| 55 |
LEFA SERAN SNF |
295001 |
1ST AND A ST/ PO BOX 1510 |
HAWTHORNE |
NV |
89415 |
2019-10-16 |
658 |
F |
0 |
1 |
LI3Z11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and document review, the facility failed to have a Standard of Practice available for reference for nursing, follow a Standard of Practice to obtain a physician's orders [REDACTED].#5 and #123). Findings Include: Lack of Standard of Practice On 10/16/19 at 10:29 AM, the Director of Nursing (DON) verbalized she did not know the facility's Standard of Practice. On 10/16/19 at 10:47 AM, the DON verbalized the facility followed American Nursing Association for a Standard of Practice. The material was referenced online. On 10/16/19 at 11:23 AM, the DON explained the facility's Standard of Practice subscription had lapsed. The DON did not know how long it had been lapsed and unavailable for reference. On 10/16/19 at 11:24 AM, the DON in training did not know the Standard of Practice followed for licensed nurses in the facility. On 10/16/19 at 11:27 AM, a Registered Nurse1 (RN) did not know the Standard of Practice followed for licensed nurses in the facility. On 10/16/19 at 11:33 AM, an RN2 verbalized the facility did not have a Standard of Practice. The DON handed down the information when there was not a policy or protocol in place. Resident #5 Resident #5 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 10/16/19 at 9:05 AM, the Director of Nursing (DON) confirmed Resident #5 had a PEG tube. The DON verbalized an order was required for a resident with a PEG tube. The DON confirmed Resident #5's clinical record lacked an order for [REDACTED]. On 10/16/19 at 11:47 AM, the RN verbalized the RN had just completed a wound dressing change on Resident #5's PEG tube site. On 10/16/19 at 11:49 AM, the RN explained the RN did a residual check, flushed with 30 milliliters (ml) of water, administered medication, and flushed with 30 ml of water. The RN administers the resident's [MEDICATION NAME] via the PEG tube. The RN flushed with 30 ml of water. On 10/16/19 at 11:54 AM, the RN verbalized the RN did not know how often the wound dressing needed to be changed. The RN verbalized there was no order for flushing for Resident #5 and explained the RN just knew the RN had to do it. On 10/16/19 at 12:08 PM, the DON verbalized the facility required an order for [REDACTED].>The facility policy titled Admission Protocol for Nursing, last revised 03/21/14, documented residents were to be admitted with clear orders from a medical provider. The facility policy titled Nasogastric/Gastrostomy Tube Feedings, effective 04/01/03, documented the facility procedure was to obtain an order for [REDACTED].>Resident #123 Resident #123 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #123's Nursing Admission Evaluation was signed by a Licensed Practical Nurse (LPN) on 10/10/19. The evaluation documented, on page 11, Physical Functioning/Structural Problems. This included the physical mobility for Range of Motion and Strength of the following: - Range of Motion documented Poor - Left and Right Shoulder (flexion, extension, and abduction) documented Poor - Left and Right Elbow (flexion and extension) documented Poor - Left and Right Wrist and Fingers (flexion and extension) documented Poor - Left and Right Hip (flexion and extension) documented Poor - Left and Right Knee (flexion and extension) documented Poor - Left and Right Ankle (flexion and extension) documented Poor - Left and Right Muscle Strength-Shoulder (flexion, extension) documented Poor - Left and Right Muscle Strength-Elbow (flexor/extensor) documented Poor - Left and Right Muscle Strength - Wrist documented Poor - Let and Right Muscle Strength Hip documented Poor - Left and Right Muscle Strength Knee documented Poor - Left and Right Muscle Strength Ankle documented Poor On 10/16/19 at 9:01 AM, the DON reviewed Resident #123's Nursing Admission Evaluation to include page 11, Physical Functioning/Structural Problems. The DON confirmed this section was an assessment of Resident #123 completed by an LPN. The DON verbalized best practice was an RN should have signed off on the LPN's evaluation/assessment within 24 hours of 10/10/19. The DON confirmed there was no documented evidence an RN had assessed the resident or signed off on the LPN's evaluation/assessment. The DON verbalized the DON had completed a review of systems for Resident #123 but could not confirm the resident's strength or muscle in the differ body parts. On 10/16/19 at 10:29 AM, the DON verbalized the facility licensed nursing staff did follow the Nevada Nurse Practice Act. Nevada Revised Statute (NRS) 632.017 Practice of practical nursing defined. Practice of practical nursing means the performance of selected acts in the care of the ill, injured or infirm under the direction of a registered professional nurse . NRS 632.018 Practice of professional nursing defined. Practice of professional nursing means the performance of any act in the observation, care and counsel of the ill, injured or infirm, in the maintenance of health or prevention of illness of others, in the supervision and teaching of other personnel, in the administration of medications and treatments as prescribed by an advanced practice registered nurse, a licensed physician, a physician assistant licensed ., a licensed dentist or a licensed podiatric physician, requiring substantial specialized judgment and skill based on knowledge and application of the principles of biological, physical and social science, but does not include acts of medical [DIAGNOSES REDACTED]. Pre-Charting by a CNA On 10/15/19 at 2:40 PM, a Certified Nursing Assistant (CNA) explained Licensed Nurses and CNAs turned residents. There was a turn sheet list for documenting who last turned the residents and when they were turned. The CNA explained Resident #5 was turned every two hours. On 10/15/19 at 2:48 PM, the CNA verbalized Resident #123 was total dependent on staff and was turned every two hours in bed and adjusted frequently when in a Geri-chair. On 10/15/19 at 2:58 PM, a CNA provided a Resident Turn Schedule for Resident #123 and Resident #5. The form documented the CNA positioned Resident #123 on rp right position at 4:00 PM and on back at 6:00 PM on 10/15/19. The form documented the CNA positioned Resident #5 on rp right position at 4:00 PM and lp left position at 6:00 PM on 10/15/19. The CNA provided nineteen additional resident's forms for the verification of the Safety of Halo Ring or Resident Turn Schedule. Each form had been pre-charted by the CNA for 4:00 PM and 6:00 PM on 10/15/19. On 10/15/19 at 2:59 PM, the DON reviewed the charting for the CNA for the turning of the residents and safety of the Halo ring. The DON verbalized it was pre-charting and it was illegal. The DON confirmed the 4:00 PM and 6:00 PM documentation was initialed by the same CNA before the times had occurred. On 10/15/19 at 3:04 PM, the CNA confirmed it was this CNA's initials documented for the turning of Resident #123 and Resident #5 at 4:00 PM and at 6:00 PM. The CNA explained if there was a change to the resident's position then the CNA would change the documentation but tried to reposition the resident's the way she documented. The CNA verbalized the CNA was not trained to pre-chart but had found this was one way it had worked for her. The CNA explained four CNAs were working the afternoon and would all reposition residents and check the halo ring for residents. The CNA verbalized this CNA did the charting for all the CNAs. On 10/16/19 at 8:57 AM, the DON verbalized the CNA was not taught to pre-chart. The DON verbalized whoever turned the resident was supposed to sign it personally and it was not one CNA documenting for all. The DON verbalized the facility did not have a written policy or protocol for CNA documentation. NRS 632.0166 Nursing assistant means a person who, under the direction of a licensed nurse, performs basic restorative services and basic nursing services which are directed at the safety, comfort, personal hygiene, basic mental health and protection of patients and the protection of the rights of patients. NRS 632.0127 Basic nursing services means the performance of acts designated by the Board which are within the practice of nursing under the direction of a registered nurse or a licensed practical nurse that do not require the substantial specialized skill, judgment and knowledge required of a registered nurse or licensed practical nurse. |
2020-09-01 |