the facility policy titled Code Status occurred on 08/16/18. This undated policy, stated, . Every resident or responsible party signs a consent for full code or no code upon admission . Red sheet of paper with DNR (do not resuscitate)/No Code is placed in the front of the chart with consent choice sheet signed right behind it. Green sheet of paper with Full Code is placed in the front of the chart with the consent choice sheet signed right behind it. The full code or no code order is noted on physician orders. Review of Resident #38's medical record occurred all days of survey. A Living Will form signed and dated on 06/25/14 by Resident #38, indicated DNR status. A physician's order, dated 10/04/17, indicated Full Code status. A green sheet of paper for Full Code was placed in the front of Resident #38's medical record with a copy of the signed physician's order attached. During an interview on the morning of 08/16/18, an administrative staff member (#16) indicated nursing staff asks the resident on admission and/or readmission what he/she would like their code to be. The facility failed to ensure the code level status was consistent in all areas of the medical record and accurately reflected the residents' current wishes.",2020-09-01
74,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2018-08-16,622,D,0,1,B0I611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide written notification for 2 of 7 sampled residents (Resident #24 and #38) transferred to the hospital. Failure to provide the resident and/or resident's family member/legal representative, in writing of a transfer, including the destination and reason for the transfer, and the resident's right to appeal the action, did not allow the resident or family member/legal representative to make an informed decision. Findings include: - Review of Resident #24's medical record occurred on all days of survey, and identified the facility transferred the resident to the hospital on [DATE] and 06/23/18. The medical record lacked evidence the facility provided the resident and/or their family member/legal representative written notice of the transfers, including the reason for the transfers, the effective date of the transfers, the location to which they transferred the residents, and the right to appeal the actions. During an interview on 08/16/18 at 9:21 a.m., a medical records staff member (#2) stated staff failed to complete Transfer Notices for Resident #24's hospital stays on 06/08/18 and 06/23/18. - Review of Resident #38's medical record occurred on all days of survey, and identified the facility transferred the resident to the hospital on [DATE] and 06/26/18. The medical record lacked evidence the facility provided the resident and/or their family member/legal representative written notice of the transfers, including the reason for the transfers, the effective date of the transfers, the location to which they transferred the residents, and the right to appeal the actions. During an interview on the morning of 08/15/18, a medical records staff member (#2) stated staff failed to complete Transfer Notices for Resident #38's hospital stays 06/23/18 and 06/26/18.",2020-09-01
75,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2018-08-16,623,D,0,1,B0I611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide the Office of the State Long Term Care (LTC) Ombudsman a written notice of transfer, including the destination, the reason for transfer, and the resident's right to appeal the action for 2 of 7 residents (Resident #24 and #38) transferred to the hospital. Failure to provide a notice of transfer or discharge does not allow the Ombudsman to keep informed of all transfers/discharges. Findings include: - Review of Resident #24's medical record occurred on all days of survey. Progress notes identified Resident #24 was hospitalized [DATE] and 06/23/18. The record lacked evidence the facility provided the State LTC Ombudsman written notice of transfer for these hospitalization s. During an interview on 08/16/18 at 9:21 a.m., a medical records staff member (#2) confirmed staff failed to complete Transfer Notices or Bed Hold for Resident #24's hospital stays on 06/08/18 and 06/23/18, and failed to notify the ombudsman of either hospital transfer. - Review of Resident #38's medical record occurred on all days of survey, and identified the facility transferred the resident to the hospital on [DATE] and 06/26/18. The medical record lacked evidence the facility provided the State LTC Ombudsman written notice of transfer for the hospitalization . During an interview on the morning of 08/15/18, a medical records staff member (#2) stated confirmed staff failed to complete a Transfer Notice for Resident #24's hospital stay on 06/23/18, and failed to notify the ombudsman.",2020-09-01
76,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2018-08-16,625,D,0,1,B0I611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide a bed-hold notice upon transfer to the hospital for 3 of 7 sampled residents (Resident #23, #24, and #38) transferred to the hospital. Failure to provide the facility's bed-hold policy does not allow residents or their legal representatives to make informed choices regarding their readmission rights. Findings include: - Review of Resident #23's medical record occurred on all days of survey, and identified the facility transferred the resident to the hospital on [DATE]. The medical record lacked evidence the facility staff provided Resident #23 and/or their family member/legal representative written notice of the bed-hold policy upon transfer to the hospital. During an interview on 08/15/18 at 10:58 a.m., a business office manager (#3) stated facility staff failed to provide the bed-hold notice. - Review of Resident #24's medical record occurred on all days of survey, and identified the facility transferred the resident to the hospital on [DATE] and 06/23/18. The medical record lacked evidence the facility provided Resident #24 and/or their family member/legal representative written notice of the the bed-hold policy upon transfers to the hospital. During an interview on 08/16/18 at 9:21 a.m., a medical records staff member (#2) stated facility staff failed to provide the bed-hold notice. - Review of Resident #38's medical record occurred on all days of survey, and identified the facility transferred the resident to the hospital on [DATE] and 06/26/18. The medical record lacked evidence the facility provided Resident #38 and/or their family member/legal representative written notice of the the bed-hold policy upon transfers to the hospital. During an interview on the morning of 08/15/18, a medical records staff member (#2) agreed the facility failed to provide the bed-hold notice.",2020-09-01
77,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2018-08-16,641,D,0,1,B0I611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.15), and staff interview, the facility failed to ensure accurate coding of Minimum Data Sets (MDSs) for 2 of 18 sampled residents (Resident #6 and #46). Failure to accurately complete Section N (Medications) and Section O (Special Treatments, Procedures,and Programs) of the MDS does not allow each resident's assessment to reflect their current status/needs, and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION N: Medication The Long-Term Care Facility RAI Manual, page N12 - N13, stated, . Coding Instructions for N0450A: Code 0, no: if antipsychotic were not received . Code 1, yes: if antipsychotic's were received on a routine basis only: Continue to N0450B, Has a GDR (gradual dose reduction) been attempted? . Code 0, no: if a GDR has not been attempted. Skip to N0450D, Physician documented GDR as clinically contraindicated. Code 1, yes: if GDR has been attempted. Continue to N0450C, Date of last attempted GDR. - Review of Resident #6's medical record occurred on all days of survey and identified a physician's orders [REDACTED]. Review of the (MONTH) Medication Administration Record [REDACTED]. The record also showed the physician rejected a GDR in (MONTH) (YEAR) for the Quetiapine. The quarterly MDS, dated [DATE], failed to identify the use of an antipsychotic. Failure to identify antipsychotic use resulted in the system not triggering staff to identify the physician's rejection of a GDR in (MONTH) (YEAR). During an interview on 08/15/18 at 3:21 p.m., an administrative staff member (#18) confirmed she coded section N0450 incorrectly on Resident #6's 07/22/18 MDS. SECTION O 0100: Special Treatments, Procedures, and Programs The Long-Term Care Facility RAI Manual, page O-3, stated, . O 0100C Oxygen therapy, Code continuous or intermittent oxygen administered via mask, cannula, . delivered to a resident to relieve [MEDICAL CONDITION] (low oxygen in tissues) in this item. This item may be coded if the resident places or removes his/her own oxygen mask, cannula. - Resident #46's medical record, reviewed (MONTH) 14-16, (YEAR), identified a physician's orders [REDACTED]. Progress notes, dated 07/28/18 at 2:09 p.m. and 07/29/18 at 3:10 p.m. identified the resident receiving oxygen at 2 liters per minute via a nasal cannula. A quarterly MDS, dated [DATE], failed to identify oxygen use. During an interview on 08/16/18 10:30 a.m. an administrative nurse (#18) confirmed she should have coded Resident #46's oxygen use at O 0100C on the 07/29/18 MDS.",2020-09-01
78,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2018-08-16,644,D,0,1,B0I611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the North Dakota Provider Manual for Preadmission Screening and Resident Review (PASARR) and Level of Care Screening Procedures For Long Term Care Services, and staff interview, the facility failed to complete a status change assessment for 2 of 4 sampled residents (Resident #2 and #48) reviewed for PASARR requirements. Failure to complete a change in status assessment may result in the delivery of care and services that are inconsistent with residents' needs. Findings include: The North Dakota PASARR Provider Manual page 13 states, . Change in Status Process . Whenever the following events occur, nursing facility staff must contact Ascend (contracted service provider for screening process) to update the Level I screen for determination of whether a first time or updated Level II evaluation must be performed. These situations suggest that a significant change in status has occurred: . If an individual with MI, ID, and/or RC (mental illness, intellectual disability, and conditions related to intellectual disability (referred to in regulatory language as related conditions or RC)) was not identified at the Level I screen process, and that condition later emerged or was discovered. - Resident #2's medical record, reviewed (MONTH) 14-16, (YEAR), identified the facility admitted the resident on 11/13/10. The record identified a diagnoses of Unspecified [MEDICAL CONDITION], dated 02/24/10 and [MEDICAL CONDITION], dated 02/10/12. The record lacked evidence staff completed a Level I assessment at the time of her admission or an updated Level I assessment with the new [DIAGNOSES REDACTED]. During an interview on 08/15/18 at 10:15 a.m., an administrative nurse (#17) stated she was unable to provide information indicating staff had completed the admission PASARR or an updated assessment in 2012. - Resident #48's medical record, reviewed on (MONTH) 14-16, (YEAR), identified the facility admitted the resident on 10/19/15. A Level I PASARR, dated 09/03/15, stated It is reported he has no [DIAGNOSES REDACTED]. If there is a change of status it is the facilities (sic) responsibility to submit proper documentation and forms. Resident #48's record identified a new [DIAGNOSES REDACTED]. During an interview on 08/15/18 at 10:15 a.m. an administrative nurse (#17) stated she was unable to find additional information identifying staff had completed an updated Level I PASARR after the [MEDICAL CONDITION] diagnosis. During an interview on the afternoon of 08/15/18, a second administrative nurse (#16) provided information showing Resident #48 has had [DIAGNOSES REDACTED].",2020-09-01
79,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2018-08-16,655,D,0,1,B0I611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a baseline care plan for 1 of 2 sampled residents (Resident #229), newly admitted to the facility. Failure to develop and implement a baseline care plan limited staff's ability to provide effective and person-centered care for the resident. Findings include: Review of Resident #229's medical record, on all days of survey, identified an admission date of [DATE]. The facility staff could not locate a baseline care plan for the resident completed prior to 08/14/18. During an interview on 08/14/18 at 8:56 a.m., the unit manager (#5) stated a baseline care plan should be completed on paper in the first 48 hours of a resident's admission and placed in the facility's baseline care plan book. The unit manager (#5) stated she started, but had not completed a baseline care plan for Resident #229. The facility failed to complete a baseline care plan within 48 hours of the resident's admission.",2020-09-01
80,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2018-08-16,656,D,0,1,B0I611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a comprehensive care plan for 1 of 18 sampled residents (Resident #277). Care planning drives the type of care and services that a resident receives. Failure to develop a care plan that includes the care and services to be provided to the resident may negatively impact the resident's quality of life. Findings include: - Review of Resident #277's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. A skin assessment, dated 08/07/18, indicated a stage 2 pressure ulcer to the coccyx measuring 5 centimeters (cm) x (by) 5 cm, red with a small amount of drainage, and treated with foam bordered dressing. Review of Resident #277's care plan occurred on 08/16/18. The care plan failed to address the resident's current stage 2 pressure ulcer and failed to provide goals and interventions to manage Resident #277's pressure ulcer. During an interview on the afternoon of 08/16/18 an administrative staff member (#16) stated the care plan was currently in process.",2020-09-01
81,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2018-08-16,657,D,0,1,B0I611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THIS IS A REPEAT CITATION FROM THE SURVEY COMPLETED ON 07/26/17. Based on observation, record review, and staff interview, the facility failed to review and revise the comprehensive care plan to reflect the current status for 2 of 18 sampled residents (Resident #8 and #35). Failure to revise the care plan limited staff's ability to communicate care needs and ensure continuity of care for each resident. Findings include: The facility failed to provide a policy regarding care plans per request. - Review of Resident #8's medical record occurred on all days of survey. The current physician's orders [REDACTED]. Observations on 08/15/18 at 3:59 p.m. and 08/16/18 at 9:33 a.m. showed Resident #8 not wearing her TED hose. The current care plan stated, . [MEDICAL CONDITION] . Administer medications as ordered, Assist with activities as needed, Dangle at edge of bed/chair before transfers, Encourage rest periods as needed, Obtain vital signs as indicated, report changes to physician, Obtain weights as needed/ordered, Report significant change. The facility failed to care plan the resident's need for/use of TED hose. - Review of Resident #35's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The current care plan stated, . Potential for skin breakdown . Keep skin clean and dry, Use lotion on dry skin, Provide wound care as ordered, (brand name) (blue) boots at night as resident allows, Reposition at routine intervals, encourage to lay down between meals and to limit time spent sitting up in chair, Special mattress/cushion on wheelchair. The facility failed to care plan the resident's need for/use of a pillow between his knees to prevent skin breakdown. Observations showed the following: * 08/14/18 at 9:52 a.m., two certified nursing assistants (CNAs) (#8 and #9) transferred Resident #35 to bed using a mechanical lift. One of the CNAs (#9) placed a pillow between the resident's knees, covered him with a blanket, and handed him his call light. * 08/15/18 at 9:11 a.m., two CNAs (#10 and #11) transferred Resident #35 into bed using a mechanical lift and provided personal cares. One CNA remarked, His knees must be so painful. The staff members failed to place a pillow between Resident #35's knees. * 08/16/18 at 10:00 a.m., Resident #35 laid in bed, with a pillow between his knees. Resident #35's medical record also identified [DIAGNOSES REDACTED]. A Speech Therapy Progress (and) Discharge Summary, dated 01/18/18, identified, . Precautions: Position at 90 degree angle during and 20 minutes after oral intake. Positioning during oral intake must be Approx. (approximately) 90 degrees. The current care plan stated, . ADL (Activities of Daily Living) self care deficit . Assist with . eating as needed. The facility failed to care plan the resident's need to be seated at a 90 degree angle prior to eating/drinking to prevent aspiration. Observation showed the following: * 08/14/18 at 9:52 a.m., Resident #35 laid on his left side in bed, with the head of the bed reclined to an approximate 20 degree angle. A certified nursing assistant (CNA) (#9) raised Resident #35's bed (with the head of the bed in the reclined position) and gave him a drink of water via a straw. * 08/15/18 at 9:11 a.m., Resident #35 laid flat on his back in bed, with his head resting on two pillows (an approximate 20 degree angle). Two CNAs (#10 and #11) gave him a drink of water via a straw. In both instances, the staff members failed to raise the head of Resident #35's bed to a 90 degree angle prior to offering him a drink of water.",2020-09-01
82,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2018-08-16,658,D,0,1,B0I611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** PRIMING INSULIN PENS 1. Based on observation and manufacturer's guidelines, the facility failed to follow professional standards of practice in priming insulin pens for 2 of 3 residents observed receiving insulin (Resident #16 and #42). Failure to remove the needle shield prior to priming an insulin pen and inverting the pen during priming may result in the resident receiving an inaccurate amount of insulin. Findings include: Prescribing information for [MEDICATION NAME]found at www.nov-pi.com/novolgpdf, stated, . Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: Turn the dose selector to select 2 units. Hold your [MEDICATION NAME] with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times. - Observation on 08/14/18 at 12:10 p.m. showed a licensed nurse (#1) prepared an insulin pen for injection for Resident #16. After placing the needle on the insulin pen, the nurse failed to remove the outer needle shield before priming the insulin pen. With the shield still in place, the nurse was unable to visualize a stream of insulin from the needle. - Observation on 08/15/18 7:47 a.m. showed a licensed nurse (#24) prepared an insulin pen for injection for Resident #42. The nurse placed the needle on the pen, removed the needle shield, and primed the pen with two units of insulin while holding it with the needle pointing downward. Priming the pen with the needle pointing downward does not ensure an adequate amount of insulin is expelled during the priming process. OBTAINING/FOLLOWING physician's orders [REDACTED].>2. Based on observation, record review, review of professional reference, and staff interview, the facility failed to obtain/follow physician's orders [REDACTED].#8, #65, and #71 ). Failure follow physician's orders [REDACTED]. Findings include: Berman, Snyder, and Frandsen's Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 10th ed., Pearson Education, Inc., Massachusetts, page 68, states, . Carrying Out a physician's orders [REDACTED]. Documentation . Nurses, therefore, need to provide accurate and complete documentation of the nursing care provided to clients. - Review of Resident #71's medical record occurred on all days of survey. The resident's Medication Administration Record [REDACTED]. The record further identified a physician's orders [REDACTED]. During an interview on the afternoon of 08/15/18, a licensed nurse (#6) stated he was unable to locate an order to discontinue Resident #71's insulin. - Review of Resident #65's medical record occurred on all days of survey. The current physician's orders [REDACTED]. The resident's record identified staff weighed Resident #65 on 13 of the 42 days since 06/20/18 and last weighed the resident on 08/06/18. During an interview on the morning of 08/16/18, an administrative staff member (#16) stated the physician had not discontinued Resident #65's daily weights. - Review of Resident #8's medical record occurred on all days of survey. The current physician's orders [REDACTED]. Observations showed the following: * 08/15/18 at 3:59 p.m., Resident #8 not wearing her TED hose. * 08/16/18 at 9:33 a.m., Resident #8 lying in bed not wearing her TED hose. During an interview on 08/16/18 at 9:38 a.m., a licensed nurse (#19) confirmed staff failed to apply Resident #8's TED hose per the physician's orders [REDACTED].>",2020-09-01
83,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2018-08-16,677,E,0,1,B0I611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and family interview, the facility failed to provide dining assistance for 2 of 18 sampled residents (Resident #8 and #15) and 3 supplemental residents (Resident #39, #40, and #49) observed during meals. Failure to cue and/or assist a resident who required assistance may result in decreased intake and/or unwanted weight loss. Findings include: The facility failed to provide a policy regarding dining assistance per request. - During an interview on 08/13/18 at 11:30 a.m., when asked questions regarding the food being served and the assistance offered to residents, a family member (AA), stated, No, (there is) not sufficient staffing. It shows up in the dining room. (The residents) barely eat and (the staff) take them back to their rooms. Review of Resident #8's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The current care plan identified, . Encourage and assist as needed to consume foods and/or supplements and fluids offered. A progress note, dated 07/21/18, identified, . Resident (#8) has been noted to have a weight loss from 106 pounds on 1/2018 to 97.4 pounds on 7/2018. Observations showed the following: * 08/13/18 at 12:22 p.m., A family member assisted Resident #8 throughout the noon meal and also provided cueing to Resident #8's tablemate. * 08/13/18 at 5:35 p.m., Resident #8 received her tray. At 5:43 p.m. (8 minutes later) an unidentified certified nursing assistant (CNA) cut her meat and potatoes into smaller pieces. No further assistance was provided, and staff later documented 26-50% intake. - Review of Resident #15's medical record occurred on all days of survey. The current care plan identified, . Encourage and assist as needed to consume foods and/or supplements and fluids offered. Observations showed the following: * 08/13/18 at 12:17 p.m., Resident #15 fed herself, demonstrating a very slow rate of intake. Staff failed to provide consistent cueing/assistance, and later documented 0-25% intake. * 08/13/18 at 5:35 p.m., Resident #15 fed herself, demonstrating a very slow rate of intake. Staff failed to provide cueing/assistance, and later documented 26-50% intake. * 08/14/18 at 8:58 a.m., Staff placed Resident #15's tray on the table in front of her, as she slept in her wheelchair. Staff failed to provide consistent cueing/assistance, and later documented 0-25% intake. - Review of Resident #39's medical record occurred on all days of survey. The current care plan identified, . Encourage and assist as needed to consume foods and/or supplements and fluids offered. Observations showed the following: * 08/13/18 at 12:22 p.m., Resident #39 called out for fish as she fed herself, demonstrating a very slow rate of intake. An unidentified CNA cut her fish into smaller pieces. A few minutes later, a second unidentified CNA observed her taking very large bites of cake and cut the cake into smaller pieces. Resident #39 was observed coughing during the meal. No further assistance was provided, and staff later documented 26-50% intake. * 08/13/18 at 5:35 p.m., Resident #39 called out for a doctor as she fed herself, demonstrating a very slow rate of intake. An unidentified CNA stated, As soon as you are done eating, (the nurse) will give you some pain medicine. At 5:45 p.m. (10 minutes later) an unidentified CNA asked Resident #39, Are you done? Okay. She made no effort to cue and/or assist Resident #39, but asked another CNA to remove her from the dining room. Staff later documented 0-25% intake. * 08/14/18 at 8:55 a.m., Staff placed Resident #39's tray on the table in front of her, as she slept in her wheelchair. Staff failed to provide cueing/assistance, and later documented 0-25% intake. - Review of Resident #40's medical record occurred on all days of survey. The current care plan identified, . Encourage and assist as needed to consume foods and/or supplements and fluids offered. Assist with meal set up. Observations showed the following: * 08/14/18 at 8:55 a.m., Staff placed Resident #40's tray on the table in front of her, as she slept in her wheelchair. An unidentified CNA stated, (Resident #40), are you going to drink your coffee. Resident #40 awoke, and took a sip of her coffee. The CNA turned to the surveyor and stated, It's probably cold by now. No further cueing or assistance was provided, and staff later documented 0-25% intake. - Review of Resident #49's medical record occurred on all days of survey. The current care plan identified, . Encourage and assist as needed to consume foods and/or supplements and fluids offered. Assist with meal set up. Observations showed the following: * 08/13/18 at 12:17 p.m., Resident #49 fed herself, eating cake directly from the bowl, which resulted in frosting smeared across her face and pieces of cake spilled onto her clothing. An unidentified CNA sat down to assist Resident #49 after she noticed the surveyor observing the resident.",2020-09-01
84,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2018-08-16,684,D,0,1,B0I611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** SWALLOW SAFETY 1. Based on observation and record review, the facility failed to ensure 1 of 1 sampled resident (Resident #35) observed being assisted to drink while lying in bed received the necessary care and services to ensure his safety. Failure to properly position Resident #35 in bed has the potential to negatively affect his overall swallow safety and placed him at risk of aspiration. Findings include: The facility failed to provide a policy regarding dysphagia or feeding assistance per request. Review of Resident #35's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. A Speech Therapy Progress (and) Discharge Summary, dated 01/18/18, identified, . Precautions: Position at 90 degree angle during and 20 minutes after oral intake. Positioning during oral intake must be Approx. (approximately) 90 degrees. Observation showed the following: * 08/14/18 at 9:52 a.m., Resident #35 laid on his left side in bed, with the head of the bed reclined to an approximate 20 degree angle. A certified nursing assistant (CNA) (#9) raised Resident #35's bed (with the head of the bed in the reclined position) and gave him a drink of water via a straw. * 08/15/18 at 9:11 a.m., Resident #35 laid flat on his back in bed, with his head resting on two pillows (an approximate 20 degree angle). Two CNAs (#10 and #11) gave him a drink of water via a straw. In both instances, the staff members failed to raise the head of Resident #35's bed to a 90 degree angle prior to offering him a drink of water. TRANSFER SAFETY/BRUISES 2. Based on observation, record review, and family and staff interviews, the facility failed to provide the necessary care and services for 1 of 18 sampled resident (Resident #8) observed being transferred into their wheelchair. Failure to report, assess, and document residents' bruises may result in lack of identification of additional bruises and/or the cause for these bruises. Findings include: The facility failed to provide a policy regarding transfers and/or skin care per request. During an interview on 08/13/18 at 11:30 a.m., when asked questions about accident hazards, a family member (AA), reported her mother has Bruises all over. (Her) legs are covered. (The facility) thinks it may be from the side rails. Review of Resident #8's medical record occurred on all days of survey. The record showed she was at risk of alterations in skin integrity. A Weekly Skin Review, dated 08/15/18, identified, . bruising to bilateral shins. The skin assessment failed to identify the number of and location of the bruises on Resident #8's legs. Observations showed the following: * 08/14/18 at 12:12 p.m., a CNA (#21) assisted Resident #8 to stand-pivot into her wheelchair. The CNA bumped/scraped Resident #8's shin when she applied the pedals to the chair. Resident #8 stated, Ow! Watch what you are doing! I have soft skin. The staff member failed to report the incident to the nurse, who is responsible for assessing Resident #8's skin. * 08/15/18 at 3:59 p.m., Resident #8 with several bruises to both legs. Both lower legs were visible, as she was not wearing her TED hose. During an interview on 08/16/18 at 9:38 a.m., a nurse (#19) confirmed staff failed to apply Resident #8's TED hose, and stated the hose would add another barrier, protecting her skin.",2020-09-01
85,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2018-08-16,689,D,0,1,B0I611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THIS IS A REPEAT DEFICIENCY FROM SURVEY COMPLETED ON 07/26/17 Based on observation, review of facility policy, record review, and staff interview, the facility failed to provide adequate supervision and assistive devices necessary to prevent accidents for 2 of 8 sampled residents (Resident #2 and #23) observed during gait belt transfers. Failure to properly use a gaitbelt and to ensure adequate assistance during gaitbelt transfers placed the residents at risk of accidents and injury. Findings include: Review of the facility policy titled Lifting and Movement of Residents occurred on 08/16/18. The policy, dated (MONTH) (YEAR), stated, . In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. 2. Manual lifting of residents shall be eliminated when feasible. 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan . 6. Gait belts will be used when the resident can bear some weight, has some upper body strength, and is easily managed by one or more staff with non-mechanical lifting devices. - Review of Resident #23's medical record occurred on all days of the survey. A significant change Minimum Data Set (MDS), dated [DATE], identified the resident required extensive assist of two for transfers. The resident's current care plan stated, . Transfer with two assist with gait belt. During an observation on 08/14/18 at 5:00 p.m., a certified nursing assistant (CNA) (#7) placed a gait belt around Resident #23 and transferred him from the recliner to wheelchair without the assistance of a second staff member. Resident #23 showed difficulty with bearing weight and standing during the transfer. - Review of Resident #2's medical record occurred on (MONTH) 14-16, (YEAR). A quarterly MDS, dated [DATE], identified the resident required extensive assist of two staff for transfers. The resident's current care plan stated, . Transfer with two assist with gait belt. Observation on 08/14/18 at 10:10 a.m. showed two CNAs (#9 and #21) assisted Resident #2 to bed utilizing a gait belt, the CNAs held Resident #2 under her arms as well as holding the gait belt during the transfer. After changing her brief, the CNAs (#9 and #21) assisted Resident #2 back to her chair utilizing a gait belt. Observation showed Resident #2 was not able to stand upright. One CNA (#21) lifted the resident under her arms while the second CNA (#9) lifted the resident's legs to position her in the chair. Observation on 08/14/18 at 2:44 p.m. showed Resident #2 resting in bed. Two CNAs (#13 and #23) transferred the resident from her bed to her chair utilizing a gait belt. Observation showed Resident #2 did not bear weight during the transfer, but half stood with her legs bent and her feet not touching floor. When informed of the above observations, during an interview on 08/15/18 at 2:30 p.m., an administrative nurse (#16) stated she was not aware of the resident's inability to bear weight and would schedule a therapy evaluation for the resident's transfer status.",2020-09-01
86,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2018-08-16,730,C,0,1,B0I611,"Based on review of performance evaluations, review of twelve months of education records, and staff interview, the facility failed to provide twelve hours of in-service education per year for 3 of 3 certified nursing assistants (CNAs) (CNA A, B, and C) based on their individual performance review. Failure to provide twelve hours of in-service education per year to CNA A, B, and C may result in staff lacking the necessary skills and knowledge to provide care and services addressing special resident needs. Findings include: Review of staff performance evaluations and twelve months of education records occurred on (MONTH) 15-16, (YEAR). The records showed the facility failed to provide twelve hours of in-service education for 3 of 3 CNAs (CNA A, B, and C). During an interview on 08/16/18 at 3:34 p.m., an administrative nurse (#17) confirmed the facility failed to ensure all staff members were provided and/or completed twelve hours of in-service education during the period between (MONTH) (YEAR)-July (YEAR). The administrative nurse (#17) did report one of the three employees had recently returned from over-seas.",2020-09-01
87,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2018-08-16,756,D,0,1,B0I611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy, and staff interview, the consulting pharmacist failed to identify and report drug regimen irregularities regarding duplicate therapy of opiate pain medications to the attending physician, the medical director, and the director of nursing for 1 of 18 sampled residents (Resident #35) reviewed. Failure to ensure the pharmacist reported the medication irregularities may result in the residents receiving unnecessary medications and experiencing adverse consequences related to the medications. Findings include: Review of the facility policy titled Consultant Pharmacist Reports occurred on 08/16/18. This policy, dated (MONTH) 2011, stated, . The administration schedule is appropriate for the resident, considering side effects (such as sedation), compatibility with other medications and manufacturer's recommendations. Resident #35's record identified the following physician's orders for opiate pain medications: [REDACTED] * 04/05/18: [MEDICATION NAME] 50 milligrams (mg) by mouth three times a day for uncontrolled pain * 04/13/18: [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg one tablet by mouth four times a day for pain Review of the resident's Medication Administration Record [REDACTED]. This schedule resulted in the resident receiving two opiate medications at 8:00 a.m. and at 8:00 p.m. each day. During an interview on 08/16/18 at 11:00 a.m., an administrative nurse (#16) reported she was unable to locate any Pharmacy reviews pertaining to either of these two pain medications.",2020-09-01
88,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2018-08-16,757,D,0,1,B0I611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the resident's medication regimen was free of unnecessary medications for 1 of 18 sampled residents (Resident #35) reviewed. Failure to ensure the resident's medication regimen did not include duplicate therapy of opiate pain medications may result in the resident receiving unnecessary medication and experiencing adverse consequences related to the medication. Findings include: Resident #35's record identified the following physician's orders [REDACTED]. * 04/05/18: [MEDICATION NAME] 50 milligrams (mg) by mouth three times a day for uncontrolled pain * 04/13/18: [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg one tablet by mouth four times a day for pain Review of the resident's Medication Administration Record [REDACTED]. This schedule resulted in the resident receiving two opiate medications at 8:00 a.m. and at 8:00 p.m. each day. During an interview on 08/16/18 at 11:00 a.m., when shown a copy of Resident #35's MAR, an administrative nurse (#16) stated, You are wondering why these (pain medications) aren't staggered, and made no further comment.",2020-09-01
89,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2018-08-16,803,E,0,1,B0I611,"Based on observation, resident interview, group interview, and staff interview, the facility failed to ensure staff consistently followed dietary menus for all residents for 6 of 11 residents with food concerns (Resident #29, #BB, #CC, #EE, #GG, and #HH). Failure to offer the residents all the menu items listed, does not allow for residents' personal food choices or follow nutritional guidelines for a balanced meal. Findings include: - Observation on 08/13/18 at 12:15 p.m., showed the lunch meal consisted of chicken, noodles, and cauliflower with an alternative option of fish. Observation showed the facility ran out of foods listed on the posted menu. The menu posted by the dining area identified Sunday's menu. - During an interview on 08/13/18 at 12:20 p.m., Resident #29 stated she did not receive the food she ordered. The resident stated she wanted the chicken and two breadsticks, instead she received roast beef, fish, and one breadstick. - During an interview on 08/13/18 at 12:23 p.m., Resident BB stated the facility ran out of both meal options during lunch. Resident BB expressed he, Resident GG, and Resident HH received a different meal which consisted of cold sandwiches or corndogs. - During an interview on 08/13/18 at 3:15 p.m., Resident EE stated the facility frequently runs out of food at meal times. - During an interview on 08/13/18 at 5:39 p.m., Resident HH stated french toast has been on the menu the last couple weeks, however they have been unable to have this due to the syrup not coming on the food truck. He also mentioned the menu does not match the food the residents are served at the meal. - During an interview on the afternoon of 08/13/18, Resident CC stated the meal tickets do not always match the meal served. - During the resident council meeting, held the morning of 08/14/18, five of ten residents stated the facility often runs out of food before they are served and the menu frequently does not match what is served. During an interview on 08/16/18 at approximately 10:00 a.m., a dietary manager (#22) stated the meals are determined by a meal tracker/production program. The kitchen staff make the minimal amount and on occasion have run out of the main meal.",2020-09-01
90,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2018-08-16,804,E,0,1,B0I611,"Based on observation, resident interview, family interview, and group interview, the facility failed to serve foods at palatable temperatures for 7 of 12 resident/family interviews (Resident #55, #70, #BB, #CC, #DD, #FF, and family member AA). Failure to serve foods at a temperature acceptable to residents may result in decreased intake, weight loss, and inadequate nutrition. Findings include: - During an interview on the morning of 08/13/18, when asked questions about the meals being served, Resident #55 stated, The food is just terrible. A lot of things come cold. She reported complaining to a staff member, who replied, You can eat it, cause that's all we got. - During an interview on 08/13/18 at 11:30 a.m., when asked questions about the meals being served to residents, a family member (AA), stated, It would be nice to have a microwave in there (dining room). Mom will say, 'Now it's cold.' It takes her a while to eat. I complained about the fish. It was horrible. I couldn't eat it. - During an interview on the 08/13/18 at 12:08 p.m., when asked questions about the meals being served, Resident #70 stated, This morning my hot cereal was cold. - During an interview on the afternoon of 08/13/18, Resident BB stated the food is usually cold. - During an interview on the afternoon of 08/13/18, Resident CC stated the food is terrible and it is impossible to gain weight at the facility. - During an interview on 08/13/18 at 3:15 p.m., Resident EE voiced concerns with temperatures of the food being cold. - During an interview on 08/13/18 at 3:54 p.m., Resident DD stated the food is cold sometimes when delivered to her room. - During an interview on 08/13/18 at 4:30 p.m., Resident FF voiced concerns with temperatures of the food not hot enough. During the group interview on the morning of 08/14/18, four of ten residents stated the food is usually cold. The surveyors received a lunch test tray on 08/14/18 at approximately 12:05 p.m. The test tray consisted of fish, rice, vegetables, pears, and cornbread. The 3 surveyors confirmed the food did not maintain a palatable texture or temperature. Failure to serve foods at palatable temperatures may negatively impact residents' meal consumption.",2020-09-01
91,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2018-08-16,840,D,0,1,B0I611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documentation and staff interview, the facility failed to obtain a written agreement or arrangement between the nursing home and the Medicare Certified [MEDICAL TREATMENT] Facility regarding the roles and responsibilities for the provision of [MEDICAL TREATMENT] care/services and failed to have policies and procedures regarding [MEDICAL TREATMENT] care for 1 of 1 sampled resident receiving [MEDICAL TREATMENT] (Resident #277). Failure to ensure an agreement/arrangement and specific [MEDICAL TREATMENT] polices/procedure has the potential to place [MEDICAL TREATMENT] residents at risk for not receiving care and services in accordance with current standards of practice. Findings include: Review of documentation provided by the facility regarding [MEDICAL TREATMENT] occurred on the afternoon of 08/13/18. The documentation stated, A formal contractual agreement between the (name of local [MEDICAL TREATMENT] unit) and skilled care facilities is not required because the patients receiving services are patients of the physician who work directly with [MEDICAL TREATMENT]. During interview on the afternoon of 08/16/18, an administrative staff member (#16) confirmed the facility had no contract with the local [MEDICAL TREATMENT] unit and the facility had no policies regarding [MEDICAL TREATMENT].",2020-09-01
92,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2018-08-16,880,E,0,1,B0I611,"Based on observation, review of facility policy, and staff interview, the facility failed to follow infection control practices for 9 of 19 sampled residents (Resident #6, #8, #14, #15, #35, #37,#46, #48, and #55). Failure to follow infection control practices during personal cares and in the laundry has the potential to transmit infections to other residents, staff, and visitors. Finding include: Review of the facility policy titled Infection Prevention and Control Manual Standard Precautions occurred on 08/16/18. The policy, dated (YEAR), stated, . Gloves . Sterile gloves and examination gloves are removed: . Between resident contacts. Before touching uncontaminated surfaces or other areas of the same resident's body that may be contaminated. Review of the facility policy titled, Hand Hygiene occurred on 08/16/18. The policy, dated (YEAR), stated, . Appropriate hand hygiene is essential in preventing transmission of infectious agents. Staff must perform hand hygiene even if gloves are utilized. - Observations on all days of survey showed the following infection control breaches: * 08/13/18 at 11:36 a.m., Two certified nursing assistants (CNAs) (#10 and #25) assisted Resident #48 to the toilet utilizing a gait belt. One CNA (#10) removed the resident's wet brief, and without performing perineal care, placed a clean brief. The second CNA (#25) placed an oxygen tank on Resident #48's wheel chair, bagged the trash, and left the room with the trash without performing hand hygiene. * 08/13/18 at 3:08 p.m., A CNA (#20) transferred Resident #55 to the toilet using a mechanical lift. The CNA (#20) removed her gloves, exited the room without performing hand hygiene, and pushed the stand lift to another unit. * 08/14/18 at 9:52 a.m., Two CNAs (#8 and #9) transferred Resident #35 into bed using a mechanical lift and provided personal cares. One of the CNA's (#8) removed her gloves and exited the room with the lift. The other CNA (#9) checked Resident #35's brief, removed her gloves, placed a pillow between his knees, covered him with a blanket, handed him his call light, then performed hand hygiene. * 08/14/18 at 11:40 a.m., An unidentified CNA entered Resident #6 and #14's room. The CNA provided personal cares to Resident #6 and failed to perform hand hygiene. The CNA then assisted Resident #14 to the bathroom. The CNA provided personal cares to Resident #14 and failed to perform hand hygiene. The CNA wheeled Resident #14 into the hallway, and discarded the garbage in the soiled utility room, then performed hand hygiene. * 08/14/18 at 11:48 a.m., Two CNAs (#9 and #10) transferred Resident #35 to his wheelchair using a mechanical lift. One of the CNAs (#10) removed her gloves, pushed Resident #35 out into the hallway, re-entered the room, then washed her hands. * 08/14/18 at 3:23 p.m., two CNAs (#14 and #15) provided perineal care to Resident #37 after an incontinent bowel movement. The CNA (#14) failed to remove her gloves before she placed a new brief on the resident, straightened the bed linens, adjusted the resident's pillow, and opened the room blinds. * 08/14/18 at 4:20 p.m., A CNA (#23) donned gloves and assisted Resident #46 to bed utilizing a sit to stand lift. Observation showed the resident's brief soaked with urine. The CNA (#23) performed perineal care and applied a new brief, then removed her gloves and left the room without performing hand hygiene. * 08/15/18 at 9:11 a.m., Two CNAs (#10 and #11) transferred Resident #35 to bed using a mechanical lift, and provided personal cares. The CNAs (#10 and #11) checked Resident #35's brief, removed their gloves, placed a pillow behind his back, placed blue boots on his feet, gave him a drink of water via a straw, covered him with a blanket before lowering the bed, then performed hand hygiene. The uncovered catheter bag laid directly on the floor when the bed was in it's lowest position. * 08/15/18 at 3:59 p.m., Observation showed Resident #8 sitting on the commode next to her bed drinking coffee and holding a cookie. She told the CNA (#4) she had a bowel movement. The CNA (#4) gloved, assisted Resident #8 to stand, performed perineal cares, adjusted the resident's clothing, and assisted her to pivot into her wheelchair, then emptied the commode bucket into the toilet. The CNA (#4) then walked back to the sink in Resident #8's room, rinsed the bucket with water obtained from the faucet, walked into the bathroom, and emptied the bucket into the toilet for a second time. The CNA (#4) failed to sanitize the sink after rinsing the commode bucket. Observation showed no bedpan washer device available in the bathroom for rinsing the commode bucket. * 08/15/18 at 4:19 p.m., Two CNAs (#4 and #7) provided Resident #15's incontinence cares, changed her clothing, transferred her into her wheelchair using a mechanical lift, brushed her hair, placed her nasal cannula (oxygen), and removed their gloves. One of the CNAs (#4) washed his hands, while the other CNA (#7) offered Resident #15 a drink of water via a straw before washing her hands. The above staff members failed to sanitize and/or perform hand hygiene after removing soiled gloves, prior to providing additional cares, and/or prior to exiting the residents' rooms, and failed to properly sanitize the sink and rinse the commode bucket. During an interview on 08/15/18 at 2:30 p.m. two administrative nurses (#16 and #17) confirmed staff should perform perineal care after urinary incontinence and should perform hand hygiene before exiting the resident's room. Review of the facility policy titled, Laundry Area and Equipment occurred on 08/16/18. The policy, dated 12/18/06, stated, .ceiling vents, floor fans and table fans are cleaned to remove lint and dust once a week. - Observation in the laundry occurred on 08/15/18 09:25 a.m. with a Housekeeping/Laundry administrator (#26). Observation in the clean linen folding area identified two fans with heavy lint/dust build up blowing on clean linen. The staff member (#26) confirmed the fans needed cleaning and stated the facility had no cleaning schedule for the fans.",2020-09-01
93,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2019-10-21,561,D,0,1,6YYS11,"Based on review of facility policy, and resident, family, and staff interviews, the facility failed to honor resident choices for 2 of 9 residents (Resident C and D) from the group interview, one sampled resident (Resident #36), and a family member (AA). Failure to honor resident choices related to sleeping and waking times does not allow the residents the right to choose their own schedule. Findings include: Review of the facility policy titled Resident Rights occurred on 10/17/19. This undated policy stated, . You have the right : To be offered choices and allowed to make decisions important to you, To expect the facility to accommodate individual needs and preferences . During an interview on 10/15/19 at 10:06 a.m., a family member (AA) stated, They (facility staff) get her (the resident) up way too early. There should be no reason she has to get up that early. Then I find her sleeping all the time with her head hanging down or leaned back in her wheelchair. She's up in her wheelchair from 5:30 (a.m.) until 8:30 (p.m.) when they put her to bed. During the group interview on 10/16/19 at 9:00 a.m. with residents identified by the facility as interviewable, Resident C stated staff get her up earlier in the morning than she chooses. If I don't get up they (staff) take my blanket and I get cold so I get up. Resident D stated staff make her get up earlier in the morning than she chooses. During a dressing change on 10/16/19 at 11:32 a.m. by an administrative nurse (#3), Resident #36 stated, Last night they (staff) wouldn't put me to bed, they made me sit here and sit here way over an hour and my back hurt. During an interview on 10/17/19 at 3:59 p.m., an administrative nurse (#1) stated she expected staff to allow residents to sleep in if they wanted.",2020-09-01
94,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2019-10-21,582,B,0,1,6YYS11,"Based on review of Medicare Part A letters/notices and staff interview, the facility failed to provide the Centers for Medicare/Medicaid Services (CMS) Notice of Medicare Provider Non-coverage (NOMNC) form (CMS- ) and/or Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) form (CMS- ) to 3 of 3 residents (Resident #15, A, and B) reviewed who were discharged from Medicare Part A services. Failure to provide the correct notices upon termination of Medicare Part A services, the updated contact information for the intermediary review agency, and ensure the resident's received the option to appeal the termination of coverage has the potential to hinder the residents' right to an expedited review of a service termination. Findings include: Review of the Medicare Part A letters/notices for Resident #15, A and B occurred on the afternoon of 10/17/19. The records identified the following: * Resident A received the NOMNC form (CMS - ) on 08/08/19. The form lacked the updated contact information for the intermediary review agency. * The facility failed to provide Resident B with the NOMNC form (CMS - ) when all covered services ended. * Resident #15 received the SNFABN form (CMS- ) on 05/06/19. The resident signed the form and returned it to the facility but failed to identify, by checking a box, whether they requested a demand bill. During an interview on 10/17/19 at 3:52 p.m., a business office staff member (#2) confirmed Resident B failed to receive the CMS - , the facility had failed to confirm if Resident #15 wanted to request a demand bill, and verified the CMS - form lacked the updated contact information for the intermediary review agency.",2020-09-01
95,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2019-10-21,641,B,0,1,6YYS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 8/16/18. Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.16), and staff interview, the facility failed to ensure the Minimum Data Set (MDS) reflected residents' status for 1 of 18 sampled residents (Resident #9) and 1 closed record (Resident #65). Failure to accurately complete Section A (Identification Information) does not allow each resident's assessment to reflect their current status/needs and may result in the development of an inaccurate care plan. Findings include: The Long-Term Care Facility RAI Manual, revised (MONTH) (YEAR), Section A: Identification Information, stated the following: * pages A-18 to A-20, A1500: Preadmission Screening and Resident Review (PASRR) . All individuals who are admitted to a Medicaid certified nursing facility, regardless of the individual's payment source, must have a Level I PASRR completed to screen for possible mental illness (MI), intellectual disability (ID) . /developmental disability (DD), or related conditions . Individuals who have or are suspected to have MI or ID/DD or related conditions may not be admitted to a Medicaid-certified nursing facility unless approved through Level II PASRR determination. Coding Instructions: . Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions. * page A-29, . A2100: Discharge Status . Code 02, another nursing home or swing bed: if discharge location is an institution (or a distinct part of an institution) that is primarily engaged in providing skilled nursing care and related services for residents who require medical or nursing care or rehabilitation service for injured, disabled, or sick persons. - Review of Resident #9's medical record occurred on (MONTH) 15-17, 2019. A Level 1 PASRR, dated 02/11/16, included Ascends' (contracted service provider for screening process) outcome, Level II is required. Positive Level I. The PASRR Summary of Findings (Level II), dated 02/27/16, stated, (Name of resident) meets PASRR Mental Illness inclusion criteria with the primary [DIAGNOSES REDACTED]. The findings included recommendations for supportive care in the nursing facility. Resident #9's annual MDS, dated [DATE], identified [DIAGNOSES REDACTED]. as 0. No. The facility coded A1500 no on all Resident #9's comprehensive assessments since the admission MDS, dated [DATE]. During an interview on 10/17/19 at 12:35 p.m., an administrative nurse (#1) agreed staff should have coded A1500 yes per the MDS coding directions. - Review of Resident #65's medical record occurred on 10/17/19. The discharge assessment - return not anticipated MDS, dated [DATE], identified the resident was discharged to an acute hospital; however, the resident's medical record showed Resident #65 was discharged to another skilled facility. During an interview on 10/17/19 at 3:24 p.m., an administrative nurse (#5) agreed she coded the MDS incorrectly.",2020-09-01
96,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2019-10-21,657,D,0,1,6YYS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED ON 8/16/18 AND THE COMPLAINT SURVEY COMPLETED ON 6/11/19. Based on observation, record review, and review of facility policy, the facility failed to review and revise a care plan to reflect the resident's current needs for 1 of 18 sampled residents (Resident #61). Failure to review/revise the care plan to reflect each resident's current status limited the staff's ability to communicate needs and ensure continuity of care for the resident. Findings include: Review of facility policy titled Care Plans - Comprehensive occurred on 10/17/19. This policy, dated (MONTH) (YEAR), stated, . An individualized, comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, psychological needs is developed for each resident. Review of Resident #61's medical record occurred on all days of survey. The record indicated the resident was hospitalized on (MONTH) 10-14, 2019 and again on (MONTH) 15-23, 2019 with [DIAGNOSES REDACTED]. The hospital discharge orders indicated Resident #61 to be NPO (nothing by mouth) status and for speech therapy to evaluate and treat. The facility failed to identify interventions/recommendations for aspiration pneumonia, NPO status, and speech therapy on Resident #61's care plan.",2020-09-01
97,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2019-10-21,658,D,0,1,6YYS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 08/16/18. Based on observation, record review, professional reference, and staff interview, the facility failed to follow professional standards of practice regarding compliance with physician's orders [REDACTED].#12 and #36). Failure to follow physicians's orders for a dressing change (Resident #12) and notification of elevated blood sugars (Resident #36) may result in adverse health effects. Findings include: Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 10th Edition, (YEAR), Pearson, Boston, Massachusetts, page 68, stated, Nurses are expected to analyze procedures and medications ordered by the physician. It is the nurse's responsibility to seek clarification . the nurse is responsible for carrying it out. - Observation on 10/15/19 at 5:41 p.m. showed Resident #12 had a [MEDICATION NAME] dressing to his right hand. Review of Resident #12's medical record occurred on all days of survey. A nursing progress note, dated 10/05/2019 at 10:44 a.m., stated, CNA (certified nursing assistant) reported resident bumped his right hand to the corner of the heater box in his room. Resident was noted to have a self inflicted injury on his right hand, sustained a skin tear (inverted L shape) measuring 3.4 cms (centimeters) x (by) 3.0 cms. Resident was so resistantduring (sic) the cleaning of the affected area so it was not well approximated. This nurse cleaned it with NS (normal saline), covered with paper tape to keep the skin together, covered with non adherent dressing, then a foam dressing to hold the non adherent dressing and wrapped with Kirlix (sic). A MD (medical doctor)/Nursing Communication sheet faxed to the MD, dated 10/05/19, stated the above information and Would you like to continue same dressing. Please advise., to which the MD responded continue (with) above dressing. Review of Resident #12's treatment record occurred on 10/16/19 and failed to identify an order for [REDACTED]. During an interview on the morning of 10/16/19, an administrative nurse (#1) stated staff failed to carry over the dressing change treatment to the treatment record. - Review of Resident #36's medical record occurred on all days of survey. A physician's orders [REDACTED]. Review of Resident #36's blood glucose levels for (MONTH) 1-16, 2019 showed the resident's fasting blood glucose greater than 140 on eight occasions and post prandial glucose level greater than 180 on eight occasions. The facility failed to notify the physician of the elevated glucose levels as ordered. During an interview on 10/17/19 at 1:54 p.m., an administrative staff member (#3) confirmed the staff failed to notify the physician as ordered.",2020-09-01
98,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2019-10-21,677,D,0,1,6YYS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility policy, and resident, family, and staff interviews, the facility failed to provide activities of daily living (ADL) assistance to 1 of 8 sampled residents (Resident #17) and 1 supplemental resident (Resident #51) who required staff assistance for toileting/check and change. Failure to provide assistance in a timely manner to residents who cannot independently carry out ADLs may result in poor grooming/hygiene and decreased self-esteem. Findings include: Review of the facility policy titled Incontinence Prevention Program occurred on 10/17/19. This undated policy stated, To provide the appropriate bowel and bladder continence interventions based upon individualized evaluation of residents. Routine toileting (ADL based) - A scheduled bladder management program will be designed to toilet an incontinent patient/resident when a voiding pattern cannot be established or for a patient/resident who is unable to communicate the need to void. Goal: Keep the resident dry. Example schedule in care plan: 'Toilet the resident every 2 hours, before and after meals, at bedtime and once during the night.'. Check and Change . residents using briefs will be checked frequently as needed for incontinent episodes and removal/replacement of soiled briefs. Perineal care will be provided after each incontinent episode. - Review of Resident #17's medical record occurred on all days of survey. The resident's current care plan stated, . ADL self-care deficit as evidenced by requires assistance related to: decreased physical function . Check and change at routine times such as before and after meals, at HS (hour of sleep) and routinely throughout the night. Transfer with full body mechanical lift, full body sling, two staff . Urinary incontinence r/t (related to) Disease process dementia . Incontinence care at routine times such as upon arising in AM, before/after meals, activities, naps, at bedtime and on scheduled rounds at night . Observations on 10/16/19 showed Resident #17 seated in the wheelchair at the following times: * 9:55 a.m. - located in the commons area (following the breakfast meal) * 11:00 a.m. - located in the commons area during an activity * 12:08 p.m. - located in the dining room for the noon meal The nursing staff failed to toilet/check and change Resident #17 after the breakfast meal, before/after an activity, or before the noon meal as stated in the resident's care plan. - Review of Resident #51's medical record occurred on 10/15/19. The quarterly minimum data set (MDS), dated [DATE], identified the resident required extensive assistance of two staff for toileting, and the resident was always incontinent of bowel. Observations on 10/15/19 showed Resident #51 seated in the wheelchair in the resident's room at the following times: * 9:48 a.m. - Odor of BM (bowel movement). The resident stated, I am not taken to a toilet. They just change me, and indicated last changed that morning. * 10:20 a.m. - Odor of BM. A certified nurse assistant (CNA) (#4) provided a snack and left the room. * 10:48 a.m. - Odor of BM * 11:18 a.m. - Odor of BM. During an interview on 10/15/19 at 10:06 a.m., a family member (AA) confirmed Resident #51 smelled like BM. The nursing staff failed to provide incontinence care in a timely manner for Resident #51. During an interview on 10/17/19 at 3:50 p.m., an administrative nurse (#13) stated she expected staff to follow each resident's toileting schedule and/or check and change at routine toileting times, and then defined routine toileting as, every two to three hours, before/after meals, and at bedtime.",2020-09-01
99,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2019-10-21,692,D,0,1,6YYS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and record review, the facility failed to adequately assess the nutritional needs to restore/maintain adequate nutritional status for 1 of 3 sampled residents (Resident #61) who received a tube feeding. Failure to meet residents' nutritional needs through diet (tube-feeding), supplements, or other interventions contributed to the resident's weight loss. Findings include: Review of the facility policy titled WEIGHT PROGRAM occurred on 10/17/19. This policy, dated (MONTH) (YEAR), stated, . Request reweighs on residents with weight change of 3 pounds or greater . Residents who are tube fed via an electric or battery powered pump should maintain a stable weight. If the resident losses 3 lbs (pounds) or greater OR gains 3 lbs or greater, the dietitian (RD) and nurse should complete a comprehensive assessment on the resident and the doctor needs to be notified as soon as possible . Review of Resident #61's medical record occurred on all days of survey. The current physician orders, dated 09/24/19, stated, . [MEDICATION NAME] 1.5 Cal (tube-feeding). Run over 15 hours at 78 ml (milliliters)/hour start at 1700 (5:00 p.m.) and end when total volume 1170 ml infused . A nutrition risk assessment, dated 09/24/19, identified the following . wasting noted in face, decrease fat and muscle mass noted. Current diet order NPO (nothing by mouth). Current feeding [MEDICATION NAME] HN (high calorie tube feeding) . does not meet estimated need . Risk for Malnutrition: low with tube feeding support . Nutritional Goal Summary: wt 180-190# (pounds) . The current care plan stated, Nutritional status I have abeen (sic) losing wt (weight) gradually. Refuses to be weighed swallowing problems I receive nutrition and hydration via tube feeding Increased need for healing . Review of Resident #61's weights identified the following: * 09/23/19 - 182.0 lbs * 10/01/19 - 175.6 lbs (failed to re-weigh and notify RD) * 10/07/19 - 176.8 lbs * 10/15/19 - 173.4 lbs (failed to re-weigh and notify RD) The weights identified a 4.8% weight loss in less than one month while receiving a tube-feeding. The facility failed to follow their policy regarding re-weighs, complete a comprehensive assessment, and notify the doctor as soon as possible. Failure to promptly re-evaluate Resident #61's nutritional status and adjust the tube feeding as needed resulted in continued weight loss.",2020-09-01
100,"MINOT HEALTH AND REHAB, LLC",355031,600 S MAIN ST,MINOT,ND,58701,2019-10-21,695,D,0,1,6YYS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide the necessary care and services for 1 of 4 residents (Resident #24) observed with continuous oxygen and/or bi-level positive airway pressure ([MEDICAL CONDITION]) use. Failure to provide humidification and utilize correct oxygen liter flow may complicate the resident's respiratory status. Findings include: Review of facility policy titled Oxygen Administration occurred on 10/17/19. This policy, dated (MONTH) (YEAR), stated, . PURPOSE: To deliver oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues. PR[NAME]EDURE: . 1. Check with physician's orders [REDACTED]. 3. h. If a bubble-type humidifier is ordered/used fill it with sterile water. 8. Precaution: Constant flow of oxygen can cause drying and thickening of normal secretions resulting in laryngeal ulceration (sores on the vocal cords). 10. At regular intervals, check liter flow contents (sic) of oxygen, fluid level in humidifier . Review of Resident #24's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The current physician's orders [REDACTED]. with 4 LPM (liter per minute) oxygen bleed (delivery of oxygen with one end of oxygen tubing attached to the oxygen concentrator and the other end of the tubing attached to the [MEDICAL CONDITION] unit), every day and night shift for Sleep apnea . O2 (oxygen) at 3L (liters) per NC (nasal cannula) every day and night shift for shortness of breath, [MEDICAL CONDITIONS] . must wear nightly [MEDICAL CONDITION] during the day if napping. The current care plan stated, . Interventions . Administer oxygen per MD (physician) orders. While not on [MEDICAL CONDITION] have oxygen concentrator at 3 LPM . [MEDICAL CONDITION] per MD orders. While on [MEDICAL CONDITION] set oxygen concentrator at 4 LPM . Observations for Resident #24 showed the following: * 10/15/19 at 9:53 a.m. - Laid in bed with nasal [MEDICAL CONDITION] on, with oxygen at 3 LPM (should be 4 LPM). The humidifier jar on the concentrator contained no water. * 10/15/19 at 10:23 a.m. - Sat at the edge of the bed with nasal [MEDICAL CONDITION] on. The humidifier jar on the concentrator remained empty. * 10/15/19 at 12:30 p.m. - Sat at the edge of the bed with nasal [MEDICAL CONDITION] on while eating. The humidifier jar on the concentrator remained empty and oxygen set at 3.5 LPM (should be 4 LPM). * 10/15/19 at 4:57 p.m. - Rested in bed with nasal [MEDICAL CONDITION] on. The humidifier jar on the concentrator remained empty. * 10/16/19 at 8:06 a.m. - Laid in bed watching television with nasal [MEDICAL CONDITION] on. The humidifier jar on the concentrator remained empty. * 10/16/19 at 9:56 a.m. - Rested in bed with nasal [MEDICAL CONDITION] on. The humidifier jar on the concentrator remained empty and oxygen now set at 4 LPM (the correct setting) During an interview on 10/16/19 at 5:25 p.m., an administrative nurse (#13) stated the facility does not have a policy on [MEDICAL CONDITION] use, and, If the machine ([MEDICAL CONDITION] unit) has a reservoir they (facility staff) would fill it, rinse, drain, and clean it per standard of practice.",2020-09-01