cms_NH
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2,308 rows sorted by facility_name
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| Link | rowid | facility_name ▼ | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 416 | 416 | APPLEWOOD CENTER | 305065 | 8 SNOW ROAD | WINCHESTER | NH | 3470 | 2016-11-03 | 159 | B | 0 | 1 | 2ZTU11 | Based on the review of the resident trust fund account and interview it was determined that the facility failed to notify residents when the amount in the resident's account reached $200 less than the SSI resource limit for the State of NH ($2500) as specified in section 1611(a)(3)(B) of the Act for 1 of 5 sampled residents. (Resident identifier is #16.) Findings include: Resident #16. Review on 11/3/16 of the Individual Statement for Resident #16 revealed that from 08/03/16-09/07/16 the balance continually exceeded $200 less than the SSI resource limit for the State of NH, in fact exceeding the $2500 limit the entire time. On 09/07/16 the balance was still within the $200.00 less than $2500.00. There was no documented evidence that the resident or their representative had been notified. Interview on 11/13/16 at the time of the review with Staff A (Business Office Manager), confirmed the above finding. | 2020-09-01 |
| 417 | 417 | APPLEWOOD CENTER | 305065 | 8 SNOW ROAD | WINCHESTER | NH | 3470 | 2016-11-03 | 456 | D | 0 | 1 | 2ZTU11 | Based on interview, facility policy and review of the manufacturer's instructions for the facility it was determined the facility failed to clean the glucometer and that the facility failed to date the test strips according to the manufacturer's instructions. Findings include: Review of the facility EVEN CARE G2 Blood Glucose Test Strips manufacturer's instruction revealed the following: WARNING AND PRECAUTIONS . Do not use test strips after their expiration date. Please check the expiration date on the test strip bottle. STORAGE AND HANDLING . Use within 6 months after first opening . Review of the facility Glucose Meter with an effective date of 06/01/96 and a revision date of 06/01/15 revealed the following .2. Disinfect meter before patient use. Observation of the medication pass on 11/1/16 at 4:10 p.m. with Staff B (Registered Nurse), revealed that Staff B obtained a blood glucose from Resident #7. Staff B removed the glucometer from the medication cart and removed one test strip from the test strip container and place the test strip on top of the glucose meter. After the blood glucose was obtained Staff B placed the glucose meter back into the medication cart without cleaning it. Observation and review Staff B (RN) verbally confirmed the above listed findings for not cleaning the glucose meter. Observation of the medication pass on 11/2/16 at 8:15 a.m. with Staff C (Licensed Practical Nurse) revealed 2 opened bottles of glucose test strips that were not dated with a date for the time of opening. During this observation and review Staff C (LPN) confirmed the above listed findings for the glucose test strips. | 2020-09-01 |
| 1933 | 1933 | APPLEWOOD CENTER | 305065 | 8 SNOW ROAD | WINCHESTER | NH | 3470 | 2011-06-23 | 225 | D | 1 | 1 | 2GE211 | Based on record review and interview the facility failed to ensure that all alleged violations involving neglect were reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures for 1 resident in a standard survey sample of 15 residents. (Resident identifier is #2.) Findings include: Review of Resident # 2's medical record on 6/22/11 revealed nurses notes dated 5/22/11 at 2350 "...(Staff C) (LNA) told me that Resident was not changed and saturated with urine and feces stating neglect was evident with resident. I witnessed laundry, towels, + other disposals in a ... bag showing saturated weighted bag that was very heavy...". Review of LNA flow sheets for April, May and June 2011 revealed incontinence care provided two or three times on each shift consistently throughout the three month period. Interview with Staff D (Administrator) on 6/22/11 at 1 p.m. revealed Staff D had not been made aware of the alleged neglect until 6/21/11 when informed by surveyor. Staff D contacted all staff involved and interviewed them. Staff D determined through interview and written statements that care had been provided to Resident #2. | 2014-10-01 |
| 1934 | 1934 | APPLEWOOD CENTER | 305065 | 8 SNOW ROAD | WINCHESTER | NH | 3470 | 2011-06-23 | 226 | D | 1 | 1 | 2GE211 | Based on record review, interview and review of facility's policies and procedures the facility failed to implement its written policies and procedures that prohibit mistreatment, neglect, and abuse of residents for 1 resident in a standard survey sample of 15 residents. (Resident identifier is #2.) Findings include: Review of facility policy number CL-676-0020 effective date 1/08 Prohibition of Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property Section 1:7 Reporting/Response reveals "...The center ensures that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property is reported immediately to the administrator of the center and to other officials, in accordance with state law through established procedures (including to the state survey and certification agency)". Review of Resident # 2's medical record on 6/22/11 revealed nurses notes dated 5/22/11 at 2350 "...(Staff C) (LNA) told me that Resident was not changed and saturated with urine and feces stating neglect was evident with resident. I witnessed laundry, towels, + other disposals in a ... bag showing saturated weighted bag that was very heavy...". Review of LNA flow sheets for April, May and June 2011 revealed incontinence care provided two or three times on each shift consistently throughout the three month period. Interview of Staff D (Administrator) on 6/22/11 at 1 p.m. revealed Staff D had not been made aware of the alleged neglect until 6/21/11 when infromed by surveyor. Staff D contacted all staff involved and interviewed them. Staff D determined through interview and written statements that care had been provided to Resident #2 | 2014-10-01 |
| 1962 | 1962 | APPLEWOOD CENTER | 305065 | 8 SNOW ROAD | WINCHESTER | NH | 3470 | 2011-06-23 | 281 | D | 0 | 1 | 2GE211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that the facility failed to follow the professional standard of practice for documentation for 1 resident and for following a physician's orders [REDACTED]. (Resident identifiers are #7, and #14.) Findings include: Standards: Review of "Fundamentals of Nursing," Patricia A. Potter and Anne Griffin Perry, Mosby, 2009, 7th Edition, revealed the following: On page 336- Physicians' Orders states, "The physician is responsible for directing medical treatment. Nurses follow physician's orders [REDACTED]. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary..." On pages 699-714 "...The prescriber often gives specific instructions about when to administer a medication." This reference also relates on page 713 that "....a registered nurse compares the list of medications on the MAR indicated [REDACTED]." Receiving Medication Orders page 713 relates, "A medication order is required for a nurse to administer any medication. Before any other interventions, ensure that the medication order contains all of the elements in Box 35-13. If the medication order is incomplete, inform the prescriber and ensure completeness before carrying out any medication order." Resident #14. Review of the medical record for Resident #14 on 6/23/11 revealed that the resident has [DIAGNOSES REDACTED]. Review of the MAR's for March 2011 and April 2011, revealed the order, "[MEDICATION NAME] (Carvedilol) 6.25 mg 1 tab by mouth tid (three times a day)- hold SBP (systolic blood pressure) < (Less than) 90 or hr (heart rate) < 60-Pulmonary Congestion and Hypostasis." Review of the MAR for June 2011 revealed the order was changed to, "[MEDICATION NAME] (Carvedilol) 12.5 mg 1 tab by mouth bid (twice a day)- hold SBP <100 or hr < 60-Pulmonary Congestion and Hypostasis." Review of the above MAR's revealed that there was no documented evidence th… | 2014-09-01 |
| 1963 | 1963 | APPLEWOOD CENTER | 305065 | 8 SNOW ROAD | WINCHESTER | NH | 3470 | 2011-06-23 | 159 | B | 0 | 1 | 2GE211 | Based on review of the documentation provided during the Resident Account review and interview, the facility failed to notify residents that receive Medicaid benefits when the amount in the resident's account reached $200 less than the SSI resource limit for the State of NH ($2500) as specified in section 1611(a)(3)(B) of the Act for 2 of 5 sampled Medicaid residents. (Resident identifiers are #18 and #19.) Findings include: Resident Trust Account was reviewed on 6/23/11. Review of the selected Resident Account Individual Statements dated 7/1/10-6/21/11 revealed that 2 of 5 selected Resident Account reviews had amounts totaling over $2500, in their resident trust fund for greater than 30 days. Further review of the provided documentation revealed that no attempt to notify residents or representatives (when the accounts reached $200 less than the SSI resource limit) had been documented until after $2500 had been surpassed for greater than 30 days. Resident #18. Review of the Individual Statement for Resident #18 revealed that from 7/30/10-10/29/10 the balance continually exceeded $200 less than the SSI resource limit for the State of NH, in fact exceeding the $2500 limit. Balances ranged from $2784.36 on 7/30/10 to $4279.43 on 10/29/10, with a high of $5299.92 on 9/3/10. Review of the documentation of an e-mail dated 9/14/10 of the facility's notification to medicaid was reviewed with Staff B (BOM) on 6/23/11 following the Account review. Staff B stated that this was the only correspondence. There was no documented evidence that the resident or their representative had been notified at all. Resident #19. Review of the Individual Statement for Resident #19 revealed that from 3/3/11-4/26/11 and from 5/3/11-6/14/11 the balances continually exceeded the $200 less than the SSI resource limit for the State of NH. Balances ranged from $3141.70 on 3/3/11 to $2360.82 on 4/26/11, and from $3161.64 on 5/3/11 to $2372.73 on 6/14/11. There was no documented evidence that the resident or representative had been notified. Interv… | 2014-09-01 |
| 1964 | 1964 | APPLEWOOD CENTER | 305065 | 8 SNOW ROAD | WINCHESTER | NH | 3470 | 2011-06-23 | 282 | D | 0 | 1 | 2GE211 | Based upon a review of a facility investigation and resident's record review the facility failed to implement the comprehensive care plan for 1 in an expanded sample of 16 residents (Resident identifier is #16). Findings include: Resident #16 Resident #16 was identified as an elopement risk on their comprehensive care plan of 4/29/11 due to confusion. The care plan goal for elopement stated that Resident #16 "will not wander from secure location unattended." On 4/30/11 at approximately 4p.m. according to a facility investigation report dated 5/4/11, Resident #16 was accompanied outdoors by Staff E (LPN). Staff E left Resident #16 unattended sitting in the outdoor patio area. Staff E, according to the facility investigation, conducted checks on Resident #16 every 5-10 minutes. Resident #16 at 5:43 p.m. was noted by the facility investigation to have proceeded to wander to the end the the facility driveway adjacent to Warwick Road before being assisted back into the facility by four staff members. The facility failed to ensure that the comprehensive care plan of Resident #16 was followed in regard to their identified elopement risk. | 2014-09-01 |
| 1965 | 1965 | APPLEWOOD CENTER | 305065 | 8 SNOW ROAD | WINCHESTER | NH | 3470 | 2011-06-23 | 323 | D | 0 | 1 | 2GE211 | Based on a facility investigation report and resident record review the facility failed to ensure that 1 Resident in an expanded sample of 16 received adequate supervision (Resident identifier is #16). Findings include: Resident #16 Resident #16 was identified as an elopement risk on their comprehensive care plan of 4/29/11 due to confusion. The care plan goal for elopement stated that Resident #16 "will not wander from secure location unattended." On 4/30/11 at approximately 4p.m. according to a facility investigation report dated 5/4/11, Resident #16 was accompanied outdoors by Staff E (LPN). Staff E left Resident #16 unattended sitting in the outdoor patio area. Staff E, according to the facility investigation, conducted checks on Resident #16 every 5-10 minutes. Resident #16 at 5:43 p.m. was noted by the facility investigation to have proceeded to wander to the end the the facility driveway adjacent to Warwick Road before being assisted back into the facility by four staff members. The facility failed to ensure that Resident #16 received adequate supervision while outdoors on 4/30/11. | 2014-09-01 |
| 2136 | 2136 | APPLEWOOD CENTER | 305065 | 8 SNOW ROAD | WINCHESTER | NH | 3470 | 2010-12-13 | 309 | J | 0NGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure that it provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for a diabetic resident with a non-pressure related wound resulting in the amputation of a toe. (Resident identifier is #1.) Findings include: Review on 12/13/10, of Resident #1 ' s medical record reveals, Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's physician ' s progress notes reveals the following: 7/16/10 Resident has [MEDICAL CONDITION]. Has diabetic [MEDICAL CONDITION]. Sees podiatrist ... regularly. There is 2+ readily [MEDICAL CONDITION] present at both shins. Plantar pain, left foot. Perhaps marked [MEDICAL CONDITION] is playing a roll. Podiatrist (Md name omitted) is being consulted. Compression stockings to be tried once Ace wraps and [MEDICATION NAME] have brought the [MEDICAL CONDITION] under some degree of control. 8/3/10 Resident is getting regular podiatry follow-up. Has diabetic [MEDICAL CONDITION], but also has had Achilles tendonitis and corns. Review of Resident #1's podiatry note dated 9/14/10, indicates the following The resident returned to the podiatrist office and was " complaining of a very painful right fifth toe. The resident reported to the podiatrist that the resident could not stand anything to touch the toe. The resident had been wearing the compression stockings and had been wearing slippers and not regular shoes. Chronic leg [MEDICAL CONDITION] and diabetic [MEDICAL CONDITION]. Has on going problems with corns of the toes. The right fifth toe has [DIAGNOSES REDACTED] (corn/callous), which is removed to reveal an underlying ulceration over the right fifth toe proximal interphalangeal joint. The wound was gently and minimally debrided. Iodosorb and a dry dressing were applied on the toe and the nursing facility will start Iodosorb and a dry dressing da… | 2014-04-01 | ||
| 2137 | 2137 | APPLEWOOD CENTER | 305065 | 8 SNOW ROAD | WINCHESTER | NH | 3470 | 2010-12-13 | 224 | J | 0NGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure that it implements policies and procedures to prohibit the neglect of residents requiring wound and pressure ulcer care management that resulted in a toe amputation, for 2 residents. (Resident idnetifiers are: #1 and #2.) Findings include: On 12/13/2010, review on of the facility ' s " Skin Care & Pressure Ulcer Management Program " policy and procedure, dated January 2008, reveals " Section 1: Assessment: Identifying Residents at Risk of Skin Breakdowns " " When a Resident Arrives, the licensed nurse reviews the preadmission screen and completes a head-to-toe assessment, documenting findings on the Nursing Assessment. This process provides the team with an accurate description of the resident ' s actual skin condition. If the resident has a pressure or other wounds at the time of admission, treatment begins promptly in accordance with physician orders. The licensed nurse continues the evaluation process to determine the risk of additional skin breakdown, evaluates rehabilitation and nutritional needs, and prepares a plan of care of the existing condition and prevention of additional skin breakdown. " " Using Standardized Tools to Evaluate Risk of Skin Breakdown. After examining a resident ' s current skin condition, the next step is to evaluate the resident ' s likelihood for future skin breakdown. Evaluating risk is an important step, because once it is determined who may be at risk of developing pressure ulcers, the team may attempt to prevent them. The licensed nurse completes the Norton Plus Pressure Ulcer Scale. " - "SECTION 2 PLANNING, IMPLEMENTATION, AND EVALUATION : CARE PLANNING APIE ... - Putting the Plan Into Action ... - Once the Care Plan is written, it is important to be vigilant. Licensed nurses, nursing assistants, and the entire interdisciplinary team must ensure that all planned interventions and treatments are carried out as written in the Care Plan ... - W… | 2014-04-01 | ||
| 2138 | 2138 | APPLEWOOD CENTER | 305065 | 8 SNOW ROAD | WINCHESTER | NH | 3470 | 2010-12-13 | 282 | G | 0NGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that the facility failed to ensure the implementation of the care plan for 2 of 2 residents. (Resident identifiers are #1 and #2.) Findings include: Review of Resident #1's Skin Integrity care plan with an initial date of 9/24/10 reveals under the "Interventions" column, Administer treatment as ordered. Change Dressing as per order, Observe skin tear for signs/symptoms of infection (redness, warmth, [MEDICAL CONDITION], pain/tenderness, drainage). Notify MD if present. Preventative measures as ordered. Antibiotics per MD order. Review of the weekly Skin Assessment section on the October 2010 TAR indicated that on October 1, 8, 15, 22 and 29th the resident had a head to toe skin assessment performed by a nurse. On each of the above skin assessment dates, there was a Y (Yes) written and the nurse ' s initials. Review of the November 2010, TAR revealed that a skin assessment was performed on November 3, 10,17 and 24. All 4 skin assessments has a Y indicating that resident #1 ' s skin is intact and has no breakdown. Review of Resident #1's 12/2/10 podiatry note reveals the following: " Subjective, resident returns to the office with family member for follow up of ulceration right fifth toe. Resident states that the toe hurts. " Objective: The right fifth toe appears swollen. There is ulceration to the plantar fifth toe sulcus at the metatarsal phalangeal joint that extends to the bone. The bone is visible. The tendon is dry. There is significant malodor and drainage. There is tube foam dressing over the toe, which is deeply adhered plantarly to the bone and tendon. The joint is involved. The foot is moderately swollen compared to the other foot. Radiographs do show osteopenic bone right foot with air pocket and what appears to be erosive change at the metatarsal head." "Assessment: Probable osteo[DIAGNOSES REDACTED] with abscess right foot. Plan: X-rays ordered today, right foot. Discussion w… | 2014-04-01 | ||
| 2139 | 2139 | APPLEWOOD CENTER | 305065 | 8 SNOW ROAD | WINCHESTER | NH | 3470 | 2010-12-13 | 272 | D | 0NGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to assess one diabetic residents foot for 2 months resulting in a toe amputation. The facility also failed to assess the foot of one resident with a history of skin breakdown resulting in a toe amputation. (Resident identifiers are #1 and #2.) Findings include: Review of Resident #1's medical record on 12/13/10 reveals podiatry notes dated 9/14/10, The resident returned to the podiatrist office and was " complaining of a very painful right fifth toe." The resident reported to the podiatrist that the resident could not stand anything to touch the toe. The resident had been wearing the compression stockings and had been wearing slippers and not regular shoes. Continued review of the podiatry note reveals " Objective: The right fifth toe extending along the right fifth rays are [DIAGNOSES REDACTED]tous with mild increase in warmth. There is hyperkeratoses (corn/callous), which is removed to reveal an underlying ulceration over the right fifth toe proximal interphalangeal joint. It does not track into the joint. It is 2 mm in diameter. There is scant amount of serous fluid within the ulceration itself. The base of the ulceration is pale." " Assessment: [MEDICAL CONDITION] right fifth toe and foot, hammer toe deformity, ulceration right fifth toe. " " Plan: The wound was gently and minimally debrided. Iodosorb and a dry dressing were applied on the toe and the nursing facility will start Iodosorb and a dry dressing daily." Resident and family member instructed to return to podiatrist for follow up appointment in two weeks. Review of the facility ' s Treatment Administration Record (TAR) for the month of September 2010, reveals that the above podiatry orders were transcribed on to the TAR and signed off by the facility nursing staff starting on 9/30/10 indicating that the orders had been carried out as ordered. Review of the podiatry notes dated 9/28/10 reveals: Resident "returned to office today for ulceration right foot with a… | 2014-04-01 | ||
| 2140 | 2140 | APPLEWOOD CENTER | 305065 | 8 SNOW ROAD | WINCHESTER | NH | 3470 | 2010-12-13 | 157 | D | 0NGB11 | Based on record review and interview it was determined that the facility failed to consult the physician of a change in condition for 1 resident. (Resident identifier is #2.) Findings include: Resident #2. Record review on 12/13/10 revealed no documented evidence that the physician was consulted of a change in skin condition for Resident #2 from 7/30/10 through 9/21/10 for a total of 52 days. Review of the facility "Pressure Ulcer Documentation Form" for Resident #2 dated "9/21" revealed a Stage 2 pressure ulcer on the right 5 th metatarsal. During interview with Staff A (Administrator) and Staff B (Director of Nursing) on 12/13/10 at approximately 1:15 p.m. after both Staff A & B reviewed the above listed findings for Resident #2, Staff A and Staff B confirmed that there was no documented evidence to show that the physician had been notified of a Stage 2 pressure ulcer on the right 5th metatarsal for Resident #2 and no documented evidence of the identification, assessment, monitoring and evaluation of a right 5th metatarsal pressure ulcer prior to 9/21/10. Staff A & Staff B further confirmed that Resident #2 required a surgical intervention with the amputation of the right 5 th metatarsal on 9/29/10 due to the pressure ulcer. | 2014-04-01 | ||
| 2141 | 2141 | APPLEWOOD CENTER | 305065 | 8 SNOW ROAD | WINCHESTER | NH | 3470 | 2010-12-13 | 281 | D | 0NGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during a complaint investigation the facility failed to meet professional standards of practice for 2 residents resulting in toe amputation. (Resident Identifiers are #1 and #2) Findings Include: The Potter-Perry, 2009, Fundamentals of Nursing 7th Edition, St. Louis, Missouri: Mosby, Chapter 23 Legal Implications in Nursing Practice, on page 336- Physicians' Orders states, "The physician is responsible for directing medical treatment. Nurses follow physician's order [REDACTED]. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary..." The Potter-Perry, 2009, Fundamentals of Nursing 7th Edition, St. Louis, Missouri: Mosby Chapter 35 Medication Administration-Recording Medication Administration on page 713 states, Administrating a medication, record it immediately on the appropriate record form. Never chart a medication before administrating it. Recording immediately after administration prevents errors. The recording of a medication includes the name of the medication, dose, route, and exact time of administration. Record the site of any injections per agency policy. " " If a client refuses a medication or is undergoing tests or procedures that results in a missed dose, explain the reason the medication was not given in the nurse ' s notes. Some agencies require the nurse to circle the prescribed administration time on the medication record or to notify the physician when a client misses a dose. " The Facility follows " Preparing for Medication Administration " procedure, which indicates initialed and circled medications are " Dose not given " Review of Resident #1 ' s record on 12/13/10, revealed a physician order [REDACTED]. Review revealed no documented evidence on the Treatment Administration Record (TAR) that the nursing staff completed the ordered procedure on the dates of, 10/1/10, 10/9/0, 10/10/10, 10/11/10, 10/… | 2014-04-01 | ||
| 2142 | 2142 | APPLEWOOD CENTER | 305065 | 8 SNOW ROAD | WINCHESTER | NH | 3470 | 2010-12-13 | 314 | J | 0NGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility policy and procedure it was determined that the facility failed to ensure that a resident who has a pressure sores receives necessary treatment and services to promote healing and prevent infection that required the amputation of a toe for 1 resident. (Resident identifier is #2.) Findings include: Review of the facility policy and procedure on 12/13/10 titled "SKIN CARE & PRESSURE ULCER MANAGEMENT PROGRAM" dated "January 2008" revealed the following: - "SECTION 2 PLANNING, IMPLEMENTATION, AND EVALUATION: CARE PLANNING APIE... - Putting the Plan Into Action... - Once the Care Plan is written, it is important to be vigilant. Licensed nurses, nursing assistants, and the entire interdisciplinary team must ensure that all planned interventions and treatments are carried out as written in the Care Plan... - Weekly Evaluation - A licensed nurse performs head-to-toe skin check of the resident and documents the findings on the Treatment Administration Record (TAR). The licensed nurse documents using the following notations: 'Y' = skin intact 'N' = not intact - If a licensed nurse documents "N," the licensed nurse writes a note in the narrative section of the TAR describing the area. If skin integrity is comprised, the process moves into the wound management phase, the physician/responsible party is notified, and the care plan is updated with appropriate interventions. - SECTION 4: EVALUATION: EVALUATING OUTCOMES - Clinical Weekly Report - On a weekly basis, the director of nursing service (DNS) gathers information from the center daily report that may also be addressed in the C.A.R.E. process, including: pressure ulcers, acquired pressure ulcers, worsening pressure ulcers, unplanned weight loss, falls, restraints, antipsychotic drugs, hypnotics, new infections, precautions, and other clinical concerns. The purpose of this report is to identify and document actions planned or taken to effect … | 2014-04-01 | ||
| 2143 | 2143 | APPLEWOOD CENTER | 305065 | 8 SNOW ROAD | WINCHESTER | NH | 3470 | 2010-12-13 | 514 | D | 0NGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that the facility failed to ensure that the medical record is complete and accurate for 2 residents. (Resident identifiers are #1 and #2.) Findings include: Resident #1 Review of the Podiatry order sheet sent to the facility dated 9/28/10, reveals the following orders, D/C (Discharge) Wound Care R (right) 5th toe. Begin foam sleeve over toe daily (R (right) 5th toe). Return to compression stocking R (right) leg. Return to shoes. F/U (follow up) in 2 months. Review of Resident #1's October 10 TAR (Treatment Administration Record) reveals the order " Apply foam sleeve to right 5th toe daily " there are no nursing initials to indicate that the physician's order [REDACTED]. The following dates had nursing initials circled which indicated that the treatment was not completed on October 3,5,6,and 16, 2010. The October 2010 TAR also reveals the physician's order [REDACTED]. were put on October 8, AM, 10 AM and PM, 18 PM, 27, 28,29 in AM. The weekly Skin Assessment section on the October 2010 TAR indicated that on October 1, 8, 15, 22 and 29th the resident had a head to toe skin assessment performed by a nurse. On each of the above skin assessment dates, there was a Y (Yes) written and the nurse ' s initials which indicates the resident ' s skin is intact Review of Resident #1's November 2010, TAR reveals the order to apply the foam sleeve to right 5th toe daily. On November 14 and 23 there TAR was blank which indicates that the treatment was not done. The order for Compression stockings on in the AM and off in the PM was also not signed off on November 4 in PM and the 23 in the AM. The November 2010, TAR also indicates that a skin assessment was performed on November 3, 10,17 and 24. All 4 skin assessments has a Y indicating that resident #1 ' s skin is intact and has no breakdown. Review of Resident #1's podiatry note dated 12/2/10 indicates Resident #1 returns to the office with family member … | 2014-04-01 | ||
| 2144 | 2144 | APPLEWOOD CENTER | 305065 | 8 SNOW ROAD | WINCHESTER | NH | 3470 | 2010-12-13 | 501 | D | 0NGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy and procedure and interviews the medical director failed to ensure the implementation of resident care policies related to Skin Management that resulted in 2 residents receiving a toe amputation. (Resident identifiers are #1 and #2.) Findings include: Review of Resident #1's medical record on 12/13/10 revealed that Resident #1 had a healed ulceration on the right 5th toe on 9/28/10. Review of the Podiatry order sheet sent to the facility dated 9/28/10, reveals the following orders, D/C (Discharge) Wound Care R (right) 5th toe. Begin foam sleeve over toe daily (R (right) 5th toe). Return to compression stocking R (right) leg. Return to shoes. F/U (follow up) in 2 months. Review of the October 2010 TAR reveals the order "Apply foam sleeve to right 5th toe daily "there are no nursing initials to indicate that the physician's orders [REDACTED]. The following dates had nursing initials circled which indicated that the treatment was not completed on October 3,5,6,and 16, 2010. Review of the weekly Skin Assessment section on the October 2010 TAR indicated that on October 1, 8, 15, 22 and 29th the resident had a head to toe skin assessment performed by a nurse. On each of the above skin assessment dates, there was a Y (Yes) written and the nurse ' s initials. Review of the November 2010, TAR reveals the order to apply the foam sleeve to right 5th toe daily. On November 14 and 23 there TAR was blank which indicates that the treatment was not done. Review of the November 2010, TAR revealed that a skin assessment was performed on November 3, 10,17 and 24. All 4 skin assessments has a Y indicating that resident #1 ' s skin is intact and has no breakdown. Review of the 12/2/10 podiatry note reveals the following: " Subjective, resident returns to the office with family member for follow up of ulceration right fifth toe. Resident states that the toe hurts. " Objective: The right fifth toe appears swollen. T… | 2014-04-01 | ||
| 2145 | 2145 | APPLEWOOD CENTER | 305065 | 8 SNOW ROAD | WINCHESTER | NH | 3470 | 2010-12-13 | 490 | G | 0NGB11 | Based on the investigation survey conducted 12/1310 it was determined that the facility was not administered in a manner that enables it to provide the highest practicable physical and psychosocial well-being of each resident. Findings include: As a result of the investigation survey it was determined that the facility has immediate jeopardy with substandard quality of care being identified in the area of resident behavior and facility practices 42 CFR 483.13(c) and in the areas of quality of care 42 CFR 483.25 and 42 CFR 483.25(c) Cross refer to F224, F309 and F314. | 2014-04-01 | ||
| 873 | 873 | AURORA SENIOR LIVING OF DERRY, LLC | 305095 | 20 CHESTER ROAD | DERRY | NH | 3038 | 2016-06-16 | 309 | D | 0 | 1 | EV6B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to have a coordinated hospice plan of care which included the care and services the facility and hospice would provide in order to be responsive to the needs of the resident for 2 of 5 hospice residents in a survey sample of 15. (Resident identifiers are #1 and #10.) Findings include: Review on 6/15/16 and 6/16/16 of Resident #1 and #10's current facility hospice care plans revealed the following interventions: Assess (resident's name omitted) coping strategies and respect (pronoun omitted) wishes. Encourage (resident's name omitted), as (pronoun omitted) is able, to express feelings, listen with non-judgmental acceptance, [MEDICATION NAME]. These were the only interventions listed for what the facility and hospice were going to provide these two residents in regards to hospice services. The plan of care did not include the frequency and types of services provided by the hospice agency for the skilled nurse, licensed nursing assistant, social worker, spiritual and volunteer staff nor were the care plan interventions individualized. Interview on 6/16/16 at 10:30 a.m. with Staff A (Director of Nurses) in which the above findings were reviewed, Staff A confirmed that the care plans did not include interventions from hospice nor did they include the frequency of services provided. Staff A also confirmed that currently documentation of what occurs during each hospice visit is provided to the facility approximately 2 days after the visit. | 2019-03-01 |
| 1051 | 1051 | AURORA SENIOR LIVING OF DERRY, LLC | 305095 | 20 CHESTER ROAD | DERRY | NH | 3038 | 2015-04-16 | 281 | D | 0 | 1 | MSZZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to meet professional standards of quality for 2 out of a sample of 15 residents. (Resident identifiers are #3 and #5). Findings include: The Potter-Perry, 2009, Review of Fundamentals of Nursing, Patricia A. Potter and Anne Griffin Perry, Mosby, St. Louis, Missouri, 2009, 7th Edition, revealed the following, Chapter 23 Legal Implications in Nursing Practice, on page 336- Physicians' Orders states, The physician is responsible for directing medical treatment. Nurses follow physician's orders [REDACTED]. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 7th Edition, St. Louis, Missouri: Mosby Elsevier, 2009, on page 699 relates Prescribers must document the diagnosis, condition, or need for use for each medication ordered and on page 708 The prescriber often gives specific instructions about when to administer a medication Resident #3: Record review revealed PRN (as needed) orders dated for April of 2015 as follows: [MEDICATION NAME] PO (Tylenol Oral tab) Give 650 by mouth every 4 hours as needed (PRN) pain/fever. [MEDICATION NAME] HCL tablet 50 mg; Give 50 mg by mouth every 6 hours as needed for pain. Resident #5: Record review revealed PRN (as needed) orders dated for April 2015 as follows: [MEDICATION NAME] PO (by mouth) 650 mg; Take 650 mg by mouth every 4 hours as needed for pain/fever. [MEDICATION NAME]-[MEDICATION NAME] tablet 5-325mg; Give 1 tablet by mouth every 4 hours as needed for pain. There are no parameters or indications for when to give each of these medications, or any record of attempt to clarify the orders. In addition, Resident #5 has the following transcription error in her Medication Administration Record: [REDACTED] [MEDICATION NAME] Gel 1mg % GEL; give 1 ml by mouth (PO) at bedtim… | 2018-05-01 |
| 1052 | 1052 | AURORA SENIOR LIVING OF DERRY, LLC | 305095 | 20 CHESTER ROAD | DERRY | NH | 3038 | 2015-04-16 | 282 | D | 0 | 1 | MSZZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that the facility failed to properly implement the resident care plan for 1 out of 15 residents. (Resident identifier #3). Findings include: Resident #3: A complaint was received regarding a fall with a fracture that occurred on 3/1/15 while Staff B (LNA) was providing a bed bath and personal care for Resident #3. Record review and interviews revealed the following: Written statement from Staff B (LNA) stated the following: As I was cleaning up (Resident #3), (the resident's) sheets were soiled and I pulled her close to me with the soaker pad underneath her and I had her roll to her left and hold onto the bar as I proceeded to take the sheets off, (Resident #3) moved her feet and she slipped off the bed, I jumped on the bed to grab her and bring her to the floor. Interview with Staff B (LNA) and with Staff A (DON) on 4/15/15 at approximately 1:15 pm revealed that Resident #3 had right sided [MEDICAL CONDITION] from a [MEDICAL CONDITION](stroke/[MEDICAL CONDITION]) she is overweight, deconditioned due to being bed ridden, and has severe [MEDICAL CONDITION] bone disease and [MEDICAL CONDITION]. Staff B stated when questioned, that Resident #3's leg slid over the side of the bed as Staff B was positioning her toward the opposite side of the bed from where Staff B was standing. Resident #3 then began to slide off the bed. This is when Staff B jumped on the bed and held the resident under her arms to lower her to the floor. Staff B stated that Resident #3's leg was rotated inward as she was sliding to the floor. Care plan concerning ADL care and assistance states: F(NAME)US: (Resident #3) has an ADL Self Care Performance Deficit r/t (related to)[MEDICAL CONDITION] right [MEDICAL CONDITION]. Right Femur fracture 3/3/15 .Target date: 7/5/15 . Interventions . Three staff to assist with all care (except eating). Date Initiated 3/6/15 Bed Mobility: She usually requires extensive assist to repositio… | 2018-05-01 |
| 1053 | 1053 | AURORA SENIOR LIVING OF DERRY, LLC | 305095 | 20 CHESTER ROAD | DERRY | NH | 3038 | 2015-04-16 | 323 | G | 0 | 1 | MSZZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to ensure that each resident recieves adequate supervision/assistance/assistive devices to prevent accidents from happening for 1 of a survey sample of 15 residents resulting in a fracture. (Resident identifier #3). Findings include: Resident #3: A complaint was received regarding a fall with a fracture that occurred on 3/1/15 while Staff B (LNA) was providing a bed bath and personal care for Resident #3. Record review and interviews revealed the following: Written statement from Staff B (LNA) stated the following: As I was cleaning up (Resident #3), (the resident's) sheets were soiled and I pulled her close to me with the soaker pad underneath her and I had her roll to her left and hold onto the bar as I proceeded to take the sheet off, (Resident #3) moved her feet and she slipped off the bed, I jumped on the bed to grab her and bring her to the floor. Interview with Staff B (LNA) and with Staff A (DON) on 4/15/15 at approximately 1:15 pm revealed that Resident #3 had right sided hemiparesis from a CVA (stroke/cerebrovascular accident), she is overweight, deconditioned due to being bed ridden, and has severe degenerative bone disease and osteoporosis. Staff B stated when questioned, that Resident #3's leg slid over the side of the bed as Staff B was positioning her toward the opposite side of the bed from where Staff B was standing. Resident #3 then began to slide off the bed. This is when Staff B jumped on the bed and held the resident under her arms to lower her to the floor. Staff B stated that Resident #3's leg was rotated inward as she was sliding to the floor. Care plan concerning ADL care and assistance states: F(NAME)US: (Resident #3) has an ADL Self Care Performance Deficit r/t (related to) CVA with right hemiparesis. Right Femur fracture 3/3/15 .Target date: 7/5/15 . Interventions . Three staff to assist with all care (except eating). Date Initiated 3/… | 2018-05-01 |
| 1054 | 1054 | AURORA SENIOR LIVING OF DERRY, LLC | 305095 | 20 CHESTER ROAD | DERRY | NH | 3038 | 2015-04-16 | 425 | D | 0 | 1 | MSZZ11 | Based on observation and the facility policy and procedure for Disposal/Destruction of Expired or Discontinued Medications it was determined that the facility failed to discard medications in a safe manner. Findings include: Review of the facility policy and procedure for the Disposal/Destruction of Expired or Discontinued Medications revealed the following: . 13. Wasted medications are defined as medications contaminated or refused that require disposal. Facility should not place wasted medications back in their original containers . 13.2 Wasted single doses of medications for disposal should be disposed of in a manner that limits access to them by unauthorized personnel or residents. 13.3 Wasted single doses of medications may be flushed or placed in public sewage only if permitted by applicable law . Observation during a medication pass on 4/15/15 at approximately 9:00 a.m. with Staff E (LMNA) revealed a labeled bottle of 100 tablets of Acetaminophen with no visible expiration date on the bottle. Staff E identified this opened Acetaminophen bottle as still containing a numerous amount of tablets with no expiration date on the label and proceeded to discard this bottle into the open trash container attached to the medication cart which can be easily accessible by any individual. | 2018-05-01 |
| 1055 | 1055 | AURORA SENIOR LIVING OF DERRY, LLC | 305095 | 20 CHESTER ROAD | DERRY | NH | 3038 | 2015-04-16 | 441 | D | 0 | 1 | MSZZ11 | Based on observation it was determined that the facility failed to implement hand hygiene to reduce the spread of infections and prevent cross-contamination. Observation during a medication pass on 4/15/15 at approximately 9:00 a.m. with Staff E (LMNA) revealed no handwashing or use of hand sanitizer (that was located on the medication cart), was performed by Staff E during the administration of multiple routes (by mouth, nasal spray and eye drops) of medications to multiple residents. Staff E failed to perform hand washing before, during, after the preparation and administration of medications to multiple residents and after direct resident contact during this medication observation. During interview with Staff A (DON) on 4/16/15, Staff A verbalized that the facility was aware of the noncompliance with handwashing performed by Staff E identified during a facility mock survey in February 2015. Staff E was inserviced and audits were completed with Staff E for this noncompliance with hand hygiene protocol at that time in February. | 2018-05-01 |
| 1056 | 1056 | AURORA SENIOR LIVING OF DERRY, LLC | 305095 | 20 CHESTER ROAD | DERRY | NH | 3038 | 2015-04-16 | 456 | E | 0 | 1 | MSZZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of the manufacturer's instructions the facility failed to maintain the facility [MEDICATION NAME] and the glucometer testing solutions and test strips in a safe operating condition. Findings include Review of the manufacturer's Clinical practice Guidelines for the facility Chattanooga [MEDICATION NAME] revealed the following; . [MEDICATION NAME] Unit Maintenance . The unit should be cleaned every 2 weeks . Recommended Operating Temperatures . The recommended unit-operating temperature is 150-170 degrees F. Note: For Chattanooga units, recommended operating temperature is 160-165 degrees F. Review of the manufacturer's User Manual for the facility Chattanooga [MEDICATION NAME] revealed the following: . MAINTENANCE The tank should also be drained and cleaned systematically at minimum intervals of every two weeks. Regularly clean and drain the tank (every two weeks). Failure to properly maintain the unit will cause premature wear and will void the warranty . Cleaning Tips 1. The interior of the unit should be cleaned, at least every two weeks, using low abrasive bathroom cleaner with a soft cloth or green, blue or white Scotch-Brite type scouring pad. Stainless steel wool may be used if necessary, but not regular carbon steel wool. Check for low or no chlorine content in your cleaner and make sure the residue is thoroughly rinsed away with water. 2. A strong solution of vinegar and water may be used to dissolve away deposits, which then must be thoroughly rinsed away . Observation on 4/15/15 in the rehabilitation room revealed a Chattanooga [MEDICATION NAME] facility unit. At this time review of the facility [MEDICATION NAME] packs Temperature Check and Cleaning Schedule for April 2015 revealed that the temperatures for this unit were documented 160 to 168 degrees. The top of this log indicated a range of 150 to 170 degrees. Review of the March 2015 log revealed temperatures of 165 degrees to 168 degree… | 2018-05-01 |
| 1229 | 1229 | AURORA SENIOR LIVING OF DERRY, LLC | 305095 | 20 CHESTER ROAD | DERRY | NH | 3038 | 2014-04-03 | 281 | E | 0 | 1 | 2BLT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to follow professional standards for the process of insulin administration for diabetic residents and for the actual administration of insulin administration for 1 resident in a survey sample of 15 residents. (Resident identifier is #11.) Findings include: Policies: Review of the facility Nursing practice Manual under Medication, Administration of, dated July 2012, revealed the following: 5. Medication passes must be started no more than one (1) hour before, and completed no more than (1) hour after the scheduled time. 8. Medication cart is to be kept locked at all times unless in use and within nurse/nursing assistant sight. Medications are not to be left on top of an unattended medication cart. 11. MEDICATION is to be checked against the medication administration record (MAR) for Dosage, time, route, medication and resident before preparing, after preparing and prior to administration. 14. When a medication is administered, the dose is to be initiated (sic) on the MAR immediately after administration, not before. Review of the Pharmacy Services procedure manual used by the facility and revised 1/1/13 revealed under General Dose Preparation and Medication Administration the following: 3 3.9 Facility staff should not leave medications or chemicals unattended. 5.5.4 Administer medications within the timeframes specified by Facility policy. 5 5.6 Observe each resident's privacy and rights .(e.g pulling privacy curtains.) 7. Facility should ensure that medication carts are always locked when out of sight of unattended. Standards: Review of Fundamentals of Nursing, Patricia A. Potter and Anne Griffin Perry, Mosby, St. Louis, Missouri, 2009, 7th Edition, revealed the following: On page 336- Physicians' Orders states, The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefo… | 2017-05-01 |
| 1230 | 1230 | AURORA SENIOR LIVING OF DERRY, LLC | 305095 | 20 CHESTER ROAD | DERRY | NH | 3038 | 2014-04-03 | 323 | E | 0 | 1 | 2BLT11 | Based on observations and interviews the facility failed to ensure that the resident's environment remained free of accident hazards and failed to ensure that residents received adequate supervision to prevent accidents and in particular 1 resident in a survey sample of 15 residents. (Resident identifier is #11.) Findings include: Observation on 4/1/14 at approx. 11:30 a.m. revealed an unlocked uncovered three tiered cart in the hallway with 2 boxes of lancets on the top shelf, bleach wipes, alcohol wipes and a glucometer and an unlocked sharps container. Staff D (LNA) was seen standing by the cart in the process of checking blood sugars. In an interview at the time of the observation Staff D stated that this was how they checked blood sugars each shift. Staff D stated that she was the LNA that usually did blood sugar checks during the day using this cart. Continued observation revealed that Staff D left the cart unattended in the hallway and checked a resident's (Resident #11) blood sugar. Staff D had her back to the cart during the time she was in this resident's room. The cart was completely out of Staff D's line of sight during the blood sugar check. In an Interview with Staff A (DON ) at the time of the 4/1/14 observation Staff A stated that the cart should not have been left unattended. Observation on 4/1/14 at 1 p.m. revealed an unlocked uncovered three tiered cart with 28 bottles of insulin on the top shelf, several loose syringes and a sharps container in the hallway. Staff B (RN/Charge Nurse) was seen standing by the cart in the process of giving out insulin's. In an interview at the time of the observation Staff B stated that this was how they administered their insulin's using this cart. Continued observation revealed that Staff B left the cart unattended in the hallway and administered Resident #11 a dose of insulin. Staff B had her back to the insulin cart during the administration of the insulin. Staff B did not pull the privacy curtain. The was no MAR on the cart. In an interview following the adm… | 2017-05-01 |
| 1231 | 1231 | AURORA SENIOR LIVING OF DERRY, LLC | 305095 | 20 CHESTER ROAD | DERRY | NH | 3038 | 2014-04-03 | 431 | E | 0 | 1 | 2BLT11 | Based on observations and interviews the facility failed to ensure that drugs and biological's were accurately dispensed and administered and that the same were securely stored. Findings include: Observation on 4/1/14 at approx. 11:30 a.m. revealed an unlocked uncovered three tiered cart in the hallway with 2 boxes of lancets on the top shelf, bleach wipes, alcohol wipes and a glucometer and an unlocked sharps container. In an interview at the time of the observation Staff D (LNA) stated that this was how they checked blood sugars each shift and the lancets and sharps were not kept locked during this time. Staff D stated that she was the LNA that usually did blood sugar checks during the day using this unlocked cart. Continued observation revealed that Staff D left the cart unattended in the hallway and checked a resident's blood sugar. Staff D had her back to the cart during the time she was in this resident's room. The cart was completely out of Staff D's line of sight during the blood sugar check. In an Interview with Staff A (DON ) at the time of the 4/1/14 observation Staff A stated that the cart should not have been left unattended. Observation on 4/1/14 at 1 p.m. revealed an unlocked uncovered three tiered cart with 28 bottles of insulin on the top shelf, several loose syringes and a sharps container in the hallway. Staff B (RN/Charge Nurse) was seen standing by the cart in the process of giving out insulin's. In an interview at the time of the observation Staff B stated that this was how they administered their insulin's using this unlocked cart. Continued observation revealed that Staff B left the cart unattended in the hallway and administered one resident dose of insulin. Staff B had her back to the insulin cart during the administration of the insulin. Staff B did not pull the privacy curtain. The cart was completely out of Staff B's line of sight during the administration of insulin. Observation at 1:15 p.m. revealed that Staff B left all of the insulin bottles unlocked and unattended in baskets at t… | 2017-05-01 |
| 1445 | 1445 | AURORA SENIOR LIVING OF DERRY, LLC | 305095 | 20 CHESTER ROAD | DERRY | NH | 3038 | 2013-03-07 | 282 | D | 0 | 1 | 919Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow the plan of care and implement interventions to reduce hazards and risks for prevention of accidents for 1 resident in a survey sample of 15 residents. (Resident Identifier is #12) Findings include: During the initial tour of the facility with Staff B (RN Day Supervisor) on 3/5/13 at approximately 9:30 a.m. it was observed that the name plate on the door of the room had a colored star next to the name of Resident #12. During interview with Staff B, Staff B stated the star is part of the facility Fall Risk program and indicates the resident is at risk for falls. When entering the room, it was observed by the surveyor and Staff B that the bed for Resident #12 was in a high position with the resident in the bed without any staff presence in the room and Resident #12 was kicking down the sheets with (pronoun omitted) legs. Staff B during interview, confirmed the bed was in a high position and using the electronic control lowered the bed to the low position. Staff B confirmed that Staff C (LNA) was assigned care for Resident #12. Staff C stated that they were the 7-3 LNA assigned to care for Resident #12. Staff C stated that they fed Resident #12 breakfast that morning and after finishing breakfast they had left the resident room without returning bed to lower position. Staff C stated they didn't realize the bed was that high. During interview with Staff E, (RN Staff Development Coordinator), Staff E revealed that they interviewed Staff D (LNA) who had provided morning care for Resident #12 on 11- 7 shift. Staff E further revealed that during the investigation with Staff D, they had admitted to providing care to Resident #12 that morning and forgot to lower the bed after being pulled away to assist another resident. Review of the punch detail for Staff D on 3/15/13 revealed that Staff D punched out of work at 7:19 a.m. During review of the medical record for Resident… | 2016-07-01 |
| 1446 | 1446 | AURORA SENIOR LIVING OF DERRY, LLC | 305095 | 20 CHESTER ROAD | DERRY | NH | 3038 | 2013-03-07 | 323 | D | 0 | 1 | 919Z11 | Based on observation, interview, and record review, the facility failed to follow the plan of care and implement interventions to reduce hazards and risks for prevention of accidents for 1 resident in a survey sample of 15 residents. (Resident Identifier is #12) Findings include: During the initial tour of the facility with Staff B (RN Day Supervisor) on 3/5/13 at approximately 9:30 a.m. it was observed that the name plate on the door of the room had a colored star next to the name of Resident #12. During interview with Staff B, Staff B stated the star is part of the facility Fall Risk program and indicates the resident is at risk for falls. When entering the room, it was observed by the surveyor and Staff B that the bed for Resident #12 was in a high position with the resident in the bed without any staff presence in the room and Resident #12 was kicking down the sheets with (pronoun omitted) legs. Staff B during interview, confirmed the bed was in a high position and using the electronic control lowered the bed to the low position. Staff B confirmed that Staff C (LNA) was assigned care for Resident #12. Staff C stated that they had fed Resident #12 breakfast that morning and after finishing breakfast they had left the resident room without returning bed to the lower position. Staff C stated they did not realize the bed was that high. During interview with Staff E, (RN Staff Development Coordinator), Staff E revealed that they interviewed Staff D (LNA) who had provided morning care for Resident #12 on the 11- 7 shift. Staff E further revealed that during the investigation with Staff D, they had admitted to providing care to Resident #12 that morning and forgot to lower the bed after being pulled away to assist another resident. Review of the punch detail for Staff D on 3/15/13 revealed that Staff D punched out of work at 7:19 a.m. During review of the medical record for Resident #12 the following information was revealed in the CAA Worksheet with an ARD of 11/7/12: (Name omitted) has impaired balance and a previ… | 2016-07-01 |
| 1447 | 1447 | AURORA SENIOR LIVING OF DERRY, LLC | 305095 | 20 CHESTER ROAD | DERRY | NH | 3038 | 2013-03-07 | 333 | D | 0 | 1 | 919Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow physician orders [REDACTED]. (Resident identifier is #16.) Findings include: During the medication pass observation on 3/6/13 at approximately 8:15 a.m., Staff A, (MNA) was preparing for administration of medications for Resident #16. The electronic MAR indicated [REDACTED]. Staff A was unable to locate the medication in the medication cart and then proceeded to access the medication from the Emergency back-up kit in the medication room at the nursing station. Staff A removed one dose of [MEDICATION NAME] 25 mg Oral Dose from the E-kit. Staff A, then returned to the medication cart and placed the whole pill in a medicine cup with several other medications that Staff A had poured for Resident #16. Staff A then proceeded to separate the medications into two separate medications cups. Staff A explained to the surveyor that Staff A was going to crush the medications in the cup containing the 25 mg dos of [MEDICATION NAME] together and administer to the resident with applesauce. The surveyor questioned Staff A and inquired if they were now going to crush the medications together in the cup (with the [MEDICATION NAME] 25 mg po) and administer them to Resident #16. Staff A confirmed with the answer yes. The surveyor again questioned Staff A again and inquired if they were now going to crush the medications together in the cup with the ([MEDICATION NAME] 25 mg po) and administer them to Resident #16. Staff A confirmed again with the answer yes. The surveyor stated to Staff A to suspend the attempt to crush the medications together and that the dosage of the [MEDICATION NAME] Staff A was about to administer to Resident #16 was 25 mg and not the 12.5 mg as listed in the electronic MAR. Staff A confirmed during interview that the dosage of the medication taken from the E-kit was actually 25 mg as stated by the surveyor and not 12.5 mg as ordered. Staff A then removed the [… | 2016-07-01 |
| 1775 | 1775 | AURORA SENIOR LIVING OF DERRY, LLC | 305095 | 20 CHESTER ROAD | DERRY | NH | 3038 | 2012-02-02 | 253 | D | 0 | 1 | 8FSG11 | Based on observation and interview, the facility failed to ensure that resident equipment was clean and properly stored in 1 of 2 Clean Utility rooms. Findings include: During tour of the Clean Utility Room located on the West Wing on 2/1/12 with Staff C (DON), it was observed that clean supplies were on the floor and dirty equipment was stored with clean equipment. These findings are as follows: 1. Several unopened boxes of patient care supplies were stacked on the floor. 2. Vinyl covered mattress lying on its side making direct contact with the floor. 3. 3 oxygen concentrators were observed, 1 had been cleaned and covered with plastic and ready for patient use, 2 were uncovered and uncleaned and should not have been stored in the Clean Utility room. 4. Several visibly uncleaned wheelchairs that should not have been stored within the Clean Utility room. Staff C stated during the tour that "dirty equipment should not be stored with clean equipment" and that "no equipment or supplies should be on the floor. " | 2015-05-01 |
| 1776 | 1776 | AURORA SENIOR LIVING OF DERRY, LLC | 305095 | 20 CHESTER ROAD | DERRY | NH | 3038 | 2012-02-02 | 371 | D | 0 | 1 | 8FSG11 | Based on observation and interview during the initial kitchen tour the facility failed to ensure proper hand hygiene during use of automatic dishwasher. The facility also failed to ensure proper hand hygiene by having alcohol based hand rub dispensers within the food service area. Findings include: During the initial kitchen tour on 1/31/12 at approximately 10 a.m., Staff A (Diet Aide) was observed scraping off dirty plates and dishes and loading them into the automatic dishwasher. Staff A was then observed handling the sanitized dishes without first washing hands. At the time of the above finding, Staff A stated that proper hand washing had not occurred between handling dirty dishes and clean dishes. Also at the time of the initial kitchen tour, it was observed that alcohol based hand rub dispensers were located throughout the food service areas. Alcohol based hand rub should not be utilized in the food service areas as it does not ensure proper hand hygiene. Staff B (Food Service Director) stated on the afternoon of 1/31/12 that the dispenser had been removed. | 2015-05-01 |
| 2163 | 2163 | AURORA SENIOR LIVING OF DERRY, LLC | 305095 | 20 CHESTER ROAD | DERRY | NH | 3038 | 2011-02-17 | 252 | E | E84811 | Based on observation and interview it was determined that the facility failed to maintain a safe and homelike environment in which doors were in good repair for 19 out of 40 doors and ceilings that were free of water stains for one resident room and two areas in the hallway. Findings include: Observation on 2/16/11 and 2/17/11 revealed scrapped and chipped wood on the side of the door which faces the hallway for resident bedrooms at the level that a wheelchair would hit the door on the following doors: Rooms #1, #2, #3, #5, #7, #9, #11, #15, #16, #19, #20, #25, #28, #29, #30, #31 and #32. It was also observed that there were scrapped and chipped wood on the side of the door which faces the hallway for the 2 resident shower rooms. Interview on 2/16/11 in the morning with Staff A (Administrator) reviewed the scrapes and chips on room #29's resident bedroom door. Staff A agreed that a plastic covering, which they had put over that area which was scrapped and chipped on the dirty utility door, could be put over the same area on room #29. Observation on 2/17/11 revealed water stains on the ceiling in the following areas: 1. Room #17 had 2 water stains on the ceiling near the outside wall of the room to the right had side of the window. 2. In the west hallway there were 4 ceiling tiles between the clean utility room and the shower room. 3. In the west hallway there was 1 ceiling tile at the air vent between Rooms #21 and #28. Interview on 2/17/11 at 2:45 p.m. with Staff A revealed there had been no accidents from the scrapped and chipped wood on the doors. Staff A explained that maintenance works on repairing these areas on the doors especially at rooms #29 and #16 which are damaged due to the electric wheelchairs. Staff A explained that maintenance had worked on these damaged doors in January, but that these areas continue to be an issue. Staff A had explained to the surveyors during the survey that there had been damage to the ceilings in a couple of areas due to dripping water from ice and snow build up on the roof … | 2014-04-01 | ||
| 2164 | 2164 | AURORA SENIOR LIVING OF DERRY, LLC | 305095 | 20 CHESTER ROAD | DERRY | NH | 3038 | 2011-02-17 | 371 | F | E84811 | Based on observation, record review and interview the Facility failed to ensure that the high temperature automatic dishwashing (ADW) machine was operating at the correct temperature during the rinse cycle to properly sanitize the dishes and failed to ensure that the back-up low temperature/bleach system was monitored properly. Findings include: On 2/15/1l at approximately 9:45 a.m. during the initial tour of the kitchen the high temperature dish machine was observed to reach a maximum rinse temperature of 143 degrees F. (Fahrenheit). This information was shared with Staff A, Administrator. A few minutes later, Staff A returned and informed this surveyor that he had achieved a rinse temperature above 180 degrees F.. We immediately returned to the dishwashing area finding the ADW to be in its wash cycle. During the following rinse cycle the ADW reached a maximum temperature of 175 degrees F.. According to the manufacturers specifications, as delineated in the instruction manual for this ADW machine, the target temperature to ensure proper sanitation is 180 degrees F.. At this point Staff A was informed that the sanitation temperature was not appropriate and that they should consider serving lunch on paper products until such time as the sanitation issues were addressed. On interview, 2/15/11, in the morning, with Staff A it was noted that the ADW machine had a bleach sanitizing system in place which operated concurrently with the high temp dishwasher in an attempt to alleviate sanitation concerns in the event that the rinse temperature fell below minimum standards. On 2/15/11, Staff A, Administrator was asked if they could accurately test the parts per million (ppm) of the bleach solution given the higher operating temperatures with the ADW set as a high temperature machine. Staff A stated that the ppm could not be accurately tested at the higher temperatures. On 2/15/11, early afternoon, this was confirmed by the chemical sanitizing solution supplier who stated that above 170 degrees Fahrenheit some of the bleach… | 2014-04-01 | ||
| 2165 | 2165 | AURORA SENIOR LIVING OF DERRY, LLC | 305095 | 20 CHESTER ROAD | DERRY | NH | 3038 | 2011-02-17 | 280 | D | E84811 | Based on record review and interview the facility failed to update the care plan for 1 resident in a standard survey sample of 15 residents. (Resident identifier is #12.) Findings include: Resident #12. Record review on 2/17/11 of the Hospice care plan dated "6/1/10" for Resident #12 revealed in the section titled "PROBLEM" the following: - "Alteration in comfort - Alteration in nutrition and/or hydration, dysphagia - Actual potential alterations in ADL needs - Alteration with coping - Grieving - Social isolation - Alteration in spiritual comfort - Alteration in safety." The above listed Hospice care plan for Resident #12 revealed a review date of "11/15/10" for the "PROBLEM" areas listed. Review of the facility contracted "HOSPICE CERTIFICATION AND PLAN OF CARE" for Resident #12 revealed a recertification period of "12/22/2010 TO 02/19/2011". During interview with Staff C (Registered Nurse) on 2/17/11 at approximately 11:45 a.m. Staff C reviewed the above listed Hospice care plan for Resident #12 and confirmed that the contracted hospice recertification period was "12/22/2010 TO 02/19/2011". Staff C confirmed that the Hospice care plan for Resident #12 had not been updated since "11/15/10". | 2014-04-01 | ||
| 2166 | 2166 | AURORA SENIOR LIVING OF DERRY, LLC | 305095 | 20 CHESTER ROAD | DERRY | NH | 3038 | 2011-02-17 | 281 | D | E84811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility policy and procedure and interview it was determined that the facility failed to follow the professional standard of practice for the administration of medication for 1 resident in a standard survey sample of 15 residents. (Resident identifier is #13.) Findings include: Review of the facility policy and procedure titled "Pain Assessment and Management" dated "1/26/00" revealed the following: - "Procedure: ... - Intensity (use pain scale 0 - 10 for resident who can verbalize, pain behavior for those who are cognitively impaired; and those who are nonverbal use the Wong-Baker Faces Pain Rating Scale.) - When planning care for resident be sure to: - Orient resident/significant other to pain management program, teach use of Pain Scale - Set goal for pain relief with resident/significant other, - Document effectiveness of pain relief measures..." Reference for the professional standard of practice is "Fundamentals of Nursing, 7th EDITION, POTTER-PERRY, MOSBY, ELSEVIER, EVOLVE, 2009", pages "1063 - 1083" shows the following: - " Intensity. One of the most subjective and therefore most useful characteristics for the reporting of pain is its severity, or intensity. A variety of pain scales are available for clients to communicate their pain intensity. Examples of pain intensity scales include the verbal descriptor scale (VDS), the numerical rating scale (NRS), and the visual analog scale (VAS). When using the NRS a report of 0 to 3 indicates mild pain, 4 to 6 moderate pain, and 7 to 10 severe pain, considered a pain emergency. These scales work best when assessing pain intensity before and after therapeutic interventions... In addition to the current pain level, also ask what rating to give the average pain and the worst pain over the past 24 hours... - Evaluation of pain is one of many nursing responsibilities that require effective critical thinking. The client's behavioral responses to pain-relief int… | 2014-04-01 | ||
| 2167 | 2167 | AURORA SENIOR LIVING OF DERRY, LLC | 305095 | 20 CHESTER ROAD | DERRY | NH | 3038 | 2011-02-17 | 253 | B | E84811 | Based on observation and interview it was determined that the facility failed to maintain an environment in good repair in which doors were in good repair for 19 out of 40 doors and ceilings were free of water stains for one resident room and two areas in the hallway. Findings include: Observation on 2/16/11 and 2/17/11 revealed scraped and chipped wood on the side of the door which faces the hallway for resident bedrooms for the lower third of the door on the following doors: Rooms #1, #2, #3, #5, #7, #9, #11, #15, #16, #19, #20, #25, #28, #29, #30, #31 and #32. It was also observed that there was scraped and chipped wood on the side of the door which faces the hallway for the 2 resident shower rooms. Interview on 2/16/11 in the morning with Staff A (Administrator) reviewed the scrapes and chips on room #29's resident bedroom door. Staff A agreed that a plastic covering, which they had put over an area which was scraped and chipped on the dirty utility door, could be put over the same area on room #29. Observation on 2/17/11 revealed water stains on the ceiling in the following areas: 1. Room #17 had 2 water stains on the ceiling near the outside wall of the room to the right hand side of the window. 2. In the west hallway there were 4 stained ceiling tiles between the clean utility room and the shower room. 3. In the west hallway there was 1 stained ceiling tile at the air vent between Rooms #21 and #28. Interview on 2/17/11 at 2:45 p.m. with Staff A revealed there had been no accidents from the scraped and chipped wood on the doors. Staff A explained that maintenance works on repairing these areas on the doors especially at rooms #29 and #16 which are damaged due to the electric wheelchairs. Staff A explained that maintenance had worked on these damaged doors in January, but that these areas continue to be an issue. Staff A had explained to the surveyors during the survey that there had been damage to the ceilings in a couple of areas due to dripping water from ice and snow build up on the roof this winter. St… | 2014-04-01 | ||
| 342 | 342 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2019-01-08 | 580 | D | 0 | 1 | ZVIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to notify the resident's physician of a weight change for 1 of 1 resident with an orders to notify physician of weight changes in a final survey sample size of 34 (Resident identifier #295.) Findings include: Review on 1/7/19 of Resident #295's physician orders [REDACTED].>3 lbs (greater than 3 pounds) or more. Review on 1/7/19 of Resident #295's weight record revealed that on Wednesday 12/26/18 the resident's weight was documented as 175 and on Thursday 12/27/18 the resident's weight was recorded as 180.4. The weight difference is a 5.4 pound gain. Review on 1/7/19 of Resident #295's progress notes from 12/26/18 to 1/1/19 revealed there was no documentation of a notification to Resident #295's provider of the 5.4 pound weight gain between 12/26/18 and 12/27/18. Interview on 1/8/19 at 9:07 a.m. with Staff D (Director of Nursing) confirmed the above weight change and that there was no documentation of the change to the provider. Interview also revealed that there was no documentation of a notification to the provider of the weight change elsewhere. | 2020-09-01 |
| 343 | 343 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2019-01-08 | 584 | B | 0 | 1 | ZVIF11 | Based on observation, interview and review of facility policy and procedure it was determined that the facility failed to maintain a clean environment for 1 resident of 1 resident with a tube feeding in a final sample of 34 residents. (Resident identifier is #36.) Findings include: Observation on 1/2/19 at approximately 7:00 p.m. of Resident #36's room revealed that the tube feed pole had a substance that was tan/beige in color adhered to the base of the pole and the pole. The substance appeared to be tube feeding. Observation on 1/3/19 at approximately 2:00 p.m. of Resident #36's room revealed that the tube feed pole had the same substance that was tan/beige in color adhered to both the base of the pole and the pole. The substance appeared to be tube feeding. Observation on 1/4/19 at approximately 10:45 a.m. of Resident #36's room revealed that the tube feed pole had the same substance that was tan/beige in color adhered to both the base of the pole and the pole. The substance appeared to be tube feeding. Interview on 1/4/19 at approximately 11:00 a.m. with Staff [NAME] (Unit Manager) revealed that Staff [NAME] had been notified today of the dried tube feeding adhered to the pole. Staff [NAME] confirmed that the tube feed pole and base of the pole had dried tube feeding adhered to it. Staff [NAME] revealed that stationary patient equipment that is kept in a patient's room is cleaned as needed, weekly or when tubing is changed. Review on 1/4/19 of the facility policy and procedure titled, IC201 Cleaning and Disinfecting, revision date 7/24/18 revealed: .Purpose . To ensure reusable medical equipment is cleaned and disinfected appropriately. Practice Standards .5. Perform routine disinfection of items used in daily care practices with Environmental Protection Agency . | 2020-09-01 |
| 344 | 344 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2019-01-08 | 610 | D | 1 | 1 | ZVIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, it was determined that the facility failed to thoroughly investigate a bruise and a skin tear for 1 resident and to perform observations and education after a medication error for 1 resident in a final survey sample of 42 residents. (Resident identifiers are #62 and #70.) Resident #62 Review on 1/3/19 of the Facility Report to the Long Term Care Ombudsman . dated 11/13/18, revealed that Resident #62 received Levetiracetam, in error, instead of [MEDICATION NAME] on 11/4/18. The report also revealed that the facility planned to do a medication pass observation/education with the nurse who had made the error. Interview on 1/8/19 at approximately 2:00 p.m. with Staff G (Administrator) revealed that there was no documented evidence that a medication pass observation or education was done with the nurse who had made the medication error. Resident #70 Observation on 1/3/19 at approximately 8:45 a.m. of Resident #70's anterior right wrist revealed a 3 cm. (Centimeter) x 2.5 cm bruise that was purple with a greenish color noted. Resident is noted to be a poor historian. Resident #70 is dependant on staff with all activities of daily living and is unable to self propel broda-wheelchair. Interview on 1/3/19 at approximately 8:50 a.m. with Staff [NAME] (Unit Manager) revealed by Staff [NAME] looking at Resident #70's right forearm that Resident #70 had a bruise. Staff [NAME] revealed that there was no investigation to how Resident #70 obtained the bruise. Resident #70 said, I did not know that bruise was there. Review on 1/8/19 at approximately 9:00 a.m. with Staff D (Director of Nurses) revealed that the anterior right wrist bruise was not investigated. Review on 1/8/19 of skin checks performed weekly by nursing (date range from 11/24/18 - 1/2/19) did not identify the bruise on Resident #70. Review on 1/7/19 of the RMS (Risk Management System) dated, 10/29/18 revealed that Resident #70 obtained a skin… | 2020-09-01 |
| 345 | 345 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2019-01-08 | 625 | B | 0 | 1 | ZVIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to provide the resident or resident's representative with written information about the bed hold policy in 2 of 4 residents reviewed with hospitalization s in a final survey sample of 34 residents. (Resident identifiers #27, and #295.) Findings include: Resident #295 Interview on 1/4/19 at approximately 1 p.m. with Staff B (Unit Manager) revealed that Resident #295 was transferred to the hospital that morning for respiratory distress. Interview on 1/7/19 at 11:00 a.m. with the Staff K (Social Worker) revealed that social services notifies the ombudsman of a resident's transfer or discharge but does not give written information about the bed hold policy to the resident or their representative. Interview on 1/7/19 at 11:06 a.m. with Staff J (Business Office Manager) revealed that Staff J does not give written information about the bed hold policy to residents or their representative at time of transfer to the hospital. Staff J will follow up with a call after a few days if looks like the resident will not return quickly to see if they want to hold their bed. Resident #47 Review on 1/7/19 of Resident #47's nursing progress notes revealed that Resident #47 was admitted to an acute care hospital on [DATE] and returned to the facility on [DATE]. There was no documented evidence that Resident #47 or their representative was offered a bed hold. Interview on 1/8/19 at approximately 12:30 p.m. with Staff I (Social Service Director) confirmed that there was no documented evidence that a bed hold was discussed with Resident #47 or their representative. | 2020-09-01 |
| 346 | 346 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2019-01-08 | 655 | D | 0 | 1 | ZVIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to develop a baseline care plan for [MEDICAL TREATMENT] and a care plan for the use of antipsychotic medication for 2 residents in a final survey sample of 34 residents. (Resident identifiers are #47 and #142.) Findings include: Resident #47 Interview on 1/3/19 at approximately 9:45 a.m. with Resident #47 revealed that Resident #47 went to [MEDICAL TREATMENT] 3 times per week and that they were on a fluid restriction. Interview on 1/8/19 at approximately 10:00 a.m. with Staff B (Unit Manager) confirmed that Resident #47 did go to [MEDICAL TREATMENT] 3 times per week, was on a fluid restriction and that they had a central venous catheter for [MEDICAL TREATMENT] access. Review on 1/8/19 of the current care plan for Resident #47 revealed that there was no [MEDICAL TREATMENT] care plan, no documentation of the fluid restriction on the care plan and no documentation on the care plan that Resident #47 had a central venous catheter. Interview on 1/8/19 at approximately 11:15 a.m. with Staff B confirmed that there was no care plan for [MEDICAL TREATMENT] for Resident #47 and that the fluid restriction and central venous catheter were not on the care plan. Staff B also confirmed that the current care plan should have included all of these areas. Resident #142 Review on 1/4/19 of Resident #142's (MONTH) 2019 Medication Administration Record [REDACTED]. Review on 1/7/19 of Resident #142's current care plan revealed that there was no care plan in place for the use of the antipsychotic medication or interventions for monitoring potential side effects of [MEDICATION NAME]. Interview on 1/7/19 at approximately 1:00 p.m. with Staff [NAME] (Unit Manager) confirmed that there was no care plan in place for Resident #142's use of antipsychotic medication and that there should have been a care plan in place. | 2020-09-01 |
| 347 | 347 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2019-01-08 | 658 | E | 0 | 1 | ZVIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed failed to follow professional standards of quality and clarify provider's orders for 1 of 1 residents with nephrostomy care, and 2 of 2 residents who receive [MEDICAL TREATMENT] care, in a final sample of 34 residents (Resident identifiers are #47, #128 and #140.) Findings include: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders. The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Review on 1/8/19 of Resident #128's physician orders [REDACTED]. There was no documentation of any other orders pertaining to dressing, nephrostomy site or skin care, and tube stabilization. Interview on 1/8/19 at 11:35 a.m. with Staff D (Director of Nursing) confirmed the above finding and revealed that the above order should be clarified to include dressing. Resident #140 Review on 1/7/19 at 11:24 a.m. of physician orders [REDACTED].#140 revealed an order for [REDACTED]. Interview on 1/7/19 at 12:10 p.m. with Staff B (Unit Manager) confirmed that Resident #140 goes to [MEDICAL TREATMENT] on Monday, Wednesday and Friday at 5:05 p.m. and revealed that Resident#140's family transports the resident and the resident takes a packed dinner to [MEDICAL TREATMENT] because they miss dinner. Interview also revealed that the physician had not been notified about the medications that are scheduled to be giving during [MEDICAL TREATMENT]. Interview also revealed that the resident does not receive the medications scheduled at the nursing home (NH) while at [MEDICAL TREATMENT]. Review on 1/7/19 of Resident #140's [MEDICAL TREATMENT] treatments revealed th… | 2020-09-01 |
| 348 | 348 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2019-01-08 | 689 | D | 0 | 1 | ZVIF11 | Based on observation and interview, it was determined that the facility failed to ensure that the environment remained free of accident hazards by using 2 space heaters in 1 resident room, on 1 unit out 4 units. (Resident identifiers are #29 and #39.) Findings include: Observation on 1/2/19 at approximately 7:15 p.m. of Resident #29 and Resident #39's room revealed 2 portable space heaters (1 on each side of the room) that were being used in their room. Interview on 1/2/19 at approximately 7:15 p.m. with Resident #29 revealed that the space heaters were provided to them a few weeks ago because the heating system was not working in their room. Resident #29 stated, They keep saying it will be fixed and all we do is wait. Interview on 1/2/19 at approximately 7:15 p.m. with Resident #39 confirmed what Resident #29 said about the heating system not working for the last few weeks. Interview on 1/2/19 at approximately 7:30 p.m. with Staff F (Registered Nurse) confirmed that the heat in that room has not been working for a few weeks. Interview on 1/2/19 at approximately 8:00 p.m. with Staff G (Administrator) revealed that there was no policy and procedure for the use of space heaters in the facility. | 2020-09-01 |
| 349 | 349 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2019-01-08 | 725 | E | 0 | 1 | ZVIF11 | Based on interview and review of the facility grievance log for the past year, it was determined that the facility failed to have sufficient staff available at all times in order to ensure residents safety and to attain or maintain the highest practicable physical, mental and psychosocial well being of the residents. Findings include: Interview on 1/3/19 at 1:00 p.m. with twenty-two residents representing three of the facility's four units revealed that a long term staffing shortage throughout (YEAR) and which according to residents remains ongoing was the resident's primary concern according to those who attended the resident's council meeting. Residents said that the shortage of staff becomes apparent when they ring their call lights requesting staff assistance. Residents reported that it often takes staff a half hour to an hour or longer to respond to their call lights. Also they stated that staff responding to call lights routinely say that they'll be right back to assist residents, but frequently never returned to provide the care and services that's essential to the resident's well being. Residents reported that they're tired of having to wait for long periods of time to be changed after having defecated or urinated in their adult diapers and clothing. Residents stated that because of the staff shortage they've filed grievances regarding missing their weekly baths or showers, having a catheter bag not being emptied in a timely manner, staff failing to get them up in time to attend activities or appointments and complained about going without receiving restorative assistance from LNA's (Licensing Nursing Assistant) who aren't available to aid them in ambulating. Residents said that during meals there's not enough staff to pass out the food and as a result cold food complaints have been made. Review of the resident's grievance log revealed that as early as (MONTH) of (YEAR) residents were complaining of poor staff responses to their call lights. Interview on 1/9/19 with Staff G (Administrator) she stated that… | 2020-09-01 |
| 350 | 350 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2019-01-08 | 755 | D | 1 | 1 | ZVIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, it was determined that the facility failed to maintain accurate narcotic records for 1 resident in final survey sample of 34 residents. (Resident identifier is #107.) Findings include: Review on 1/8/19 of the 'MEDICATION ADMINISTRATION RECORD (MAR) for Resident #107 dated 1/1/19 revealed a physician order [REDACTED]. Further review of this MAR showed no documentation on 1/3/19 to show that [MEDICATION NAME] 15 MG was given to Resident #107. Review on 1/8/19 of the Narcotic Book page #93 for Resident #107 revealed that one tablet of [MEDICATION NAME] 15 MG was given to Resident #107 on 1/3/19. Review on 1/8/19 of the Nurse Notes for Resident #107 revealed no documentation that [MEDICATION NAME] 15 MG was given to Resident #107 on 1/3/19. Interview on 1/8/19 with Staff C (Registered Nurse) confirmed that the Narcotic Book page #93 showed [MEDICATION NAME] 15 MG one tablet was given to Resident #107 on 1/3/19 and no documentation was found on the MAR and Nurse Notes to show that Resident #107 was given [MEDICATION NAME] 15 MG on 1/3/19. | 2020-09-01 |
| 351 | 351 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2019-01-08 | 757 | E | 1 | 1 | ZVIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, it was determined that the facility failed to ensure that residents receive medications as ordered, not in excessive dose and not in the presence of potential allergies [REDACTED]. (Resident identifiers are #39, #47, #62 and #71.) Findings include: Resident #47 Review on 1/8/19 of Resident #47's (MONTH) (YEAR) and (MONTH) 2019 Medication Administration Records revealed that Resident #47 was receiving [MEDICATION NAME] 200 mg (milligrams) every morning and [MEDICATION NAME] 700 mg every evening, which was ordered on [DATE]. Prior to that, Resident #47 had been receiving [MEDICATION NAME] 200 mg in the morning and [MEDICATION NAME] 300 mg in the evening. Review on 1/8/19 of Resident #47's (MONTH) 27, (YEAR) Pharmacy Consultant Report revealed that the pharmacist wrote The Manufacturer recommends daily dosing and not to exceed 700 mg daily at this level of [MEDICAL CONDITION]. The pharmacist then recommended that the physician adjust the dose of [MEDICATION NAME] 700 mg by mouth at bedtime for pain . For the Physician's Response, section of the report, Staff L (Advanced Practice Registered Nurse) accepted the recommendation and signed it on 12/28/18. Interview on 1/8/19 at approximately 12:00 p.m. with Staff L confirmed that they said that they changed the evening dose of [MEDICATION NAME] to 700 mg, based on the pharmacy recommendation, but forgot to discontinue the morning dose of [MEDICATION NAME], which resulted in Resident #47 receiving more than the recommended dose of [MEDICATION NAME]. Resident #62 Review on 1/3/19 of the Facility Report to the Long Term Care Ombudsman . dated 11/13/18, revealed that Resident #62 received Levetiracetam, in error, instead of [MEDICATION NAME] on 11/4/18. Review on 1/7/19 of the Facility's Risk Management form for this medication error revealed that Resident #62 had received Levetiracetam instead of [MEDICATION NAME]. It also revealed that the error was discovered on… | 2020-09-01 |
| 352 | 352 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2019-01-08 | 761 | D | 0 | 1 | ZVIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review, it was determined that the facility failed to ensure proper storage of expired treatment supplies and ensuring temperature logs were completed for 2 observed medication rooms out of 2 observed medication rooms and 1 observed code cart out of 2 observed code carts. Findings include: Review on [DATE] of the facility's policy titled, Storage and Expiration dating of Medication, Biologicals, Syringes, and Needles, revision date [DATE], revealed that .facility should ensure that medications and biologicals that : (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines .are stored separate from other medication until destroyed or returned to the pharmacy or supplier . Review on [DATE] of the facility's policy, Medication and Vaccine Refrigerator/Freezer Temperatures, revision date [DATE], revealed that Refrigerator .use to store medications and vaccines will operate within acceptable temperature range and will be checked twice a day . Observation on [DATE] at 9:10 a.m. of the Frost unit medication room with Staff A (Registered Nurse) revealed 1 Miniloc safety infusion set with a use by date of (YEAR)-06, 8 filter needles with expired date of (YEAR)-02, 5 filter needles with expired date of (YEAR)-06, 1 tube feed tubing with expired date of (YEAR)-02, 2 female Speci-Cath Kit with expired date of ,[DATE], one 1 ml (milliliter) syringe with expired date of ,[DATE], five purple top vacuettes with expired date of ,[DATE], and eight red top vacuettes with expired date of ,[DATE], and five nasopharayngeal sample collection kits for viruses with expired date of (YEAR)-05, that were stored with non expired treatment supplies. Observation of the Frost unit medication room refrigerator revealed that there were one box of influenza vaccine and 2 packets of Prevnar 13 vaccines. Review on [DATE] of the Frost unit refrigerator tem… | 2020-09-01 |
| 353 | 353 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2019-01-08 | 835 | E | 1 | 1 | ZVIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interviews and a review of the facility grievance log, it was determined that the facility failed to be administered in a way permitting all residents to maintain or attain their highest practicable well being.(Resident identifiers are #29 and #39.) Findings include: Observations on 1/2/19 during tour in room [ROOM NUMBER] on the[NAME]Wing revealed the use of two portable space heaters one on each side of the room providing heat. Residents #29 and #39 were interviewed during the tour and revealed that the two space heaters had been used to provide heat in their room for weeks. Resident #29 and #39 stated that although the space heaters were being used for heating their room was still cold. It was determined that the space heaters are a fire hazard and by regulation prohibited from being used in any resident areas including their rooms. Interview on 1/2/19 with Staff G (Administrator) revealed that Staff G had no knowledge until 1/2/19 when the survey team brought it to her attention of the two space heaters being used in room [ROOM NUMBER] on the[NAME]Wing. Staff O (Director of Maintenance) said during a 1/2/19 interview that the space heaters found in room [ROOM NUMBER] were in their third week of being used. Staff O said they were unaware of the regulation prohibiting the use of space heaters in resident areas including resident rooms. Staff G and Staff O informed the survey team on 1/2/19 that the space heaters would be removed from room [ROOM NUMBER] and a secondary heating source used instead specifically the baseboard electrical heat that's been available and in working condition. According to Staff O during the 1/2/19 interview, but wasn't utilized until 1/2/19. Staff G and Staff O gave no reason why this secondary heating source wasn't used when the primary heating source didn't work in room [ROOM NUMBER]. Interview on 1/3/19 at 1:00 p.m. with twenty-two residents representing three of the facility's four units… | 2020-09-01 |
| 354 | 354 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2019-01-08 | 842 | E | 1 | 1 | ZVIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, it was determined that the facility failed to ensure complete and accurate medical records for Foley catheter output, fluid intake, self administration of medications, [MEDICAL TREATMENT] treatments, a medication administration error, DPOA (Durable Power of Attorney) notification, and IV (Intravenous) administration for 7 residents in a final survey sample of 42 residents. (Resident identifiers are # 11, #57, #62, #69, #107, #140 and #295.) Resident #62 Review on 1/3/19 of the Facility Report to the Long Term Care Ombudsman . dated 11/13/18, revealed that Resident #62 received Levetiracetam, in error, instead of [MEDICATION NAME] on 11/4/18. Interview on 1/7/19 at approximately 11:15 a.m. with Staff [NAME] (Unit Manager) confirmed that on 11/4/18, Resident #47 was given Levetiracetam, which they had no order for, instead of [MEDICATION NAME], in error. Review on 1/7/19 at approximately 11:30 a.m. of Resident #62's nursing progress notes and Resident #62's assessments revealed that there was no documentation that Resident #62 had received any medication in error, nor was there any documentation that Resident #62's DPOA was notified of the error. Interview on 1/7/19 at approximately 11:40 a.m. with Staff [NAME] confirmed that there was no documented evidence in Resident #62's medical record that Resident #62 received the wrong medication or that Resident #62's DPOA was notified. Staff [NAME] confirmed that these should have been documented in the medical record. Resident #69 Interview on 1/3/19 at approximately 8:50 a.m. with Resident #69 revealed that Resident #69 was receiving [MEDICATION NAME] IV. Review on 1/7/19 of Resident #69's (MONTH) (YEAR) Medication Administration Record [REDACTED]. The review also revealed that there was no documentation on the Medication Administration Record [REDACTED]. Review on 1/7/19 of Resident #69's nurses notes, dated 12/13/18 at 3:55 p.m. revealed a note that read .or… | 2020-09-01 |
| 355 | 355 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2019-01-08 | 867 | D | 1 | 1 | ZVIF11 | > Based on interview and record review, it was determined that the facility failed to document on the Facility's quarterly QAPI (Quality Assurance and Performance Improvement) plan the implementation of a plan of action to address the identified problem of medication errors. Findings include: Interview on 1/3/19 at approximately 1:00 p.m. with residents at Resident Council revealed that the residents complained that medication errors have been ongoing and continue to be a problem at the facility. Review on 1/3/19 of the investigation survey done at the facility on 5/22/18 revealed that the facility received a deficiency for medication errors. Review on 1/8/19 of the facility's agenda for the quarterly QAPI meetings for 5/15/18, 8/21/18, and 11/20/18 revealed that Medication Error Reduction Plan was included on the 5/15/18 and the 8/21/18 agendas. Medication errors were not included on the 11/20/18 agenda. Interview on 1/8/19 at approximately 2:15 p.m. with Staff G (Administrator) and Staff N (Administrator in Training) confirmed that medication errors continued to be a problem area at the facility. Staff G also confirmed that the medication error reduction plan was not listed on the agenda for the 11/20/18 quarterly meeting. | 2020-09-01 |
| 356 | 356 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2019-01-08 | 926 | D | 0 | 1 | ZVIF11 | Based on observation, interview, and facility policy review, it was determined that the facility failed to ensure that the facility addresses smoking safety by allowing residents to have lighters on their person for 1 resident in a final survey sample of 34 residents. (Resident identifier is #135.) Findings include: Observation on 1/4/19 at approximately 8:10 a.m. revealed that Resident #135 was outside to smoking on campus. Review on 1/7/19 of the facility policy titled Smoking last revised on 7/24/18, revealed that .Smoking supplies (including, but not limited to, tobacco, matches, lighters, lighter fluid, etc.) will be labeled with the patient's name, room number, and bed number, maintained by staff, and stored in a suitable cabinet kept at the nursing station .If the patient is cognitively and physically able to secure all smoking materials, the Center may allow him/her to maintain his/her own tobacco or electronic cigarette products in a locked compartment .Patients will not be allowed to maintain their own lighter, lighter fluid, or matches . Interview on 1/7/19 at approximately 10:45 a.m. with Resident #135 revealed that Resident #135 stated that they kept their cigarettes and lighter with them. Resident #135 also stated that they had never been asked by anyone at the facility to give their lighter or their cigarettes to staff. Resident #135 stated that they would have given their lighter to staff, if they had been asked to. Interview on 1/7/19 at approximately 11:00 p.m. with Staff [NAME] (Unit Manager) confirmed that they had never read the facility's smoking policy and were not aware that residents were supposed to be asked for their lighters. Interview on 1/7/19 at approximately 1:00 p.m. with Staff [NAME] confirmed that they had just read the facility's smoking policy, and that after reading it they realized that Resident #135 should have been asked to give their lighter to staff. | 2020-09-01 |
| 357 | 357 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2018-05-22 | 609 | D | 1 | 0 | CHY811 | > Based on record review, observation and interview the facility failed to ensure that all alleged violations were reported to other state certification agencies in accordance with State law through established procedures and not following the facility's policies for 1 resident in a survey sample of 10 residents. (Resident identifier is #7.) Findings include: Resident #7 Review on 5/22/18 at 11:30 a.m. of Resident #7's medical record revealed nurses notes dated 4/5/18 at 9:00 a.m. a change of condition note,Other change in condition medication error 4/5/2018 in the morning. Orders obtained include: Frequent CBG (capillary blood glucose) checks, labwork d/t (due/to) using another using another patients pen, cross contamination Blood Tests Review on 5/22/18 of Resident #7's Event Summary Report revealed that Staff F (LPN nursing student) patient received 10 units of insulin that was meant for a different patient via insulin pen by 2 (pronoun omitted) LPN students. ARNP (Advanced Registered Nurse Practitioner) notified. DON (Director of Nursing) notified. Labs to be drawn on both patients involved d/t using another patients insulin pens cross contamination. Review on 5/22/18 at 11:30 a.m. of Resident #7's medical record revealed a condition follow up note written on 4/5/18 at 8 p.m. med error made with insulin No complications noted CBG 162/191 Review on 5/22/18 at 11:45 a.m. of the facility's policy titled Nursing Facility Reporting Requirements, with no date or update, Other Reportable Occurrences III Explained and/or witnessed incidents resulting injury (ie actual harm) caused by unusual circumstances, including environmental hazards, inadequate staffing, medication errors, etc. Interview on 5/22/18 at 1:00 p.m. with Staff B (Director of Nurses) revealed Staff B had contacted the facility's corporate regional personnel and it was felt that it was not a reportable event to the State Certification agency. The Administration will not allow nursing students to give insulin until the nursing school has addressed the f… | 2020-09-01 |
| 358 | 358 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2018-05-22 | 658 | D | 1 | 0 | CHY811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interview, it was determined that the facility failed to ensure that medications were given as ordered for 3 residents in a survey sample of 10 residents. (Resident identifiers are #1, #6 and #7.) Findings include: Professional reference: Potter, [NAME] [NAME], and Perry, Anne Griffin. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336 The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary Resident #1 Review on 5/22/18 of the RMS (Risk Management System) Event Summary Report, dated 4/15/18, for Resident #1 revealed that on 4/15/18, the facility determined that on 4/14/18 at 8:00 p.m. Resident #1 was given 3 tablets of Oxy IR ([MEDICATION NAME] Immediate Release) instead of 3 tablets of [MEDICATION NAME]. Review on 5/22/18 of Resident #1's (MONTH) (YEAR) Medication Administration Record [REDACTED].) Review also revealed that Resident #1 had an order for [REDACTED]. Review on 5/22/18 of the facility's Controlled Substance Log book revealed that on 4/15/18, the facility documented that the count of Oxy IR and the count of [MEDICATION NAME] were incorrect and that there were 3 tablets of Oxy IR missing and that there were 3 extra tablets of [MEDICATION NAME]. Interview on 5/22/18 at approximately 2:10 p.m. with Staff B (Director of Nursing) revealed that this medication error should not have been made. Resident #7 Review on 5/22/18 at 11:30 a.m. of Resident #7's medical record revealed nurses notes dated 4/5/18 at 9:00 a.m. a change of condition note,Other change in condition medication error 4/5/2018 in the morning. Orders obtained include: Frequent CBG (capillary blood glucose) checks, labwork d/t (due/to) using another using anot… | 2020-09-01 |
| 359 | 359 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2018-05-22 | 759 | E | 1 | 0 | CHY811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interview, it was determined that the facility failed to ensure that the medication error rate was not greater than 5% during 88 medication pass observations. (Resident identifiers are #2, #3, and #4.) Findings include: Resident #2 Observation on 5/22/18 at approximately 7:40 a.m. during medication pass revealed that there was a medicine cup on Resident #2's overbed table with a green tablet inside it. Resident #2 was sitting across the room from the overbed table. Interview on 5/22/18 at approximately 7:45 a.m. with Staff A (Licensed Practical Nurse) revealed that the pill inside the medicine cup was a Tums tablet 500 mg (milligram) that had been administered to Resident #2 by the 11-7 shift nurse. When asked, Staff A said that Resident #2 had a physician's order to self administer medications. Review on 5/22/18 of Resident #2's (MONTH) (YEAR) Medication Administration Record [REDACTED]. The review revealed that this medication was to be administered at 6:00 a.m. and 6:00 p.m. Review on 5/22/18 of Resident #2's medical record revealed that there were no physician orders, assessment or care plan for self administration of medications. Interview on 5/22/18 at approximately 10:00 a.m. with Resident #2 revealed that Resident #2 said that they had chewed one of the Tums tablets, when it was administered at approximately 6:00 a.m., but that Resident #2 liked to save the other tablet for after they had coffee in the morning. Interview on 5/22/118 at approximately 2:00 p.m. with Staff B (Director of Nursing) confirmed that there were no documented orders or assessment for Resident#2's self administration of medications and that the tablets should not have been left unattended for Resident #2. Resident #3 Observation on 5/22/18 at approximately 7:46 a.m. during medication pass revealed that Resident #3 received Vitamin C 500 mg by mouth and Vitamin D 400 IU (International Units) by mouth. Review on 5/22/18 of… | 2020-09-01 |
| 360 | 360 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2018-05-22 | 880 | D | 1 | 0 | CHY811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record and facility policy review, and interview, it was determined that the facility failed to provide a sanitary environment to prevent the potential transmission of communicable diseases during 1 of 3 medication pass observations and 1 of 11 record reviews. (Resident identifiers are #7 and #8.) Findings include: Resident #8 Observation on 5/22/18 at approximately 7:55 a.m. during medication pass revealed that Staff A (Licensed Practical Nurse) used a glucose meter to check Resident #8's blood sugar. After removing the test strip, with blood on it, from the glucose meter, Staff A placed the glucose meter, without cleaning it, in the left front pocket of their shirt. Interview on 5/22/18 at approximately 10:00 a.m. revealed that when asked, Staff A stated that the glucose meter was no longer in their pocket. Staff A said that they had removed the glucose meter from their pocket, cleaned it and placed it back in its holder. When asked what Staff A used to clean the glucose meter, Staff A pulled an alcohol prep pad out of the right front pocket of their shirt and said that they always use alcohol prep pads to clean the glucose meter between resident use. Review on 5/22/18 of the Facility's Policy titled Glucose Meter, dated 6/1/96, revised 3/16/17, revealed that the glucose meter is to be disinfected .before and after each patient use with .Environmental Protection Agency (EPA) approved disinfectant against [MEDICAL CONDITIONS](do NOT use an alcohol prep pad) . Interview on 5/22/18 at approximately 2:00 p.m. with Staff B (Director of Nursing) confirmed that the glucose meter should not have been placed in Staff A's pocket and that it should have been disinfected with Bleach wipes. Surveyor: Wyman, Debora [MI] Resident #7 Review on 5/22/18 at 11:30 a.m. of Resident #7's medical record revealed nurses notes dated 4/5/18 at 9:00 a.m. a change of condition note,Other change in condition medication error 4/5/2018 in the morn… | 2020-09-01 |
| 361 | 361 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2019-06-06 | 658 | D | 1 | 0 | 7LRG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview it was determined that the facility failed to follow the professional standard of practice for physician orders [REDACTED]. (Resident identifier is #2.) Findings include: The reference for the professional standard of practice is the following: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 713 .A registered nurse compares the list of medications on the MAR indicated [REDACTED]. After administering a medication, record it immediately on the appropriate record form . Recording immediately after administration prevents errors. Review on 6/6/19 at approximately 10:00 a.m. of the physician's orders [REDACTED]. Review on 6/6/19 at approximately 10:00 a.m. of the 'Medication Administration Record [REDACTED] Potassium Chloride ER Tablet Extended Release 20 MEQ Give 1 tablet by mouth two times a day for [DIAGNOSES REDACTED]. Review on 6/6/19 at approximately 10:00 a.m. of the above listed MAR indicated [REDACTED] 20 meq one tablet twice a day for 8 days from 4/2/19 through 4/9/19 for a total of 16 doses. Review on 6/6/19 at approximately 10:00 a.m. of the potassium laboratory results for Resident #2 revealed the following: 4/2/19 potassium level 3.2 (indicating low level) 4/4/19 potassium level 4.5 (indicating within range) 4/10/19 potassium level 6.0 (indicating high level) Interview on 6/6/19 with Staff A (Registered Nurse) at approximately 1:00 p.m. confirmed that the physician was notified on 4/10/19 of the high potassium level for Resident #2 and at that time it was discovered that the 4/2/19 physician order [REDACTED]. | 2020-09-01 |
| 362 | 362 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2019-06-06 | 760 | D | 1 | 0 | 7LRG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and review of the facility policy and procedure, it was determined that the facility failed keep residents free from significant medication errors by not notifying the physician when medications were not available for 1 out of 2 residents reviewed. (Resident identifier is #1.) Findings include: Review on 6/6/19 of Resident #1's (MONTH) 2019 and (MONTH) 2019 MAR (Medication Administration Record) revealed the following medications NA (not available): April 2019 [MEDICATION NAME]-[MEDICATION NAME]-[MEDICATION NAME] Suspension; Give 5 Ml's (Milliliters) orally four times a day for thrush, order dated 4/12/19. 4/12/19 3 doses not available at 1200, 1600, and 2000. 4/13/19 3 doses not available at 1200, 1600, and 2000. Famciclovir Tablet 500 MG (Milligram); Give 1 tablet my mouth three times a day for [MEDICAL CONDITION] for 7 days, order dated 4/6/19. 4/6/19 1 dose not available at 1200. [MEDICATION NAME] Suspension 00 Unit/Ml; Give 5 Ml's by mouth four times a day for thrush related Candidal Stomatitis for 10 days, order dated 4/9/19. 4/14/19 2 doses not available at 0800 and 1200. 4/15/19 4 doses not available at 0800, 1200, 1600 and 2000. 4/16/19 3 doses not available at 0800, 1200 and 1600. [MEDICATION NAME] HCL ([MEDICATION NAME] Acid) Suspension; Give 250 MG's (Milligram) by mouth every 6 hours related to [MEDICATION NAME] due to [MEDICAL CONDITION] (C diff), order dated 4/3/19. 4/9/19 1 dose not available at 1200. May 2019 [MEDICATION NAME]-[MEDICATION NAME]-[MEDICATION NAME] Suspension; Give 5 Ml's orally four times a day for thrush, order dated 4/21/19. 5/13/19 4 doses not available at 0700, 1100, 1700 and 2000. Interview on 6/6/19 at approximately 12:15 p.m. with Staff A (Director of Nurses) revealed that there was no record of the physician being notified of the missed doses of medications. Review on 6/6/19 of the facility policy and procedure titled; NSG (Nursing) Medication Administration: General,… | 2020-09-01 |
| 363 | 363 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2019-10-11 | 585 | B | 0 | 1 | ECKJ11 | Based upon a Resident's Council group interview, staff interview and a review of the facility audits revealed that the facility failed to effectively respond to resident's grievances that staff do not answer the resident's call lights in a timely manner. Findings include: Interview on 10/12/19 at a Resident's Council meeting revealed that the facility staff were not either answering their call lights or responding to them in a timely manner. Residents revealed that staff unresponsiveness to call bells has remained an ongoing problem on three of four units since the last survey. A review of facility monthly audits involving only 3-9 residents rooms monitoring the response of staff to call lights ended in (MONTH) of 2019 even though residents, in the group interview, reaffirmed that this continues to be an unresolved problem. In the Initial Audit undated it's noted that a resident indicates that they're not always satisfied with the staff response to their call bell. Another resident stated that they're satisfied with staff response to their call light most but not all of the time. Review on 10/12/19 of the facility audits of responses to call lights revealed the audit was limited in March, (MONTH) and (MONTH) of 2019 to three resident's rooms each month and there was no audits after (MONTH) 2019. In a 10/12/19 interview with Staff A (Administrator) confirmed that the audits had stopped and stated that only three grievances a month were being made by residents who continued complaining about a lack of staff responsiveness to their call lights. | 2020-09-01 |
| 364 | 364 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2019-10-11 | 689 | D | 0 | 1 | ECKJ11 | Based on observation, record review and interview, it was determined that the facility failed to ensure that the resident environment remains as free of accident hazards as is possible by providing assessments to determine safety needs for 3 residents that smoke in a survey sample size of 27 residents. (Resident identifiers are: #110, #128 and #241). Findings include: Resident #241: Observation on 10/8/19 at approximately 10:00 a.m. revealed Resident #241 was smoking a cigarette outside the facility. An interview with Staff A, (Administrator) on 10/8/19 at approximately 9:00 a.m. revealed that the Facility is a smoke-free facility. An observation on 10/8/19 at approximately 3:00 p.m. of Resident #241 revealed that Resident #241 was sitting outside the front entrance of the facility smoking a cigarette. Staff A (Administrator) and Staff B (Corporate Representative of the facility) were immediately notified and went to the front entrance of the facility to observe Resident #241 smoking a cigarette. Review on 10/9/19 at approximately 10:30 a.m. of Resident #241's medical record revealed a care plan that stated that the resident was not going to smoke, and had started a smoking cessation program, (ie; donning a Nicotine Patch), but did not include any safety measures to implement that would cover the times when Resident #241 decided to go out to smoke. Further nurses notes documented on 10/3/19 and 10/8/19 revealed that Resident #241 regularly smokes 4-5 cigarettes per day on facility grounds. Interview on 10/9/19 at approximately 11:00 am with Resident #241 revealed that Resident #241 stated, the patch is not working and I want to try the pill, and other people are out there smoking and everyone knows it. Resident #241 also stated during this interview that he/she was approached by Staff A and Staff B, who told him he/she could not smoke, as this is a smoke-free facility. Resident #241 stated that he/she told them that he/she will quit smoking, but the patch doesn't work and he/she wants to try the pill. Resident #2… | 2020-09-01 |
| 365 | 365 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2019-10-11 | 758 | D | 0 | 1 | ECKJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to ensure that a PRN (as needed) [MEDICAL CONDITION] drug was limited to 14 days except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order, for 1 resident in a final sample size of 27 residents. (Resident identifier is #39.) Findings include: Review on 10/10/19 of Resident #39's current physician orders [REDACTED].#39 had an order for [REDACTED]. Review on 10/10/19 of Resident #39's (MONTH) to (MONTH) 2019 EMAR (Electronic Medication Administration Record) revealed that Resident #39 received PRN [MEDICATION NAME] 25 mg on 6/25/19, 6/28/19, 6/29/19, 7/5/19, 7/7/19, 7/12/19, 7/18/19, 7/21/19, 7/23/19, 7/27/19, 7/31/19, 8/1/19, 8/11/19, 8/30/19, 9/1/19, 9/8/19, 9/9/19, 9/30/19 and 10/4/19. Review on 10/11/19 of Resident #39's progress notes and chart between (MONTH) 2019 and (MONTH) 2019 revealed that Resident #39's in-house psychiatrist did not have documentation for the rationale and indication of duration for Resident #39's PRN [MEDICATION NAME] order that was started on 6/25/19. Review on 10/11/19 of Resident #39's APRN (Advanced Practice Registered Nurse) progress note dated 6/21/19 revealed that Resident #39's APRN had ordered for PRN [MEDICATION NAME] 25 mg but with no documented rationale and duration for the order. Further review of Resident #39's APRN progress notes revealed that Resident #39 had APRN progress notes dated 7/2/19, 7/8/19, 7/26/19, 8/1/19, 8/27/19, 9/4/19, 9/16/19 and 9/27/19 with no documented rationale and indication of duration for Resident #39's PRN [MEDICATION NAME] order that was started on 6/25/19. Interview on 10/11/19 at 10:00 a.m. with Staff G (Unit Manager) confirmed that above findings. Staff G stated that there should have been … | 2020-09-01 |
| 366 | 366 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2019-10-11 | 880 | D | 0 | 1 | ECKJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to provide a sanitary environment for wound treatments for 2 residents in a final survey sample of 27 residents. (Resident identifiers are #128 and #396) Findings include: Resident #396 Interview on 10/8/19 at approximately 10:15 a.m. with Staff C (Unit Manager) revealed that Resident #396 had a Stage 4 pressure ulcer on their sacrum which was being treated with a wound vac. Staff C also revealed that Resident #396 was on contact precautions [MEDICAL CONDITIONS] in their blood and in the wounds that they had on their toes. Observation on 10/9/19 at approximately 9:55 a.m. of the wound vac dressing change to Resident #396's sacrum revealed that the supplies for the dressing change were placed on a tan overbed table by Staff C. The table had a laminated overlay and Staff C noticed that approximately 1/8 of the laminate was lifted exposing the underneath particle board, and the table also had multiple areas of torn laminate with tattered edges on the side of the table. Staff C initially cleaned the table with a bleach wipe, but then removed the table and said that it would be taken out of service due to its torn areas. Staff C then took another overbed table and it was noticed that this table also had multiple areas of torn laminate with tattered edges on the side of the table. Staff C wiped the table with a bleach wipe and then placed the dressing supplies on the overbed table. Staff C did not place a clean pad or towel on top of the table. Staff C did the wound vac dressing change using that overbed table to hold supplies. Observation on 10/9/19 of the overbed tables on the Frost Unit revealed that there were 19 overbed tables with the same tan laminate and that 13 of them had torn laminate on the sides, with tattered edges. Resident #128 Interview on 10/8/19 at approximately 10:15 a.m. with Staff C revealed that Resident #128 had a Stage 4 pressure ulcer on their s… | 2020-09-01 |
| 367 | 367 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2019-10-24 | 550 | D | 1 | 0 | 8J3T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and observation, it was determined that the facility failed to ensure that resident's right to refuse medication was supported by staff for 1 resident out of a survey sample of 3 residents with diabetes. (Resident identifier is #2.) Findings include: Review on 10/24/19 of a facility reported incident to the state agency on 10/15/19 revealed a medication error had occurred on 10/15/19 at approximately 9:20 p.m. involving Resident #2 receiving medication that was intended for another resident (Resident #1.) Review on 10/24/19 of Resident #2's medical record revealed that Resident #2 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Resident #2 has a BIMS (Brief Interview Mental Staus) of 13, which suggests an intact cognitition. Interview on 10/24/19 at approximately 10:00 a.m. with Resident #2, who has a BIMS (Brief Interview for Mental Status) of 13 and is alert and oriented, revealed that on 10/15/19 at approximately 9:20 p.m. Staff A (Travel nurse) entered Resident #2's room to administer insulin via [MEDICATION NAME] Solution Pen Injector. Resident #2 asked Staff A what the medication was. Staff A responded that it was insulin and Resident #2 informed Staff A that I don't take insulin. Resident #2 further stated that Staff A told Resident #2 that there were orders for Resident #2 to have insulin. Resident #2 stated that Staff A then injected the insulin: Jab, right in my stomach. Resident #2 stated Then they kept me up all night making me eat and checking my sugar. Phone interview on 10/31/19 at 12:51 p.m. with Staff A, (Registered Nurse travel) revealed that Staff A had no orientation and had many interruptions during the medication pass that evening and many supplies were missing. While getting the insulin pen ready for Resident #1 Staff A could not find a pen needle so Staff A took a syringe an withdraw 5 units from the insulin pen and injected (Resident #2) with it. If (Resident #2) had said somet… | 2020-09-01 |
| 368 | 368 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2019-10-24 | 552 | D | 1 | 0 | 8J3T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, it was determined that the facility failed to inform a resident of their health status for 1 resident out of a survey sample of 3 residents with diabetes. (Resident identifier is #1.) Findings include: Review on 10/24/19 of Resident #2's progress note, dated 10/15/19, revealed that there was a medication error where Resident #1's [MEDICATION NAME] Solution Pen Injector was used to administer insulin to another resident (Resident #2). Observation on 10/24/19 at 8:30 a.m. of the[NAME]Unit medication cart revealed a baggie that had a pharmacy label with Resident #1's name that contained one [MEDICATION NAME] Solution Pen Injector inside it. On the pharmacy label, it had an issue date of 10/4/19 in the right hand corner and a label to be discarded on 11/1/19. There was no date that stated when it was opened. Review on 10/24/19 at approximately 10:45 a.m. of Resident #1's medical record revealed that Resident #1's Durable Power of Attorney (DPOA) was activated. Further review revealed no notification of the resident's DPOA documented in the medical record. Interview on 10/24/19 at approximately 11:12 a.m. with Staff B (Center Nurse Executive) confirmed that Staff B did not notify Resident #1's activated DPOA that the resident's insulin pen had been used on Resident #2 on 10/15/19 and returned to the medication cart and since been used on Resident #1. Staff B revealed that no testing for infectious diseases had been offered to either Resident #1 or Resident #2. | 2020-09-01 |
| 369 | 369 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2019-10-24 | 610 | D | 1 | 0 | 8J3T11 | > Based on record review and interview, it was determined that the facility failed to thoroughly investigate a medication error that resulted in immediate jeopardy for 1 resident in of a survey sample of 3 residents. (Resident identifier is #2.) Findings include: Review on 10/24/19 of a facility reported incident dated 10/15/19, revealed a medication error had occurred on 10/15/19 at approximately 9:20 p.m. involving Resident #2 receiving medication that was intended for another resident (Resident #1.) Interview on 10/24/19 at approximately 10:00 a.m. with Resident #2, who has a BIMS (Brief Interview for Mental Status) of 13 and is alert and oriented, revealed that on 10/15/19 at approximately 9:20 p.m. Staff A (Registered Nurse) entered Resident #2's room to administer insulin. Resident #2 asked Staff A what the medication was. Staff A responded that it was insulin and Resident #2 informed Staff A that I don't take insulin. Resident #2 further stated that Staff A told Resident #2 that there were orders for Resident #2 to have insulin. Resident #2 stated that Staff A then injected the insulin: Jab, right in my stomach. Resident #2 stated Then they kept me up all night making me eat and checking my sugar. Interview on 10/24/19 at approximately 11:15 a.m. with Staff B (Center Nurse Executive) confirmed that the only in-service that had been provided to staff was the Med administration/right patient in-service and that the facility did not report the incident to the Board of Nursing. Staff B had not discovered during their investigation an insulin pen had been use to draw up the insulin into a syringe and used on Resident #2, then the insulin pen was returned to the medication cart and has been used on the original resident (Resident #1) since. Staff B also had not informed the infection preventionist about the incident or informed the DPOA (Durable Power of Attorney) of Resident #1 that the resident's insulin pen had been used for another resident. Phone interview on 10/31/19 at 12:51 p.m. with Staff A revealed tha… | 2020-09-01 |
| 370 | 370 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2019-10-24 | 760 | D | 1 | 0 | 8J3T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, it was determined that the facility failed to ensure that residents are free of significant medication errors by giving insulin that was not physician ordered to a resident who does not take insulin, placing that resident in Immediate Jeopardy for 1 resident out of 3 residents with diabetes in a survey sample. (Resident identifer is #2.) Findings include: Review of a facility generated report dated 10/15/19, revealed a medication error in which Resident #1's [MEDICATION NAME] Solution Pen Injector was used to administer insulin to Resident #2 which Resident #2 was not prescribed. Review on 10/24/19 at approximately 10:45 a.m. of Resident #2's (MONTH) Medication Administration Record [REDACTED]. Review on 10/24/19 of the change of condition report, dated 10/15/19, for Resident #2 revealed that on 10/15/19 at 9:40 p.m. Staff F (Nurse Practitioner) was notified that Resident #2 was administrated the wrong medication. New order to take CBG's (Capillary Blood Glucose) every two hours from midnight until 0800. NP (Nurse Practitioner) will follow up in the morning. Review of the CBG's report for Resident #2 revealed the CBG's were within normal limits throughout the night between the hours midnight and 8:00 a.m. Interview on 10/24/19 at approximately 11:12 a.m with Staff B (Center Nurse Executive) confirmed that Staff B did not know that Resident #2's medication error was from an insulin pen because the dose was 5 units. Staff B also revealed that Staff B did not inform Staff C, (Infection Preventionist) of the insulin medication error or throw the insulin pen away. Interview also confirmed that Resident #2 did not have an order for [REDACTED].>Review on 10/24/19 of the facility policy and procedure titled, Medication Administration, General Revised on 07/01/19 revealed: Do not reuse the same lancet, syringe, needle, pen or injection device (e.g., pre-filled, manufacturer, insulin or any other medication or bi… | 2020-09-01 |
| 371 | 371 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2019-10-24 | 880 | J | 1 | 0 | 8J3T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, it was determined that the facility failed to ensure agency staff were accurately trained/oriented on the facility's policies for infection control for insulin pens, failed to identify infection control risks associated with insulin pens, and failed to protect a resident from and subsequently address potential cross contamination of blood borne pathogens for 1 of 3 residents with diabetes in a survey sample resulting in Immediate Jeopardy. (Resident identifier is #2.) Findings include: Immediate Jeopardy (IJ) was identified on 10/24/19 for failing to ensure that staff followed Center for Disease Control (CDC) guidelines for single patient use of insulin pens placing one resident at risk for exposure to the potential of blood borne pathogens when an insulin pen from one resident was used for another resident. Review on 10/25/19 of the CDC Clinical Reminder: Insulin Pens Must Never Be Used for More than One Person revealed that insulin pens not be used for more than one person because the potential of blood borne pathogens transmission risk is still present due to the regurgitation of blood into the insulin cartridge. Retrieved from https://www.cdc.gov/injectionsafety/clinical-reminders/insulin-pens.html accessed on 10/25/19 Review on 10/24/19 of the facility policy and procedure titled, Insulin Pens, date reviewed 3/1/19, revealed: Insulin pens containing multiple doses of insulin are meant for single patient use only and must never be used for more than one person, even when the needle is changed. Insulin pens will be clearly labeled with the patient name or other identifier to verify that the correct pen is used on the correct patient .To prevent risk of bloodborne pathogen exposure. Review of a facility generated report dated 10/15/19 revealed on 10/15/19, Staff A (Registered Nurse) used Resident #1's [MEDICATION NAME] Solution Pen Injector to administer insulin to Resident #2. Interview on 10/24/19 a… | 2020-09-01 |
| 372 | 372 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2017-10-26 | 157 | D | 0 | 1 | T5BJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to immediately notify the resident's physician when the resident had an accident which resulted in an injury that had the potential for requiring physician intervention for 1 of 6 residents reviewed with falls (Resident identifier is #25). Findings include: Review on 10/26/17 of Resident #25's progress notes revealed on 6/3/17 at 5:45 a.m., Resident #25 had a fall and sustained a bump on the back of their head. Further review of progress notes revealed that the primary care physician was not notified until 9:30 a.m. when staff were unable to arouse the resident and the resident's pupils became dilated and non-reactive. Review on 10/26/17 of statements dated 6/4/17 concerning the above fall from Staff F (Licensed Nursing Assistant (LNA)) and Staff G (LNA) revealed after the fall the resident was placed in the resident's wheelchair and brought to the nurse's station for observation and the resident started vomiting and wanted to lay down. Review on 10/26/17 of Resident #25's physician orders [REDACTED]. [MEDICATION NAME] Tablet 75 MG - Give 1 tablet by mouth one time a day for [MEDICAL CONDITIONS] [MEDICATION NAME] Aspirin Tablet 325 MG - Give 1 tablet by mouth one time a day for CAD ([MEDICAL CONDITION]) Interview with Staff B (Director of Nursing) on 10/26/17 at approximately 2:00 p.m. confirmed the above progress notes, LNA statements, and medications. | 2020-09-01 |
| 373 | 373 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2017-10-26 | 281 | B | 0 | 1 | T5BJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow the professional standard of practice for 1 resident with pronouncement at the time of death, failed to complete an assessment after a fall for 2 residents in a survey sample of 24 residents and failed to ensure medication parameters for 4 residents in a survey sample of 24 residents. (Resident identfiers are #3, #4, #5, #6, #13, #22 and #23.) Findings include: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Pages 479 - 480 reveals: Federal and state laws require that institutions develop policies and procedures for certain events that occur after death: requesting organ or tissue donation, autopsy, certifying and documenting the occurrence of a death, and providing safe and appropriate postmortem care . Documentation of death provides a legal record of the event. Follow agency policies and procedures carefully to provide an accurate and reliable medical record of all assessments and activities surrounding a death . Nursing documentation becomes relevant in risk management or legal investigations into a death, underscoring the importance of accurate, legal reporting . Documentation of End-of-Life Care . Time and date of death and all actions taken to respond to the impending death . Name of health care provider certifying the death . Persons notified of the death (e.g., health care providers, family members, organ request team, morgue, funeral home, spiritual care providers) and who comes to the setting at the time of death . Request for organ or tissue donations made and by whom . Special preparations of the body (e.g., desired or required religious/cultural rituals) . Medical tubes, devices, or lines left in or on the body . Personal articles left on and secured to the body . Personal items given to the family with description, date, time, to whom given . Location of body identification tags . Time of… | 2020-09-01 |
| 374 | 374 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2017-10-26 | 431 | E | 0 | 1 | T5BJ11 | Based on observation, interview, record review and policy review, the facility failed to ensure to ensure medications are not used after the expiration date for 2 residents and stock medications and supplies are not available for use after thier expiration date on 4 of 4 residential units. (Resident identifiers are #34 and #35.) Findings include: Resident #34 Observation on 10/24/17 at approximately 9:30 a.m. on the Homestead unit medication cart revealed a bottle of Lantus Solution belonging to Resident #34. The bottle was labeled Do not use after 10/22/17. Review on 10/25/17 of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Resident #35 Observation on 10/24/17 at approximately 9:30 a.m. on the Homestead unit medication cart revealed a bottle of Levemir Solution belonging to Resident #34. The bottle was labeled Do not use after 10/23/17. Review on 10/25/17 of the (MONTH) (YEAR) MAR for Resident #35 revealed that the resident received an injection of Levemir Solution from the above bottle in the morning on 10/24/17 after the do not use after date of 10/23/17 labeled on the bottle. Interview with Staff H (Unit Manager) confirmed the findings for the expired medications for Resident #34 and Resident #35 and they were the medication vials currently in use. During tour of the medication storage room on the Frost Unit with Staff C (RN/Unit Manager) it was revealed that a bottle of Naproxen that was available for resident use had expired 3/17. Interview with Staff C on 10/26/17 at 12:35 p.m. confirmed that the bottle of Naproxen had expired 3/17 and was available for resident use in the medication storage room. Observation on 10/24/17 in the AM, of the medication room located on the[NAME]Unit, in the presence of Staff [NAME] (Licensed Practical Nurse), revealed an unopened bottle of B-Complex vitamin on the medication storage shelf with an expiration date of 4/17. Interview at that time with Staff E, Staff [NAME] indicated that part of Staff E's monthly (Pierce Unit) audit examines for expired medicati… | 2020-09-01 |
| 375 | 375 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2017-10-26 | 456 | B | 0 | 1 | T5BJ11 | Based on observation, interview and facility policy review, it was determined that the facility failed to maintain oxygen concentrators in sanitary operating condition for 5 out of 5 oxygen concentrators observed during tour of the[NAME]Unit. (Resident identifier's are #28, #30, #31, #32 and #33.) Findings include: Observation on 10/24/17 at approximately 9:30 a.m. on[NAME]Unit tour with Staff A (Unit Manager) revealed that Resident #28, #30, #31, #32 and Resident #33's oxygen concentrator filters had approximately 1/4 inch of dust and debris adhered to them. Staff B (Director of Nurses) was also present during part of the tour and was present for the findings of #28 and #30's oxygen concentrator filters that were observed. Interview on 10/24/17 at approximately 9:45 a.m. with Staff A confirmed that the filters had a visible amount of dust and debris adhered to them. Staff A stated, That is so bad, while observing Resident #32's oxygen concentrator filter. Review on 10/26/17 of the facility policy named Respiratory Equipment/Supply Cleaning/Disinfection Effective Date: 4/1/07 revealed in the section titled Routine cleaning of equipment in patient room: . 1.6.4 Oxygen Concentrators: Rinse and dry the external filter weekly and as needed when visibly dusty. Interview on 10/26/17 at approximately 1:00 p.m. with Staff B revealed that the Oxygen concentrator filters should be cleaned weekly. | 2020-09-01 |
| 376 | 376 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2017-10-26 | 514 | D | 0 | 1 | T5BJ11 | Based on record review and interview the facility failed to ensure that the medical record is complete and accurate for 1 resident in a survey sample of 24 residents and 1 out of sample resident. (Resident identifiers are #12 and #25.) Findings include: Resident #12. Review on 10/25/17 of Resident #12's NEUROLOGICAL ASSESSMENT FLOW SHEET revealed an incomplete flow sheet with no dates listed for 15 entries. A second NEUROLOGICAL ASSESSMENT FLOW SHEET for Resident #12 reviewed at this time revealed in the date section the following dates 5/16, 5/17, 5/18 and 5/19 with no year listed on this flow sheet. Interview on 10/25/17 at approximately 8:45 a.m. with Staff [NAME] (Registered Nurse) confirmed that the one NEUROLOGICAL ASSESSMENT FLOW SHEET listed above had no dates and the second NEUROLOGICAL ASSESSMENT FLOW SHEET had no year listed for Resident #12. Resident #25 Review on 10/26/17 of Resident #25's Neurological Assessment Flow Sheet from 6/3/17 revealed an incomplete flow sheet. At 6:20 a.m. and 6:50 a.m., the Level of Consciousness (L[NAME]), pupil response, motor function, temperature, pulse, respiration, and blood pressure were not recorded on the flow sheet. Interview with Staff B (Director of Nursing) on 10/26/17 at approximately 1:45 p.m. confirmed the above Neurological Assessment Flow Sheet was incomplete. Review of the facility's policy titled Assessment: Neurological, revision date 7/17/14, revealed the following 10 Document: 10.1 L[NAME], pupil reaction, motor function, temperature, pulse, respiration, and blood pressure on Neurological Assessment Flow Sheet. | 2020-09-01 |
| 757 | 757 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2016-11-16 | 155 | D | 0 | 1 | Q1DI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that the facility failed to adhere to the State of New Hampshire's Chapter 137-J, WRITTEN DIRECTIVES FOR MEDICAL DECISION MAKING FOR ADULTS WITHOUT CAPACITY TO MAKE HEALTH CARE DECISIONS, Section 137-J:5 for 3 residents in a standard survey sample of 24 residents. (Resident identifier's are #10, #12 and #17.) Findings include: Review of New Hampshire state law for Advance Directives, Section 137-J:5, effective (MONTH) 21, 2009 reveals the following: II. An agent's authority under an advance directive shall be in effect only when the principal lacks capacity to make health care decisions, as certified in writing by the principal's attending physician or APRN, and filed with the name of the agent in the principal's medical record. When and if the principal regains capacity to make health care decisions, such event shall be certified in writing by the principal's attending physician or APRN, noted in the principal's medical record, the agent's authority shall terminate, and the authority to make health care decisions shall revert to the principal . Resident #10. Record review on 11/15/16 revealed a physician order [REDACTED].#10. Resident #17. Record review on 11/16/16 revealed a physician order [REDACTED].#17. Interview on 11/16/16 with Staff D (Registered Nurse) and review of the medical record for Resident #10 and #17 showed no documentation of an assessment to determine that Resident's #10 and #17's capacity for decision-making and no written statement by the physician to certify that Resident #10 and Resident #17 lack the capacity to make health care decisions prior to activating the Durable Power of Attorney for Health Care (DPOA-HC). Resident #12 Record review on 11/16/16 revealed a physician order [REDACTED].#12. There was no documentation of an assessment to determine Resident's #12's capacity for decision-making and no written statement by the physician to certify that Resident #12… | 2019-11-01 |
| 758 | 758 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2016-11-16 | 280 | D | 0 | 1 | Q1DI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of records and interview, the facility failed to review and revise comprehensive care plans for 1 of 24 residents in a survey sample (Resident identifier #19) Findings include: Review of Resident #19's care plan revealed interventions for both a [MEDICAL TREATMENT] catheter and a fistula. Review of Resident #19's [MEDICAL TREATMENT] Communication book revealed that the resident had a fistula used for [MEDICAL TREATMENT]. Interview with Staff [NAME] (Registered Nurse, Unit Manager) on 11/16/16 at 3:10 p.m. confirmed the above finding and revealed that Resident #19 has not had a catheter since (YEAR). | 2019-11-01 |
| 759 | 759 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2016-11-16 | 281 | D | 1 | 1 | Q1DI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interview it was determined that the facility failed to follow the professional standard of practice for pronouncing at the end of life for 1 closed record resident, failed to follow professional standard of practice for discarding medications for 1 out of sample resident, failed to follow the professional standard of practice for the administration of medications for 1 out of sample resident and documentation of narcotic medications for 2 out of sample residents. (Resident identifier's are #6, #20, #25, #29, #30 and #31.) Findings include: Reference is Fundamentals of Nursing, 7th Edition, MOSBY/ELSEVIER, 2009, Evolve, pages 479 - 480, reveal the following: Federal and state laws require that institutions develop policies and procedures for certain events that occur after death: requesting organ or tissue donation, autopsy, certifying and documenting the occurrence of a death, and providing safe and appropriate postmortem care .Documentation of death provides a legal record of the event. Follow agency policy and procedures carefully to provide an accurate and reliable medical record of all assessments and activities surrounding a death .Nursing documentation becomes relevant in risk management or legal investigations into a death, underscoring the importance of accurate, legal reporting Documentation of End-of-Life Care .Time and date of death and all actions taken to respond to the impending death Name of health care provider certifying the death Persons notified of the death (e.g. health care providers, family members, organ request team, morgue, funeral home, spiritual care providers) and who comes to the setting at the time of death Request for organ or tissue donations made and by whom Special preparations of the body (e.g., desired or required religious/cultural rituals) Medical tubes, devices, or lines left in or on the body Personal articles left on and secured to the body Personal items give… | 2019-11-01 |
| 760 | 760 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2016-11-16 | 329 | D | 0 | 1 | Q1DI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that the facility failed to monitor two residents by not conducting the ABNORMAL INVOLUNTARY MOVEMENT SCALE and failed to refer one resident for a complete neurological exam following the results of this monitor for 3 of 9 resident's receiving antipsychotic medications in a survey sample of 24 residents. (Resident identifier's are #1, #4 and #10.) Findings include: Resident #4. Record review on 11/15/16 of the Abnormal Involuntary Movement Scale (AIMS) for Resident #4 dated 10/22/16 revealed that Resident #4 scored 2 in two areas of Section B. Extremity Movements and scored 2 in one area of Section C. Trunk Movements. Review of the interpretation of AIMS score reveal that when a resident scores 2 in two or more of the seven body areas REFERRAL FOR COMPLETE NEUROLOGICAL EXAM. Interview on 11/15/16 with Staff A (Registered Nurse) at approximately 10:00 a.m. after Staff A reviewed the above listed AIMS findings, Staff A verbally confirmed that that no referral for a neurological exam was done for Resident #4. Resident #10 Record review on 11/15/16 of the physician orders [REDACTED].#10 was receiving the antipsychotic medication [MEDICATION NAME]. Further record review revealed no documented evidence of an AIMS completed for Resident #10. Interview on 11/15/16 and review of the medical record with Staff A revealed no evidence of a AIMS completed for Resident #10. Resident #1 Record review on 11/15/16 of the physician orders [REDACTED].#1 was receiving the antipsychotic medication [MEDICATION NAME]. Further record review revealed no documented evidence of an AIMS completed for Resident #1 Interview with Staff [NAME] (Register Nurse, Unit Manager) on 11/15/16 at 2:05 p.m. confirmed the above finding and revealed that Resident #1 should have had an AIMS completed at admission. The resident was admitted on [DATE]. | 2019-11-01 |
| 761 | 761 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2016-11-16 | 514 | D | 0 | 1 | Q1DI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain clinical records for 2 of 24 resident in a survey sample (Resident identifiers #1 and #12). Findings include: Resident #1 Review of the resident's allergies [REDACTED]. Interview with Staff [NAME] on 11/15/16 at 2:15 p.m. confirmed the above finding and revealed that the practice would be to refer to the MAR for allergies [REDACTED].>Resident #12 Review of the resident's Treatment Administration Record (TAR) for 11/1/16 to 11/15/16 revealed Empty Foley Catherter Drainage Bag every shift and as needed every shift was missing doucmentation of completion on 11/7/16, 11/10/16, 11/11/16, and 11/14/16 from 7 a.m. to 3 p.m. and on 11/8/16 from 3 p.m. to 11p.m. Further review of the TAR revealed the following tasks not documented on 11/11/16 and 11/14/16 during the 7 a.m. to 3 p.m. shift: Air mattress 5 LED (Light Emitting Diode) from the floor every shift, antifungal powder to groin BID (twice a day) unresolved every day and evening shift for redness, check air mattress Q (every) shift for bottoming out, encourage patient to turn and reposition in bed every 2 hours as patient allows every shift, float heals in bed as patient allows every shift, perform catheter care every shift, and side rails 2 1/2 (two half side rails) as an enabler for turning and repositioning in bed every shift. | 2019-11-01 |
| 883 | 883 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2015-10-29 | 252 | B | 0 | 1 | 0U9B11 | Based upon observations made on a 10/29/15 tour of the facility, the doors of residents' rooms in 3 of 4 units were scarred and in need of repair. Findings include: Resident's room doors in 3 of 4 units were scarred and in need of attention for rooms #109,#114,#201,#206,#207,#208,#209,#213,#215,#216,#219,#301,#303 and #305. | 2019-02-01 |
| 884 | 884 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2015-10-29 | 280 | D | 0 | 1 | 0U9B11 | Based on medical record review and interview it was determined that the facility failed to update resident care plans for 1 resident out of a standard survey sample of 24 residents. (Resident identifier is #15.) Findings include: Review on 10/29/15 of Resident #15's medical record revealed a Potential Skin breakdown . care plan with a target date of 12/22/15. The facility failed to update the care plan when Resident #15 had developed a new actual skin breakdown related to pressure ulcer, incontinence, limited mobility, Friction/Shear Stage II pressure ulcer on 10/23/15 that would require a care plan. Review on 10/29/15 of the medical record revealed a nurse's note on 10/23/15 for a new onset/change in skin integrity as evidenced by ulcer-pressure .Physician notified of change in condition .New orders obtained. Interview on 10/29/15 at approximately 2:30 p.m. with Staff D (License Practical Nurse) confirmed the above care plan has not been updated. | 2019-02-01 |
| 885 | 885 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2015-10-29 | 281 | D | 0 | 1 | 0U9B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to clarify a medication order for 1 resident and failed to administer medication according to physician order for [REDACTED].#25 and #26.) Findings include: Review of Fundamentals of Nursing,Patricia A. Potter and Anne Griffin Perry, Mosby, 2009, 7th Edition, St. Louis, Missouri, revealed the following: On page 336- Physicians' Orders states, The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Resident #25. Reconciliation of medication for Resident #25 following the medication pass observation on 10/28/15 at 9:30 a.m., revealed a physician order for [REDACTED]. Interview on 10/28/15 at 8 a.m. with Staff B (LPN) indicated the medication will be administered after Resident #25 had breakfast because Resident #25 had a habit of not eating breakfast and Staff B did not want Resident #25 to bottom out. Staff B also confirmed the medication had been administered after meals on previous days when the CBG's were Resident #26. Observation on 10/28/15 at 8:32 a.m. with Staff C (Registered Nurse) revealed the preparation of [MEDICATION NAME] Power (Polyethylene [MEDICATION NAME] 3350) Give 17 gram in 8 ounces of water. Staff C was observed administering this 8 ounce cup to Resident #26 at which time Resident #26 was unable to finish. Staff C proceed to leave the cup of [MEDICATION NAME] medication with the resident and exited the room. Interview at this time with Staff C regarding the above listed observation confirmed that there was no physician order to self-administer this medication for Resident #26. Reconciliation of medication for Resident #26 following the medication pass revealed no assessment for self-administration for the [MEDICATION NAME] or a … | 2019-02-01 |
| 886 | 886 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2015-10-29 | 371 | E | 0 | 1 | 0U9B11 | Based on interview, record review and observation the facility failed to maintain the proper rinse temperature of the dishwasher to ensure sanitization and failed to maintain sanitary conditions in the kitchen. Findings include: Tour of the kitchen on 10/27/15 at 9:05 a.m. revealed that the high temperature dishwasher reached a temperature of 172 degrees Fahrenheit (F) during the rinse cycle. Review of the (MONTH) temperature log for the high temperature dishwasher revealed the minimum temperature for the rinse cycle is 180 degrees F and the kitchen records the rinse temperature each day at breakfast, lunch and dinner. The only rinse temperature in (MONTH) that was below 180 degrees F was taken at dinner time on 10/25/15. Interview with Staff E (Director of Food Services) on 10/27/15 at 9:05 a.m. confirmed the rinse temperature the rinse temperature was too low during tour and that the minimum temperature for the rinse cycle is 180 degrees F. Staff E revealed Staff E was not notified and that no action was taken on 10/25/15 when the temperature for the rinse cycle was below 180 Degrees F. Tour of the kitchen on 10/27/15 at 9:10 a.m. revealed flying insects in a doorless closet in the corner of the dish room of the kitchen. This closet area contained broken tiles on the floor. When weight was applied to the floor, water seeped up through the cracks in the tile. There was also a drain in the floor that contained debris. Interview with the Staff F (Maintenance Director) on 10/28/15 at 12:00 p.m. confirmed the above findings and revealed that the flying insects have been an ongoing issue in the kitchen and pest traps had been set up. Record review confirmed the facility has a current contract with a pest service and that pest services had provided the facility with traps and services at least quarterly for over a year. Tour of the kitchen on 10/27/15 at 9:00 a.m. revealed that the vent above the food service tray line had round grayish spots on the exterior. Return visit on 10/28/15 at 12:00 p.m. revealed that the sp… | 2019-02-01 |
| 887 | 887 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2015-10-29 | 431 | D | 0 | 1 | 0U9B11 | Based on observation, interview and review of the facility's policy it was determined that the facility failed to ensure that 1 out of 8 medication carts was locked and secure from access by unauthorized personnel. Findings include: Review of the facility policy and procedure titled 5.3 Storage and Expiration Dating of Drugs, Biologicals, Syringes, and Needles : with REVISION DATE: 05/16/11 revealed the following: Policy: Drugs, biological, syringes, and needles are stored under proper conditions with regard to sanitation, temperature, light, moisture, ventilation, segregation, safety, security, and expiration date as directed by state and federal regulations and manufacturer/supplier guidelines. Purpose .To Prevent theft, loss, or access by non-authorized staff or patients. Process . 2.2 All drugs and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room, inaccessible by patients and visitors. During a medication administration pass on 10/27/15 at approximately 4:05 p.m. with Staff A (Registered Nurse), Staff A was observed to leave the medication cart unlocked and unattended in the resident hallway in the Frost Unit. Staff A was observed to proceed down the hallway and into a resident's room to administer medications. Upon returned from the medication pass interview with Staff A confirmed the observation of the unlocked, unattended medication cart. | 2019-02-01 |
| 1098 | 1098 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2014-12-23 | 160 | E | 0 | 1 | P72211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the resident trust fund and interview it was determined that the facility failed to convey resident funds within 30 days to the estate of the individual probate jurisdiction administering the residents estate for 2 out of sample residents. (Resident identifiers are #25 and #26). Findings include: Review of deceased resident's accounts on [DATE] at approximately 3:45 p.m. revealed that Residents #25 and #26's probate paperwork had been filed after the 30 days limit. Review of accounts revealed the following: Resident #25 had expired on [DATE] with a balance of $122.56 remaining in this resident's account. Probate paperwork for Resident #25 was filed on [DATE]. Resident #26 had expired on [DATE] and the probate paperwork had been filed on [DATE] and was closed in the facilities business office on [DATE]. Interview with Staff B (Business Office Manager) on [DATE] at approximately 4 p.m., who verbally confirmed the facility failed to convey resident funds within 30 days of demise. | 2017-12-01 |
| 1099 | 1099 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2014-12-23 | 441 | D | 0 | 1 | P72211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure (1) sanitary food preparation and service in the main kitchen, (2) proper infection control practices for resident room precautions, (3) proper cleaning/disinfecting of equipment used by multiple residents, and (4) timely [DIAGNOSES REDACTED] (TB) screening for new admissions for 2 residents in a survey sample of 24 residents. (Resident identifiers are #6 and #11.) Findings include: During initial tour of the kitchen on the afternoon of 12/21/14, Staff J (Cook) was observed preparing food, Staff J did don gloves after handling the garbage area before returning to handle food, but Staff J did not perform handwashing before donning the gloves. Subsequent interview with Staff H, (Food Service Director) revealed that Staff J should be washing his/her hands between glove changes. Also observed were two ice scoopers in the holder at the ice machine in the main kitchen, but positioned in a way that the base, scooping part, of one was resting against the handle of the other. Tour of the kitchen on 12/21/14 with Staff H, an item was observed in the walk-in refrigerator labeled UB 12/18. Staff H identified this item as ranch dressing with a use by date of 12/18 and Staff H removed it from the refrigerator and discarded it. Staff I (Dietary Aide) was observed taking steam table food temperatures in the main kitchen on 12/23/14. Staff I discarded garbage by lifting the cover to the trash can then regloved without handwashing and resumed taking temperatures. Interview with Staff G, (Infection Control) revealed that kitchen staff should be washing hands between changing of gloves. During initial tour of the Frost unit on the afternoon of 12/21/14, it was observed that four precaution rooms were clustered at the end of one hall. On 12/22/14 in the afternoon Staff E (Housekeeping) was observed gowned, gloved and masked entering one of these precaution rooms for housekeeping pur… | 2017-12-01 |
| 1100 | 1100 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2014-12-23 | 456 | E | 0 | 1 | P72211 | Based on observation and interview the facility failed to ensure patient care equipment is in safe operating condition for 3 of 4 units. Findings include: On 12/22/14 at approximately 4 p.m. it was noted on review of the high and low range glucometer solutions on the Frost Unit that the bottles were not labeled as to when they were opened. Interview on 12/22/14 at approximately 4:05 with Staff D (RN, Unit Manager) who verbally confirmed the bottle of high and the bottle of low solutions were not dated. On 12/22/14 at approximately 12 p.m. it was noted on review that the high and low range glucometer solutions on the Webster Unit that the bottles were dated that they were opened 9/1/14. Interview on 12/22/14 at approximately 12 p.m. with Staff A (RN Unit Manager) who verbally confirmed the bottle of high and the bottle of low solutions were dated as being opened on 9/1/14 and he/she was aware that the glucometer bottles were only good for 30 days after they are opened. On 12/22/14 at approximately 12:15 p.m. it was noted on review of the high and low range glucometer solutions on the Solana Unit that the bottles of solution were not dated only the box the solutions were stored in was dated at 12/16/14. Interview on 12/22/14 at approximately 12:15 with Staff C (LPN, Unit Manager) who verbally confirmed the bottle of high and the bottles of low solutions were not dated. | 2017-12-01 |
| 1306 | 1306 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2014-03-13 | 159 | B | 0 | 1 | MQIX11 | Based on the review of the resident trust fund account and interview it was determined that the facility failed to notify residents when the amount in the resident's account reached $200 less than the SSI resource limit for the State of NH ($2500) as specified in section 1611(a)(3)(B) of the Act for 2 of 5 sampled residents. (Resident identifiers are #13 and #26.) Findings include: Note: Resident Trust Fund Account review and interviews were conducted on 3/13/14. Resident #13. Review of the Individual Statement for Resident #13 revealed that from 6/20/13-8/27/13 the balance continually exceeded $200 less than the SSI resource limit for the State of NH, in fact exceeding the $2500 limit the entire time. The balance ranged from $4,157.80-$5,131.99. There was no documented evidence that the resident or their representative had been notified. In an interview at the time of the review with Staff C (BOM) and Staff D (Administrator), Staff C confirmed the above finding. Resident #26. Review of the Individual Statement for Resident #26 revealed that from 9/3/13-3/3/14 the balance continually exceeded the $200 less than the SSI resource limit for the State of NH in fact exceeding the $2500 limit, in fact exceeding the $2500 limit from 12/3/13-3/3/14. The balance ranged from $2,320.47-$3,131.15. There was no documented evidence that the resident or their representative had been notified until January 2014. In an interview at the time of the review with Staff C and Staff D, Staff C revealed that notification to residents or representatives should have been completed in September 2013, when the accounts reached $200 less than the SSI resource limit of $2500. | 2017-01-01 |
| 1307 | 1307 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2014-03-13 | 371 | E | 0 | 1 | MQIX11 | During the Resident Council meeting of 3/12/14 several residents a majority of those present complained of cold food being served in the facility main dining room particularly at lunchtime. Based on observation, record review and interview the Facility failed to ensure that all food served in the main dining room, at lunch time, was served at the proper temperature. Findings include: On 3/12/14, based on a report from another State Agency surveyor that complaints of cold food in the main dining room (MDR) had been made by some of the residents participating in the group meeting held earlier that day. A decision was made to conduct a test tray in that setting. Review of the document entitled meal service times reveals that lunch is scheduled to be served in the main dining room at 11:30 a.m. Meals are individually served from a steam table in the MDR. Review of the Federal regulations for long term care facility's at F371 in the section entitled FACTORS IMPLICATED IN FOODBORNE ILLNESSES at the paragraph entitled: Final Cooking Temperatures reveals Cooking is a critical control point in preventing foodborne illness. Cooking to heat all parts of food to the temperature and for the time specified below will either kill dangerous organisms or inactivate them sufficiently so that there is little risk to the resident if the food is eaten promptly after cooking. Monitoring the food's internal temperature for 15 seconds determines when microorganisms can no longer survive and food is safe for consumption. (A table of various food types and required internal temperatures follows this paragraph in the text of the regulation.) Review of the Federal regulations for long term care facility's at F371 in the section entitled FACTORS IMPLICATED IN FOODBORNE ILLNESSES at the paragraph entitled: Tray line and Alternative Meal Preparation and Service Area- reveals The tray line may include, but is not limited to the steam table where hot prepared foods are held and served, and the chilled area where cold foods are held and served. A… | 2017-01-01 |
| 1308 | 1308 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2014-03-13 | 386 | D | 0 | 1 | MQIX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview it was determined that the facility failed to ensure physicians sign and dated all orders in a timely fashion for 2 of 24 residents in a standard survey sample. (Resident identifiers are #6 and #14.) Findings include: Resident #6. Record review on 3/12/14 revealed a clarification order written and noted on 10/17/13 by Staff A, (LPN), change indwelling catheter 18fr. (french) inflate with 10cc (cubic centimeter) to c/d (change) q(every) month and PRN (as needed). Further review of the revealed an order written [REDACTED]. 10cc Q month N.O. indwelling catheter 20 Fr and(crossed out) something circled then crossed out.30 cc. only inject inject 20 cc to inflate change Q month and PRN. T.O. Staff B LPN Further review revealed an order that was written on 2/6/14, D/C Phenobard HS (hour of sleep)-100 mg(milligrams) Give Phenobard supp (suppository) 100mg q am T.O.R.B (telephone order read back) Staff B LPN dated 2/9/14. Interview on 3/13/14 and 3/14/14 with Staff A revealed that there were above orders had not been signed in a timely manner. Resident #14. Record review on 3/11/14 of the Physician's Orders for Resident #14 revealed the following telephone physician orders were not dated and signed: 2/8/14 . Increase [MEDICATION NAME] to 0.8 mg po (by mouth) Q (every) Day @ 2000 . 1/30/14 . [MEDICATION NAME] 5 mg BID (twice a day) PRN (as needed) . 1/20 . Flexiril 5 mg po x 1 dose now . 1/21 . CxR (chest x-ray) today . CBC (complete blood count) & BNP (Basic Panel) tomorrow 1/22/13 . 12/22/13 . HOLD [MEDICATION NAME] 80 mg TODAY @ 1400, GIVE 40 mg [MEDICATION NAME] PO TODAY ONLY. CXR TODAY . During interview with Staff A (LPN) on 3/13/14 at approximately 2:00 p.m., after Staff A reviewed the above listed telephone physician orders and medical record Staff A confirmed that the above listed telephone physician orders were not dated and signed by a physician. | 2017-01-01 |
| 1560 | 1560 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2013-02-15 | 160 | B | 0 | 1 | O4PI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview during the Resident Trust Account review, upon the death of 23 residents, who had deposited their funds at the facility, the facility failed to initiate probate court proceedings within the 30 day allowable period of time (for 21 of 23 residents)and in some instances the facility did not initiate probate proceedings at all (for 7 residents) and in other instances the facility was notified of the final decision of the court ( for 8 residents) but did not follow the mandated instructions of the court and disperse the funds as directed. (Resident identifiers are #25 through #47.) Findings include: During the Resident Trust Account review conducted on [DATE], with Staff C (Business Office Manager/BOM) and Staff D (Accounts Receivable Field Director) it was stated by Staff C and confirmed by Staff D that the prior BOM had terminated employment at the facility in the beginning of September, 2012. The current BOM, Staff C had started employment at the end of [DATE]. Staff D during interview at the time of the Resident Trust Account review stated having oversight of this department and records during the prior BOM employment. During the review of accounts, it was determined during interview with Staff C and Staff D that 7 residents with accounts had died and the probate filing had not yet been initiated by the facility and was past the 30 day allowable requirement for filing, 8 residents with accounts had died and probate filing had been done but was not completed by the facility within the 30 day allowable time frame and 8 additional residents with accounts had had filing to the probate court completed and filed late by the facility, and the facility failed to take action and follow the directives of the probate court decision which they were notified of (for these additional 8 residents) and the facility did not disperse the residents funds as court directed. This was for a total of 23 residents and $10,02… | 2015-12-01 |
| 1561 | 1561 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2013-02-15 | 278 | B | 0 | 1 | O4PI11 | Based on record review and interview, it was determined that the facility failed to ensure that the pain assessment portion of Section J of the Resident Assessment Instrument was complete for 3 residents in a survey sample of 24 residents. (Resident identifiers are: #10, #11 and #19.) Findings include: Resident #10: Review on 2/14/13 of Resident #10's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 9/8/12, Section J Health Conditions items 0100 through 0850 revealed that resident pain assessment had not been completed. Resident #11: Review on 2/14/13 of Resident #11's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/18/13, Section J Health Conditions items 0100 through 0850 revealed that resident pain assessment had not been completed. Resident #19: Review on 2/14/13 of Resident #19's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 9/10/12, Section J Health Conditions items 0100 through 0850 revealed that resident pain assessment had not been completed. During an interview on 2/15/13 with Staff A and Staff B (MDS Coordinators), both confirmed that Section J for Residents #10, #11 and #19 had not been completed. | 2015-12-01 |
| 1562 | 1562 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2013-02-15 | 371 | D | 0 | 1 | O4PI11 | Based on the initial tour of the facility kitchens with Staff E (Interim Food Service Director) it was confirmed through interview and observation that the facility failed to properly administer supplementary products by failing to use the date of thaw on reused products. Findings include: On review of the manufacturer's product information sheet related to frozen supplements it states: 1) Shelf Life: Unopened: 12 months frozen 2) Once thawed, under Refrigerated, 14 days. During the initial tour of the facility's kitchen on 2/13/13 at 9:00 a.m. with Staff E it was observed that 3 containers of supplements were in the refrigerator with patient names on them to be given for 2/13/13. On the bottom of each container was a date dated 2/11/13, Staff E was asked what the date on the bottom of the container represented. Staff E found out that the date on the bottom of the container is the 14 day expiration date. Based on this information Staff E remove the 3 containers with the expiration dates on them and replaced them with new product. | 2015-12-01 |
| 1563 | 1563 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2013-02-15 | 514 | D | 0 | 1 | O4PI11 | Based on record review and interview with staff the facility failed to maintain records that are readily accessible along with services provided for 2 of 4 residents receiving hospice in a survey of 24 sampled residents. (Resident identifiers are #9 and #15). Findings include: Review of the Hospice Service Agreement on page 6 states 6.9 Documentation of Services/Information. Both partes shall maintain appropriate documentation of services provided under this Agreement in accordance with applicable state and federal law and regulations. Patient medical records and documentation maintained by each party shall be available for review and inspection by the other party as necessary for the proper evaluation, screening, and provisions of services to Patients under this Agreement . During review of Resident #9 and Resident #15's medical records, it was found the both residents have hospice services. During review of the hospice note book it was found that there were no up to date notes within the chart. Staff B (Unit Manager) was asked about the lack of notes, Staff B stated that the notes were in the computer but did not know how to access them. Two other staff member also nurses for the unit were asked by Staff B on how to get into the computer and both were unable and unaware of how to access the hospice notes for services provided to resident #9 and #15. Once staff were shown how to access the notes for both resident still the records/notes failed to be current. Review of Resident #9's record revealed the last note documented in computer or hand written was 1/23/13 but the sign in sheet for hospice staff shows 11 direct care staff have been in to see Resident #9 up until 2/14/13 with no documentation of services provided. On review of Resident #15's record it shows the last note documented in the computer or hand written was dated 1/28/13 but the sign in sheet for hospice staff shows 11 direct care staff have been in to see Resident #15 up until 2/14/13 with no documentation of services provided. | 2015-12-01 |
| 1609 | 1609 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2012-10-03 | 157 | D | 1 | 0 | WLKL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to timely consult with the physician of a change in resident condition and failed to follow their policy for change in condition of a resident for 1 resident in a survey sample of 5 residents. (Resident identifier is #4.) Findings include: Policy: Policy # CL-676-0111 titled Change in Condition of a Resident with an effective date 1/08 page 1 of 6 under Procedure, it states the following: 1. The Licensed Nurse determines if there has been a change in condition of a resident. 2. The Licensed Nurse notifies via telephone, the attending physician and the resident's responsible party of the specific nature of the change of condition. During a review of the medical record for Resident #4 on 10/3/12, it was revealed that the resident was admitted to the facility on [DATE] with a documented medical [DIAGNOSES REDACTED]. On 10/3/12, during a review of current physician orders [REDACTED]. 1. [MEDICATION NAME] (Insulin [MEDICATION NAME]) 100 unit/ml solution subcutaneous - three times a day everyday: [MEDICATION NAME] ([MEDICATION NAME]) scale AC & HS) SC 150-199 - 1 unit, 200-249 - 3 units, 250-299 - 5 units, 300-349 - 7 units, > 350 - 9 units. (Scale for CBG results.) 2. [MEDICATION NAME] 70/30 (Insulin [MEDICATION NAME] & Reg (Human)) - SQ Dose: (70-30) 100 units/ml daily everyday 7 units at 1430. 3. [MEDICATION NAME] 70/30 (Insulin [MEDICATION NAME] & Reg (Human)) - SQ Dose: (70-30) 100 units/ml daily every day 18 units every AM (Scheduled on the MAR for 8:00 a.m. daily.) Review of the Nursing Progress Notes signed by Staff A, (LPN) dated 9/22/12 revealed the following: Patient alert, CBG results @ 7:30 a.m. was 81 mg/dl. The CBG was checked at 11:30 a.m with a result of 88 mg/dl. The patient was not consuming lunch. The patient became lethargic and Staff A, notified the supervisor. At 1:30 p.m., the patient was still lethargic and Staff A checked the blood glucose and it read HI. (Manufactu… | 2015-10-01 |
| 1610 | 1610 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2012-10-03 | 281 | D | 1 | 0 | WLKL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to follow physician orders, administered medication without an order and failed to document medication administration within professional standards for 1 resident in a survey sample of 5 residents. (Resident identifier is #4.) Findings include: Professional Standards: Review of Fundamentals of Nursing, Patricia A. Potter and Anne Griffin Perry, Mosby, 2009, 7th Edition, revealed the following: On page 336- Physicians' Orders states, The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary. On page 699 . The prescriber must document the diagnosis, condition, or need for use for each medication ordered.on page 708 .The prescriber often gives specific instructions about when to administer a medication.This reference also relates on page 713 that .A medication order is required for a nurse to administer any medication.A registered nurse compares the list of medications on the MAR indicated [REDACTED]. On page 713, under the medication administration standard for Recording Medication Administration, After administering a medication, record it immediately on the appropriate record form .Recording immediately after administration prevents errors. If a client refuses a medication or is undergoing tests or procedures that result in a missed dose, (the nurse) explains the reason the medication was not given in the nurses' notes. During a review of the medical record for Resident #4 on 10/3/12, it was revealed that the resident was admitted to the facility on [DATE] with documented medical [DIAGNOSES REDACTED]. On 10/3/12, during a review of current physician orders [REDACTED]. 1. [MEDICATION NAME] (Insulin [MEDICATION NAME]) 100 unit/ml solution subcutaneous… | 2015-10-01 |
| 1611 | 1611 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2012-10-03 | 333 | D | 1 | 0 | WLKL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure that 1 resident in a survey sample of 5 residents was free of significant medication errors. (Resident identifier is #4.) Findings include: During a review of the medical record for Resident #4 on 10/3/12, it was revealed that the resident was admitted to the facility on [DATE] with documented medical [DIAGNOSES REDACTED]. On 10/3/12, during a review of current physician orders [REDACTED]. 1. [MEDICATION NAME] (Insulin [MEDICATION NAME]) 100 unit/ml solution subcutaneous - three times a day everyday: [MEDICATION NAME] ([MEDICATION NAME]) scale AC & HS) SC 150-199 - 1 unit, 200-249 - 3 units, 250-299 - 5 units, 300-349 - 7 units, > 350 - 9 units. (Scale for CBG results.) 2. [MEDICATION NAME] 70/30 (Insulin [MEDICATION NAME] & Reg (Human)) - SQ Dose: (70-30) 100 units/ml daily everyday 7 units at 1430. 3. [MEDICATION NAME] 70/30 (Insulin [MEDICATION NAME] & Reg (Human)) - SQ Dose: (70-30) 100 units/ml daily every day 18 units every AM (Scheduled on MAR for 8:00 a.m., daily.) Review of the Nursing Progress Notes signed by Staff A, (LPN) dated 9/22/12 revealed the following: Patient alert, CBG @ 7:30 a.m. was 81 mg/dl. The CBG checked at 11:30 a.m. with a result of 88 mg/dl. The patient was not consuming lunch. The patient became lethargic and Staff A, notified the supervisor. At 1:30 p.m., the patient was still lethargic and Staff A checked the blood glucose and it read HI. (Manufacturer Instruction Manual page 37 reveals a HI reading displayed means blood glucose level may be above 600 mg/dl.) Again, Staff A notified the supervisor. The note states the supervisor instructed Staff A to give 9 units of [MEDICATION NAME] coverage and Staff A administered the dose. Staff A then assisted Resident #4 to bed and the note states the resident was responsive but lethargic. During a review of the MAR indicated [REDACTED]. The [MEDICATION NAME] 70/30 dose ordered for 0800 hours was not sign… | 2015-10-01 |
| 1612 | 1612 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2012-10-03 | 514 | B | 1 | 0 | WLKL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to keep accurate complete clinical records for 1 resident in a standard survey sample of 5 residents. (Resident identifier is #4.) Findings include: During a review of the medical record for Resident #4 on 10/3/12, it was revealed that the resident was admitted to the facility on [DATE] with a documented medical [DIAGNOSES REDACTED]. On 10/3/12, during a review of current physician orders [REDACTED]. [MEDICATION NAME] (Insulin [MEDICATION NAME]) 100 unit/ml solution subcutaneous - three times a day everyday: [MEDICATION NAME] ([MEDICATION NAME]) scale AC & HS) SC 150-199 - 1 unit, 200-249 - 3 units, 250-299 - 5 units, 300-349 - 7 units, > 350 - 9 units. (Scale for CBG results.) [MEDICATION NAME] 70/30 (Insulin [MEDICATION NAME] & Reg (Human)) - SQ Dose: (70-30) 100 units/ml daily everyday 7 units at 1430. [MEDICATION NAME] 70/30 (Insulin [MEDICATION NAME] & Reg (Human)) - SQ Dose: (70-30) 100 units/ml daily every day 18 units every AM (Scheduled for 8:00 a.m. daily) Review of the Nursing Progress Notes signed by Staff A, LPN dated 9/22/12 revealed the patient was alert with CBG @ 7:30 a.m. 81. CBG checked at 11:30 a.m. @88. The patient was not consuming lunch. The patient became lethargic and Staff A, notified the supervisor. At 1:30 p.m., the patient was still lethargic and that Staff A checked the blood glucose and the result was HI. (Manufacturer Instruction Manual page 37 reveals a HI reading displayed means blood glucose level may be above 600 mg/dl.) Again, Staff A notified the supervisor. The note states the supervisor instructed Staff A to give 9 units of [MEDICATION NAME] coverage and Staff A administered the dose. Staff A then assisted Resident #4 to bed and the note states the resident was responsive but lethargic. During a review of the MAR for Resident #4, it was noted that the [MEDICATION NAME] 70/30 dose ordered for 1430 hours was not signed out as administered for 9/21 … | 2015-10-01 |
| 1710 | 1710 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2012-03-08 | 224 | D | 1 | 0 | L5V311 | Based upon a review of a facility's investigation report and staff interview the facility failed to ensure that one of one resident was free from mistreatment. (Resident identifier is #1). Findings include: On March 3, 2012 the facility self reported an incident that occurred on the same day 3/3/12 at 9:30 am. The Facility report states as follows "Resident was combative with care, kicking, scratching and spitting at staff while(Resident) was being assisted to the bathroom. Two (2) LNA's (Staff A and Staff B) were assisting resident. (Staff A) attempted to stop the resident from spitting on them by placing her hand at resident's mouth. Concerned about being bit, she replaced her hand with a towel, loosely covering resident's mouth, while (Staff B) held resident's hands to inhibit scratching. Another LNA (Staff C) came in to assist staff and upon seeing this asked them to immediately stop and had them leave the room. (Staff C) finished assisting resident with care, helped (Resident #1) to calm, then reported observations to the nurse. Supervisor and Administrator were immediately notified and (Staff A and Staff B) were suspended pending further investigation..." On 3/8/12 Staff D (Administrator) confirmed through interview the above findings. Staff D stated that both staff members have been terminated. Staff D also confirmed that the board of nursing and the local Police department have been notified, along with the family and physician. Also as part of the investigation the facility contacted both the physician and mental health provider and both assessed Resident #1 and documented in the medical record that there was no distress or pain and no recall of the above event. | 2015-07-01 |
| 1711 | 1711 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2012-03-08 | 226 | D | 1 | 0 | L5V311 | Based on record review and interview with staff it was determined that the facility failed to implement the prohibition of abuse, neglect, and mistreatment...policy under the section for prevention of mistreatment, by two employees failing to follow care plan interventions. (Resident identifier is: #1.) Findings include: On review of the facility's Policy Number CL-676-0020 dated 1/2008 it states "It is the center's policy that every reasonable effort within its control is taken to prevent the mistreatment, neglect, and abuse of residents and misappropriation of resident property. Staff must not engage in nor permit anyone else to engage in verbal, mental, sexual, or physical abuse; neglect; mistreatment, or misappropriation of resident property." Review of Resident #1's care plan dated 3/6/12 with a target date of 6/5/12 reveals under Focus "(Resident #1) exhibits behaviors of verbal outbursts towards others with cursing at times, physical behaviors including striking out towards staff at times while rejecting care, (Resident #1) has a (history of) being sensitive to staff and peers entering (Resident #1) space, (Resident #1) is difficult to redirect at times..." Under Interventions Description it states: -If strategies are not working, leave resident & re-approach in 10 min -Allow resident time to respond to directions or requests -Approach the resident slowly and from the front -Be sure you have the residents attention before speaking or touching -Assist to quiet areas if becomes agitated -Use consistent routines (timing and sequencing) for ADL's -If resident is upset allow (Resident #1) space and time to relax and then re-approach On March 3, 2012 the facility self reported an incident that occurred on the same day 3/3/12 at 9:30 am. The Facility report states as follows "Resident was combative with care, kicking, scratching and spitting at staff while (Resident) was being assisted to the bathroom. Two (2) LNA's (Staff A and Staff B) were assisting resident. (Staff A) attempted to stop the resident from spitt… | 2015-07-01 |
| 1712 | 1712 | BEDFORD HILLS CENTER | 305060 | 30 COLBY COURT | BEDFORD | NH | 3110 | 2012-03-08 | 282 | D | 1 | 0 | L5V311 | Based on record review and interview it was determined that the facility failed to provide care and services to Resident #1 as written in the care plan. Review of Resident #1's care plan dated 3/6/12 with a target date of 6/5/12 it states under focus "(Resident #1) exhibits behaviors of verbal outbursts towards others with cursing at times, physical behaviors including striking out towards staff at times while rejecting care, (Resident #1) has a (history of) being sensitive to staff and peers entering (Resident #1) space, (Resident #1) is difficult to redirect at times..." Under Description it states: -If strategies are not wording, leave resident & re-approach in 10 min -Allow resident time to respond to directions or requests -Approach the resident slowly and from the front -Be sure you have the residents attention before speaking or touching -Assist to quiet areas if becomes agitated -Use consistent routines (timing and sequencing) for ADL's -If resident is upset allow her space and time to relax and then re-approach On March 3, 2012 the facility self reported an incident that occurred on the same day 3/3/12 at 9:30 am. The Facility report states as follows "Resident was combative with care, kicking, scratching and spitting at staff while (Resident) was being assisted to the bathroom. Two (2) LNA's (Staff A and Staff B) were assisting resident. (Staff A) attempted to stop the resident from spitting on them by placing her hand at resident's mouth. Concerned about being bit, she replaced her hand with a towel, loosely covering resident's mouth, while (Staff B) held resident's hands to inhibit scratching. Another LNA (Staff C) came in to assist staff and upon seeing this asked them to immediately stop and had them leave the room. (Staff C) finished assisting resident with care, helped (Resident #1) to calm, them reported observations to the nurse. Supervisor and administrator were immediately notified and (Staff A and Staff B) were suspended pending further investigation..." | 2015-07-01 |
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CREATE TABLE [cms_NH] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );