| 11370 |
MONTCLAIR NURSING AND REHABILITATION CENTER |
285054 |
2525 SOUTH 135TH AVENUE |
OMAHA |
NE |
68144 |
2012-02-29 |
490 |
H |
1 |
1 |
IWZ611 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.02 Based on observations, record review, and interviews, the facility failed to ensure effective management of facility resources to maintain the high practical well being of residents and the facility as evidenced by failure to ensure the facility identified and developed plans of action to correct deficient practices and failure to maintain correction for previously cited areas of deficient practice and failed to provide Medical Director required docuemntation to fulfill Medical Directors duties. The survey sample was 26 residents with 4 non-sampled residents. The total facility census was 157 residents. Findings are: A. The facility was found to be deficient in multiple areas of regulatory compliance. The following is a list of F tags cited, please refer to the tag citation for specific detailed findings: -F157 Failed to notify resident's physician and/or family members of changes in condition -F221 Failed to evaluate a tilt and space wheelchair as a restraint -F225 Failed to report possible abuse or neglect immediately, investigate and submit investigation in accordance with federal requirements -F253 Failed to maintain equipment and furniture in clean condition and in good repair -F279 Failed to implement comprehensive care plan -F281 Failed to follow physician order [REDACTED]. -F309 Failed to evaluate skin breakdown and implement interventions -F311 Failed to provide restorative services -F323 Failed to evaluate causal factors, implement interventions and reevaluate interventions to prevent accidents -F325 Failed to weigh residents, evaluate weight changes and implement caloric count -F329 Failed to complete behavioral monitoring for aggressive behaviors -F332 Failed to ensure medication error rate of less than 5% with a medication error rate of 18.6% -F333 Failed to ensure residents were free from significant medication errors -F371 Failed to ensure dietary staff utilized hand washing techniques and install back flow prevention device -F467 Failed to maintain ventilation system in working order -F469 Failed to maintain an effective pest control program -F520 Failed to maintain an effective Quality Assurance Program B. The facility failed to maintain correction of the following tags cited during the previous annual survey completed 3/3/11: F157, F253, F280, F315, F323, and F329. C. The facility policy titled Physician Services revised on 11/11 listed the following duties for the Medical Director: - "Review and sign all incident reports, identify hazards to health and safety, and provide recommendations to the Facility's Administrator to promote a safe and sanitary environment for residents, guests, and personnel." - "Participate in identifying the need for, developing, amending, recommending, approving, implementing and monitoring written policies governing resident care including policies related to: i. admissions transfers, and discharges ii. infection control iii. use of restraints iv. physician privileges and practices v. responsibilities of non-physician health care workers (e.g., nursing, rehabilitation therapies, and dietary services in resident care, emergency care, and resident assessment and care planning). A review of 15 facility incident reports dated between 10/4/11 and 2/6/12 did not reveal signatures from either of the facility's Medical Directors. A review of the Administrative Manual of policies and procedures did not reveal a signature from either of the facility's Medical Directors indicating the manual had been reviewed and approved. The Administrative Manual of policies and procedures was approved by the Administrator on 4/27/11 and the Director of Nursing on 5/5/11. In an interview on 2/29/12 at 11:42 AM, Medical Director GG reported Medical Director GG had not recently been provided with incident reports to review and sign or the policy and procedure manual to approve. In an interview on 2/29/12 at 12:30 PM, Medical Director HH reported Medical Director HH had not been provided with incident reports to review and sign or the policy and procedure manual to approve. |
2015-06-01 |