| 10232 |
KEARNEY COUNTY HEALTH SERVICES |
2.8e+298 |
727 EAST 1ST STREET |
MINDEN |
NE |
68959 |
2012-08-01 |
520 |
H |
0 |
1 |
NRZX11 |
LICENSURE REFERENCE NUMBER: 175 NAC 12-006.07C Based on observations, record review, and interviews conducted during the annual standard survey; the facility failed to ensure the Quality Assessment and Assurance Committee (QA&A) failed to identify areas of deficient practice. The QA&A committee also failed to develop and implement plans of action to correct multiple issues of deficient practice relevant to resident care and services The facility failed to implement plans of action to maintain correction for previously cited areas of deficient practice identified during survey on 9/27/11, 7/14/11, 11/9/10, 5/5/10, 5/27/09, 12/23/08, and 6/4/08. The facility census was 30. Findings are: A. Review of the facility's undated policy Long Term Care Continuous Quality Improvement Plan (CQI) revealed: - Policy Statement: This facility shall develop, implement, and maintain an ongoing program designed to monitor and evaluate he quality of resident care, pursue methods to improve quality care, and to resolve identfied problems. - Authority: 2. The administrator has been delegated responsibility for assuring the CQI Program of this facility is in compliance with federal, state, and local regulatory agency requirements. - Goals of the Committee: 1. To monitor and evaluate the appropriateness and quality of care provided within the framework of the CQI Plan; and 2. To provide a means whereby negative outcomes relative to resident care can be identified and resolved through an interdisciplinary approach, and positive outcomes can be reinforced through education and monitoring. - Committee Actions: 1. The committee will develop and implement plans of action to correct identified negative care outcomes. B. The facility was found to be deficient in multiple areas of regulatory compliance after the tasks of the annual standard survey were completed. The facility failed to maintain corrections for the regulations identified as repeat deficiencies and failed to identify and develop plans of action to prevent deficient practice in the areas identified below. Please refer to the Tag citations for specific detailed findings: - F156 Failed to inform residents of items and services not covered by Medicaid benefits; - F157 Failed to notify residents' families of change in condition; - F159 Failed to ensure resident personal funds accounts were available on evenings and weekends, failed to pay interest on accounts over $50, and failed to provide quarterly statements; - F161 Failed to secure a surety bond for assurance of residents' financial security; - F166 Failed to address residents' grievances; - F176 Failed to assess residents for the ability to self-medicate; - F224 Failed to protect residents belongings. Previously cited on 9/27/11 and 5/27/09; - F225 Failed to report to the State agency and investigate allegations of abuse, neglect, misappropriation and injuries of unknown origin; - F226 Failed to screen new employees and failed to protect residents during abuse/neglect investigations; - F242 Failed to honor the residents' right to choose what time to get up in the morning; - F248 Failed to plan and implement activities of residents interests; - F253 Failed to provide a clean and well-maintained environment. Previously cited on 7/14/11 and 6/4/08; - F258 Failed to provide comfortable sound levels; - F272 Failed to complete comprehensive assessments of residents needs; - F279 Failed to develop comprehensive care plans that addressed residents needs; - F280 Failed to revise the comprehensive care plan to reflect the actual care provided to residents. Previously cited on 12/23/08; - F281 Failed to follow standards of practice for medication administration, following physicians orders, and accurate documentation. Previously cited on 5/5/10, 5/27/09, and 12/23/08; - F309 Failed assess and identify causal factors for change in condition, pain, skin conditions, and anxiety in residents. Previously cited on 11/9/10; - F318 Failed prevent the decrease in residents' range of motion; - F323 Failed to implement intervention to prevent resident falls. Previously cited on 5/27/09 and 6/4/08; - F327 Failed to monitor residents' fluid restrictions; - F329 Failed to ensure resident medications had indications for usage and failed to implement non-pharmacological interventions prior to the use of psychoactive medications; - F333 Failed to ensure residents were free of significant medication errors. Previously cited on 7/14/11 and 6/4/08; - F334 Failed to ensure residents pneumatically immunization were current; - F356 Failed to ensure the posting of nurse staffing was accessible, visible and accurate; - F406 Failed to provide psychological services; - F428 Failed to ensure the consultant pharmacist identified and reported irregularities in residents medication regimen; - F441 Failed to follow infection control program related to hand hygiene and the tracking and trending of infections. Previously cited on 7/14/11, 5/27/09, and 6/4/08; - F492 Failed to ensure compliance with applicable Federal and State laws and regulations; - F496 Failed to receive Nurse Aide Registry verification prior to nurse aide employment; - F497 Failed to complete Nurse Aide performance reviews and competence in-service training; - F498 Failed to ensure Nurse Aides were able to demonstrate competency in skills needed to care for residents. Previously cited on 5/27/09; - F500 Failed to have agreements with outside sources for the provision of services; - F501 Failed to ensure the Medical Director provided oversight for the coordination of resident care; - F503 Failed to obtain a contract for the provision of laboratory services; - F506 Failed to obtain an agreement for the transportation of residents to laboratory services; - F509 Failed to obtain a contract for the provision of radiology services; - F512 Failed to obtain an agreement for the transportation of residents to radiology services; - F514 Failed to ensure accurate and completed documentation in residents medical records. Previously cited on 6/4/08; - F520 Failed to maintain an effective Quality Assurance Program. C. During an interview on 7/26/12 at 4:02 PM, the Quality Assurance Coordinator (QA-C) revealed the QA&A Committee receives concerns and problems from a lot of sources including incident reports, resident council meetings, care plan meetings, audits on resident rights, hand washing audits, past surveys, and nursing home compare website. The QA-C revealed a lot of medication errors, documentation problems, medication omissions had been identified, and felt was a problem with a lack of accountability. The QA-C revealed the QA&A Committee had not identified or addressed the following issues: - investigations to ensure they were completed and not addressed the need for education; - review Long Term Care policies and procedures; - orientation for new employees to ensure lift education was adequate for staff to use the lifts, splint, and other equipment ; - schedule of physical or occupational therapy interfering with resident activities; - documentation issues, including the accuracy of documentation; - usage of the mechanical lifts (2 staff employed for 6 months didn't know how); - resident trust accounts; - infection control and hand washing was one of our first studies in January. The QA-C stated I don't know if direct care staff know how to access the QA committee. The QA-C revealed no one had looked at education about documentation for a long, it was probably more than 5 years ago. . During an interview on 7/26/12 at 3:00 PM, Medication Aide (MA)-MM stated I don't' think they have a QA Committee. MA-MM revealed the MA didn't know who was on the QA&A committee. An interview with Nurse Aide (NA)-KS on 7/26/12 at 3:10 PM, revealed if the NA-KS had a concern, the NA would tell Registered Nurse-S or the Director of Nursing (DON), but was not sure whether or not they were on the committee. NA-KS revealed sometimes the facility would have changes in process or the way to do things, but those were signed by the DON and didn't know if the QA&A Committee was involved in those changes or not. An interview with NA-HB on 7/26/12 at 3:15 PM, revealed NA-HB thought the facility had a QA&A committee, but was not sure who was on it or how to access the committee. |
2016-02-01 |